A 34 year old primigravida was diagnosed with morbidly adherent placenta during third stage of labour. Failure to manually remove the placenta led to massive haemorrhage requiring 40 unit blood transfusion, laparotomy and hysterotomy. After a short ITU stay the patient made a good recovery and the obstetric consultant recommended that any subsequent pregnancy was delivered by elective LSCS at 38/40. No risk factors or causes for placenta accreta were identified from her medical history.
The woman became pregnant again within 3 years and was referred to Queen Elizabeth Hospital, Kings Lynn for consultant led care. USS at 12/40 raised the suspicion of recurrent placenta accreta which was confirmed at 20/40.
Detailed obstetric and anaesthetic planning was made for her anticipated delivery, including consultant anaesthetists, haematologists, paediatricians, obstetricians, theatre team, midwives and patient herself. Initially delivery was planned for 38/40, however the woman had premature rupture of membranes at 30/40. This was managed as an inpatient with steroids, tocolysis, antibiotics and pregnancy continued to 35/40 when elective caesarean was carried out.
The baby was delivered via a transverse lower segment incision, and placental blood vessels were seen directly beneath the peritoneal layer with oozing. Uterine rupture was considered imminent and therefore hysterectomy was carried out. Estimated blood loss was 1000mls, blood transfusion was avoided and a healthy baby girl was delivered. Placenta accreta can be successfully managed in a district general hospital with appropriate planning, resources and support.
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