Uterine rupture and intestinal injury resulting from postpartum penetrating placental implantation: a case report

Uterine rupture and intestinal injury resulting from postpartum penetrating placental implantation: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Uterine rupture and intestinal injury resulting from postpartum penetrating placental implantation: a case report Qingge Zhang, Zongyu Liu, Ruimin Zhao, Fei Wu, Limei Fan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4970998/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jul, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 12 You are reading this latest preprint version Abstract Background The refractory obstetric hemorrhage that can occur as a result of placental implantation remains a major cause of maternal mortality. Abnormal placental implantation rates have risen markedly in recent years, with the increasing frequency of cesarean sections and other procedures such as myomectomy having contributed to uterine scarring. Penetrating placental implantation resulting in uterine rupture, however, is far less common. This report describes a case of postpartum penetrating placenta implantation leading to uterine rupture and intestinal injury. Case: A 38-year-old G2P1 female presented to the hospital 34 days following a normal delivery with symptoms including 10 days of irregular vaginal bleeding and a 1-day history of fever. She had previously undergone surgical treatment for multiple smooth muscle uterine tumors. Ultrasound and magnetic resonance imaging findings were indicative of myometrial occupancy, prompting speculation that placental implantation may have occurred. Following anti-infection treatment and the correction of anemia, open exploratory surgery was performed. During this procedure, the placenta was found to have penetrated the uterus and caused small bowel erosion. A subtotal hysterectomy and partial small bowel resection were performed, and postoperative pathology confirmed a case of penetrating placenta implantation. Conclusion Penetrating placenta implantation is a rare complication for which few additional testing options are available, complicating the diagnostic process. Greater awareness of this condition should thus be emphasized to minimize the incidence of adverse pregnancy outcomes. penetrating placental implantation subtotal hysterectomy intestinal tract injury vaginal delivery Figures Figure 1 Figure 2 Figure 3 1. Introduction Placental implantation is a serious pregnancy complication in which the placental villi invade the myometrium and may penetrate the uterine plasma layer, potentially impacting proximal organs including the bowel and bladder. In cases when the placenta penetrates the uterine plasma layer, the condition is referred to as penetrating placenta implantation [ 1 , 2 ]. While rare, this condition is a clinical emergency that warrants prompt attention as it is associated with high rates of mortality and complications. Incomplete placental abruption during late pregnancy and labor can result in dangerous outcomes including hemorrhage, uterine rupture, infection, damage to pelvic organs, and even maternal death [ 3 – 5 ]. Risk factors for this adverse outcome include a history of cesarean sections or other procedures with the potential to cause uterine scarring [ 3 , 6 , 7 ]. The primary approach used for the diagnosis of placental implantation is ultrasonography, while magnetic resonance imaging (MRI) can provide complementary insight into the depth and extent of infiltration [ 8 ]. Hysterectomy is considered the standard treatment for placental implantation. In patients who are in stable condition without any active bleeding, conservative treatment is an option [ 9 ]. In this report, we describe a case of penetrating placenta implantation that was not successfully diagnosed prenatally, ultimately leading to uterine rupture and small bowel injury following vaginal delivery. This case is published with the goal of providing a clinical reference for the management of similar cases. 2. Case Presentation A 38-year-old patient, gravida 2 para 1 (G2P1), presented to our hospital with a 10-day history of irregular vaginal bleeding and a 1-day history of fever. She had previously undergone surgical treatment at a local hospital to remove multiple uterine smooth muscle tumors. Thirty-four days before presenting with these symptoms, she had given birth to a male infant at our hospital via vaginal delivery. After delivery, manual placental removal was necessary owing to the presence of adhesions and significant bleeding. Ultrasound-guided uterine evacuation was performed owing to the presence of dense placental adhesions. She had been discharged three days postoperatively. No significant abnormalities were detected by ultrasonography at 1-week postpartum. On day 28 postpartum, however, the patient began experiencing vaginal bleeding that was initially suspected to be menstrual in nature. The blood was bright