Uterine Preservation Following Catastrophic Hemorrhage From an Undiagnosed First-Trimester Placenta Increta: A Case Report and Review of the Literature

TL;DR

A woman with a missed abortion and prior cesarean deliveries experienced life-threatening bleeding due to an undiagnosed placenta increta, highlighting the need for better early detection in high-risk pregnancies.

Contribution

This case highlights the risk of undiagnosed first-trimester placenta increta and emphasizes the importance of improved diagnostic strategies in high-risk patients.

Findings

Undiagnosed placenta increta in early pregnancy can lead to catastrophic hemorrhage despite a high-risk profile.

Uterine preservation was achieved through emergency surgery, including artery ligation and placental excision.

The case underscores the critical need for enhanced imaging and risk assessment in early pregnancy for patients with prior cesarean deliveries.

Abstract

Placenta accreta spectrum (PAS) in the first trimester is a rare but potentially fatal condition. Preoperative diagnosis during early pregnancy remains extremely challenging, particularly in individuals with a previous cesarean delivery. We describe the case of a 35-year-old woman (gravida 3, para 2) with two prior cesarean deliveries who presented at eight weeks of gestation for the management of a missed abortion. Despite her high-risk status, PAS was not suspected on initial ultrasound. Medical induction with misoprostol resulted in sudden massive hemorrhage and hemorrhagic shock 12 hours later. An emergency dilation and curettage (D&C) was unsuccessful in controlling the bleeding. The patient was stabilized with immediate exploratory laparotomy, which revealed a 4 × 4 cm placenta increta. Hemostasis was achieved through bilateral internal iliac and uterine artery ligation, excision of the placental mass, and repair of the uterine defect, allowing for uterine preservation and a smooth postoperative course. This report underscores the significant risk of catastrophic hemorrhage from previously unrecognized PAS in patients with prior cesarean deliveries and highlights a critical diagnostic gap in early pregnancy care. It demonstrates that while fertility-sparing surgery is achievable with rapid intervention, greater emphasis should be placed on prevention through enhanced preoperative risk assessment and optimized imaging protocols for high-risk patients.

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