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CDK 175 / vol.37 no. 2 / Maret - April 2010

LAPORAN KASUS

INTRODUCTION

Post partum bleeding is still a major cause of mortality and

morbidity during delivery.

1,2,3

Post partum bleeding de-

ned as 500 1000 ml blood loss after vaginal delivery or

more than 1000 ml after cesarean section.

The incidence is

about 5 % in normal delivery. Post partum hemorrhage can

be classi ed as primary if occurred within the rst 24 hour

usually caused by vaginal laceration, uterine atony, placenta

retention, or coagulopathy; and secondary if occurred after

24 hours, usually within 5 to 14 days with mean at day 7. It

can occur after placental retention, sub-involution of pla-

centa implantation site and in incision site, lysis of clot and

thrombus. It is occurred more commonly in primipara.

1, 2

Retained placenta is a common cause of postpartum hem-

orrhage. The etiology can be functional such as weak con-

traction, adhesive placenta or abnormal placental site: pla-

cental accreta, increta, percreta. These abnormal placental

site caused by absence of whole or part of decidual base

and improperly developed brous tissue, allowing invasion

of placental villi into myometrium (accreta) or penetrate

through myometrium (percreta).

1,2,5

The adhesion can be

total - all cotyledon invades the myometrium, or partial or

focal. The incidence was 1 in about 7000 deliveries.

The problem may occurred at delivery, especially during

placenta delivery. Bleeding depends on depth or width or

the amount of adhesive cotyledon. In total adhesion, the

bleeding is minimal or not occured until placental manual

procedure. Total adhesion can cause uterus inversion after

pulling the cord, and also placenta delivery failure.

2, 6

Partial

or focal adhesion usually caused more bleeding because of

partial removal in placental implantation site, and rsidual

cotyledon after placental manual. The management consist

of hysterectomy and blood transfusion.

Hysterectomy is operative approach to evacuate whole or part

of uterus (excluding cervix). Finney (John Hopkins University)

indicates that this operation was for life saving, to eliminate

symptoms and deformities. Hill and Beischer reported that

hysterectomy was done in uncontrolled postpartum hemor-

rhage.

7-10

This paper featured a case of hysterectomy done in

day after cesarean section because of undiagnosed pla-

centa increta. The proper diagnosis and management, com-

plication, prognosis and social aspect will be discussed.

CASE REPORT

A 28 year-old woman was sent by local midwife with lower

abdominal pain. The amnion was already ruptured. She had

5 ANC visits at Kombos PHC and the last one at Manado

General Hospital. USG and NST was scheduled three days

later, but she failed to come. She married for one and half

years; her last menstrual period was November 5

, 2000.

Her pregnancy is about 43 to 44 weeks. She never had

abortion before. Vital signs were within normal limits. Body

height was 156 cm and the body weight was 64 kg. The fun-

dal height was 37 cm with left back cephalic presentation.

Estimated fetal weight was about 4000g. Fetal heart sound

was decreasing and intrauterine resuscitation was done fol-

lowed with emergency cesarean section.

A female baby was born, 4080g, 51 cm, with APGAR score

3-5-7; there was slight meconium and 40% infarction of pla-

centa. No bleeding was found. Uterus, both fallopian tube

Post Cesarean Placenta Increta

Eddy Suparman

Dept. of Obstetrics and Gynecology, Sam Ratulangi University/General Hospital, Manado, Indonesia

ABSTRAK

Perdarahan post partum masih merupakan penyebab utama mortalitas dan morbiditas persalinan. Angka

kejadiannya sekitar 5 % dari persalinan normal. Perdarahan post partum dapat dibagi atas perdarahan post

partum dini jika terjadi sebelum 24 jam pasca persalinan ; terutama disebabkan karena laserasi vagina, atonia

uterus, retensio plasenta, dan koagulopati. Dan perdarahan post partum lambat jika terjadi setelah 24 jam

post partum ; dapat disebabkan oleh retensio plasenta, sub-involusi, dari tempat implantasi, lisis bekuan dan

trombus.

Laporan kasus ini mengenai seorang wanita 28 tahun dengan kehamilan 43 44 minggu yang menjalani sek-

sio sesarea atas indikasi makrosomia. Meskipun operasi berjalan lancar, pada hari ke lima post seksio sesarea

timbul perdarahan dari jalan lahir. Setelah dilakukan kuretase dan tampon utero-vaginal tetap terjadi perdara-

han, maka dilakukan histerektomi subtotal. Pemeriksaan histopatologi menemukan suatu plasenta inkreta.