red, contained clots, and exhibited a fetid odor, but did not coincide with any abdominal pain. Ultrasonography revealed the presence of a heterogeneous 7.4 x 4.5 cm slightly hyperechoic mass on the left side of the uterine cavity, protruding from the left uterine horn (Fig. 1 ). Subsequent MRI examination revealed the presence of an abnormal signal shadow within the myometrium that could not be clearly differentiated from the left uterine horn (Fig. 2 ). Routine blood test results on admission were as follows: white blood cell count, 25.9 x 10^9/L; neutrophil percentage, 89.0%; hemoglobin, 69 g/L; platelet count, 385.0 x 10^9/L, and blood human chorionic gonadotropin (hCG), 246.123 mIU/mL. As these findings were consistent with a severe infection, the patient was admitted for treatment, which initially consisted of symptomatic supportive care together with anti-inflammatory medications, blood transfusion, iron sucrose transfusion, and erythropoietin (EPO) to correct anemia. After successfully controlling the patient’s anemia and infection, in light of the imaging results indicative of myometrial occupation, we opted to perform open exploratory surgery. During this procedure, the uterine corpus and most of the right adnexal region were found to be densely adherent to the small bowel, sigmoid colon, and rectum, with diffuse enlargement and softening. The severity of the adhesions also precluded the exposure of the left adnexal region, suggesting a potential case of placental implantation, and we asked our surgeon to perform the surgery with the same surgeon (Fig. 3 ). We treated the left adnexal area conservatively after carefully separating the adhesions. Additional intraoperative exploration led to the discovery that the placental tissue had penetrated the myometrium and invaded the small bowel. Intraoperative rapid pathology results confirmed that degenerated chorionic tissue was present between the myometrial walls with localized chorionic invasion throughout the myometrium, consistent with a case of penetrating placenta implantation. To ensure that the lesion was fully removed in order to abrogate associated bleeding, a subtotal hysterectomy was performed. Given the limited amounts of necrosis observed in some of the small bowel lesions, the surgeon also performed the partial resection and anastomosis of the affected portion of the small bowel. The procedure was successful, and was completed with good intraoperative hemostasis and no significant complications. The patient underwent routine postoperative antibiotic treatment and received symptomatic care with nutritional support. Her intestinal function gradually recovered after the procedure, and her hemogloblin levels gradually rebounded. On day 9 postoperatively, she met the criteria for discharge as she had experienced good recovery without any apparent complications. Follow-up examination performed 1-month post-discharge revealed no apparent abnormalities, and the patient reported no further bleeding or any other symptoms. 3. Discussion Rising uterine surgery rates in recent years have contributed to a corresponding rise in the incidence of placental implantation [ 10 ]. While placental implantation can occur anywhere within the uterus, it is particularly common in the lower portions of the uterus, and cases of uterine body implantation resulting in uterine rupture are rare [ 11 ]. The diagnosis of uterine rupture is generally fairly straightforward, as it is characterized by severe abdominal pain and fetal heart deceleration during the antepartum and postpartum periods. Uterine rupture typically causes the mother to experience a sharp, sudden abdominal pain that lessens over time together with the cessation of uterine contractions. If not promptly treated, internal bleeding can lead to shock and the absence of fetal heart sounds even though the fetal body can still be palpated through the abdominal wall. Postpartum uterine rupture, in contrast, is primarily characterized by vaginal bleeding, shock, or blood loss that is not consistent with the vital signs exhibited by the affected patient, with intra-abdominal hemorrhage occurring in some cases [ 12 ]. The patient in the present case did not exhibit any clear signs or symptoms of uterine rupture prior to, during, or following delivery. This is likely attributable to the fact that uterine rupture in this case was a consequence of penetrating placenta implantation rather than another cause. One potential explanation is that placental penetration of the uterine plasma membrane layer can result in continuous bleeding from the uterine fissure, but the blockage of this fissure by the placental implantation limits the ability of blood to enter the abdominal cavity [ 13 ]. In such cases, if the fissure is small, it can be difficult to detect via ultrasonography, complicating diagnostic efforts and contributing to a high risk of a missed diagnosis of uterine rupture. Efforts to diagnose placental implantation are