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Management of a pregnancy with dichorionic-diamniotic twins complicated by placenta percreta
  1. EH Shaw,
  2. T-L Appleyard
  1. Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom

Abstract

Introduction Rising caesarean rates may increase incidence of abnormal placentation. Appropriate multidisciplinary management is needed. We report the first documented case of successful outcome of placenta percreta with twins.

Case report A 40 year old P4 (all caesarean sections) with dichorionic-diamniotic twins had an anterior low placenta at anomaly scan.

Following an antepartum haemorrhage at 30+1weeks, hospital admission with subsequent investigations revealed intermittent haematuria. An inconclusive MRI was compared with a greyscale ultrasound scan, resulting in a provisional diagnosis of placenta percreta, involving the posterior bladder wall. A proforma was designed to arrange a large multiprofessional team for delivery.

Contractions at 34+1weeks prompted emergency delivery. Utilising the proforma to coordinate primed teams meant interventional radiology followed by caesarean with general anaesthetic ensued. Both twins were born in good condition, requiring a short SCBU admission. The upper placenta separated easily. The lower placenta was morbidly adherent, extending through the uterus into the right broad ligament. It approximated the bladder surface but did not breach the muscle. Management necessitated hysterectomy; difficult identification of tissue plains resulted in a cystotomy, which urologists repaired. Blood loss was 3000ml; transfusion with autologous blood was achieved.

Discussion Management of this case of twins with placenta percreta using reusable management template, which was designed assisted by RCOG Guidelines, resulted in successful pregnancy outcome. This is first report of successful outcome of twins with abnormal placentation; previous cases have discussed early uterine rupture. Conservative options were discussed as alternative management for the adherent placenta.

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