Kata kunci: perdarahan post partum, plasenta inkreta

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CDK 175 / vol.37 no. 2 / Maret - April 2010

112

LAPORAN KASUS

and both ovaries were normal. After surgery, patient was in

good condition. On fth day post surgery, the patient had

vaginal bleeding. The blood pressure was 100/60 mmHg,

pulse rate was 96 and her hemoglobin was 6.4 g/dL. Uterus

contraction was not good, treated with uterotonic injection;

fundal height was 2 ngers below umbilicus. Three bags of

whole blood transfusion was given.

There was still bleeding. Blood pressure dropped to 90/60

mmHg and the patient became anemic. Curettage was done,

evacuating rest placenta but there was still bleeding even

though tamponade had been done. So laparotomy was done

: the uterus was as big as baby's head with weak contraction.

The bleeding came from placental site at posterior corpus

uteri. No bleeding from cavum abdomen or low segment inci-

sion. Subtotal hysterectomy was done. The patient condition

was good after operation.The histopathology nding on myo-

metrium was normal smooth muscle cells invaded by placental

tissue. There was brin with focal necrosis and in ammation.

No neoplasm was found. Conclusion: placental increta.

DISCUSSION

This case was primipara, 28 years old, 43-44 weeks of preg-

nancy, rst stage of labor; intrauterine fetal, singleton, alive,

cephalic presentation, macrosomia, with decreased of fe-

tal heart sound. Macrosomia was diagnosed from fundal

height (37 cm - Johnson's rule is 4030g).

The patient had vaginal bleeding 5 days after operation.

The conjunctivae were anemic.

This is a late postpartum hemorrhage that could happen

between 5th to 14th day postpartum, usually on 7th day, be-

cause of clot lysis and thrombosis removal.

1,3

At inspection,

the bleeding was from external os. There was no vaginal

laceration and also no incision bleeding. Fundal height was

2 ngers below umbilicus and hemoglobin was 6.2 g/dL. It

was uterine atony. Predisposition factor of uterine atony are

low nutritional status, uterine muscles' weakness, deliveries

under anesthesia and overdistended pregnancy.

1, 2, 3

This patient had overdistended uterus and anemia.

The management of uterine atony is uterus massage, utero-

tonic (oxytocine 10 IU IM and 40 IU in 500ml normal saline/

RL), intravenous uid for restoring uid and drugs delivery. If

bleeding still continues and the uterus cannot contract well,

bimanual compression can be done. Misoprostol 400mg

can also be given per rectal to induce contraction. If still

unsuccessful, ligation of uterine arteries can be done. If the

bleeding still continues, hysterectomy is the last choice.

This patient had cesarean section; so vaginal laceration,

trauma, uterine rupture, and uterine inversion can be ex-

cluded. Residual placenta is the common cause of late

postpartum hemorrhage, especially in primipara; tropho-

blast invading the myometrium can cause sub-involution

and perform thrombus recanalization after delivery.

1, 2

This case had already have uterine massage and uterotonic

also had been given; but there was rebleeding. Evacuation

of about 300 ml of clot and placental tissues from cavum

uteri has been done digitally; continued by curettage. This

patient was prepared for laparotomy, to seek other causes

of uncontrolled bleeding.

7, 8

The histopathology nding

was placental increta. This condition is dif cult to detect

on prenatal examination and can only be diagnosed prop-

erly by histopathology that showed invading villi chorialis

into myometrium. Placental implantation can be totally or

just partially invaded. In total condition there will be less or

no bleeding until manual placenta procedure. Inversion of

uterine can occur during pulling out the umbilical cord, and

also at placental removal.

Partial or focal condition usually

cause more bleeding.

MANAGEMENT

This case was managed with hysterectomy due to uncon-

trolled bleeding. Subtotal hysterectomy was chosen to min-

imize bleeding.

3,4

The outcome depended on the correct

timing of hysterectomy and blood transfusion. Methrotrex-

ate can help in focal placental accreta, but its ef cacy and

safety is uncertain.

Hysterectomy was delayed because of

misdiagnosis. Since there were no dif culties in placenta

delivery during the cesarean section, abnormalities on pla-

cental implantation were not considered. Placental increta

can be diagnosed only by histopathology examination.

5, 7

PROGNOSIS

Postpartum hemorrhage is still unpredictable despite care-

ful attention. It is still an important cause of maternal death.

This case got a `dubia ad bonam' prognosis, both for the

mother and the baby.

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Hankin V, Clark L, Cunningham G. Obstetric Hysterectomy. In: Operative Obstetrics. Connecticutt: Appleton and Lange, 1995: 333-42

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