A Case Study of Placenta Percreta and Small Bowel Obstruction in Pregnancy

Background:

Placent percreta is a rare and potentially life-threatening complication of pregnancy.  Its incidence has been increasing and is reported to be 1 in 533 delivers.  Risk factors include history of previous cesarean section/scarred uterus,placenta previa, history of manual extraction of placenta, multiple pregnancies, dilatation and curettage, endometrious, high parity and advanced maternal age. Intestinal obstruction in pregnancy is rare and occurs 1 -3000 deliveries.  Symptoms are often unspecific and fetal and maternal mortality rates are higher during pregnancy as diagnosis can be delayed due to symptoms mimicking typical pregnancy-associated complaints. Significant morbidity or mortality is associated with both complications. Concern for fetal outcomes while managing these two complications raises therapeutic, ethical, moral and social dilemmas.

Case:

A 32 year old multigravida patient with a history of extensive adhesions of the small bowel into the anterior abdominal wall and significant hemoperitonuem was admitted at 28 weeks gestation for sudden sharp abdominal pain, nausea and elevated blood pressure. The fetal heart rate was 147 and a category I. Routine and PIH labs were within normal limits. Sonogram and MRI showed a small bowel obstruction  and placenta percreta.   Patient was scheduled for cesarean section and hysterectomy at 32 weeks. A multidisciplinary team including the patient's obstetrician, gynecology/oncology, maternl fetal medicine, neonatologist, anesthesia, interventional radiologist, representative from blood bank, clinical nurse specialist and managers from Labor and Delivery and the operating room met and planned for the delivery. At 31 weeks gestation the patient's pain worsened and her hemaglobin and hematacrit dropped.The patient was delivered of a viable baby girl via repeat cesarean section under general anethesia.  Patient received numerous blood product transfusions for postpartum hemorrhage,  had a right ureteral stent placed for incidental cystomy and expereienced an embolic event. Infant was transferred to NICU and patient went to ICU for recovery. Postpartum course was significant for fluctuatig BP that was treated intermittantly with meds. Patient was discharged home on post-op day seven.

 Conclusion:

The presence of two rare complications necessitated extensive planning for the anticipated delivery and well-being of mother and infant. Significant learning from this case included education for nursing on a variety of diagnoses uncommon to daily obstetrical practice, support for the nursing staff, and a multidisciplinary team approach to care.   Daily High Risk Multidiscipinary Planning Rounds and strong collegial relationships that focused on the patient and infant’s welfare facilitated the promotion of evidence-based care of critically ill mothers and babies.

Keywords: placenta percreta, abnormal placenta adherence, small bowel obstruction, abdominal adhesions, high risk pregnancy