currently dependent on ultrasonography and MRI [ 3 , 6 , 14 ]. As a complementary approach to ultrasonography, MRI can offer insight into the depth and lateral extension of myometrial infiltration while being less prone to diagnostic error stemming from factors including the position of placental attachment and maternal size. Ashraf et al. confirmed the superior sensitivity, specificity, and positive predictive value of MRI relative to ultrasonography when diagnosing cases of low-lying adherent placenta [ 7 , 15 , 16 ]. As in the present case, the ultrasonographic findings were not clearly indicative of placental implantation, but MRI results were suggestive of the significant thickening of the anterior and fundal uterine walls. These findings provided a clinical foundation for the diagnosis of placental implantation and the selection of an appropriate treatment plan.However, in patients with typical penetrating placenta implantation, although ultrasound examination did not clearly indicate the presence of placenta implantation, but in conjunction with the clinical manifestations of the highly suspected combination of uterine rupture, it may be a waste of time to carry out nuclear magnetic examination to clarify the diagnosis at this time. Therefore, the diagnosis of placental implantation cannot be completely excluded in patients with obvious clinical manifestations that cannot be confirmed by ultrasound. Hysterectomy is currently the standard approach to treating cases of placental implantation [ 8 , 17 , 18 ]. However, conservative treatment is a viable option for stable patients without any other complications [ 19 ], particularly for women with long-term fertility requirements and a strong preference for uterine preservation. The International Federation of Gynecology and Obstetrics (FIGO) has proposed four conservative treatment approaches [ 9 ], allowing for the management of placental implantation on an individualized basis. In the present case, the patient had already given birth and had no future reproductive requirements. As such, a subtotal hysterectomy was performed after comprehensive consideration. 4. Conclusion In summary, while cases of penetrating placenta implantation combined with uterine rupture are rare, when they manifest they need to be urgently treated as the condition of affected patients is often poor. Given the limited auxiliary examination options for this condition, there is a pressing need to raise awareness of this condition and to adopt effective, active interventional strategies to treat affected patients in an effort to reduce maternal mortality. The overall quality of prenatal and perinatal healthcare for pregnant women should also be improved where possible by detecting potential risk factors in a timely manner to mitigate potential prenatal, perinatal, and postnatal health risks. Declarations Ethics declarations Ethical approval and consent to participant The study was approved by the Ethics Committee of the Second Hospital of Jilin University[SB(2024) Annual Review No. (114)]. Research funding No funding was obtained for this study. Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Competing interests None. References Zhao H, Wang Q, Han M, Xiao X. Current state of interventional procedures to treat pernicious placenta previa accompanied by placenta accreta spectrum: A review. Medicine (Baltimore). 2023;102:e34770. Silver RM. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet Gynecol. 2015;126:654–68. Jauniaux E, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, et al. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. Bjog. 2019;126:e1–e48. Zhu L, Yang X, Sun W, Qian L, Li S, Li D. Myomectomy scar pregnancy: a case report and review of the literature. J Int Med Res. 2020;48:300060520924542. Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, et al. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol. 2014;43:383–95. Gulati A, Anand R, Aggarwal K, Agarwal S, Tomer S. Ultrasound as a Sole Modality for Prenatal Diagnosis of Placenta Accreta Spectrum: Potentialities and Pitfalls. Indian J Radiol Imaging. 2021;31:527–38. Sawant R, Patil S, Warghade SS, Shirsat SY. The Role of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of the Adherent Placenta: An Observational Study. Cureus. 2024;16:e53856. Sentilhes L, Seco A, Azria E, Beucher G. Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study. Am J Obstet Gynecol. 2022;226:839.e1–839.e24. Jauniaux E, Ayres-de-Campos D. FIGO consensus guidelines on placenta accreta spectrum disorders: Introduction. Int J Gynaecol Obstet. 2018;140:261–4. Silver RM, Fox KA, Barton JR, Abuhamad AZ, Simhan H, Huls CK, et al. Center of excellence for placenta accreta. Am J Obstet Gynecol. 2015;212:561–8. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997;177:210–4. Toppenberg KS, Block WA Jr. Uterine rupture: what family physicians need to know. Am Fam Physician. 2002;66:823–8. Cramer S, Hatem F, Heller DS. Placenta Increta Presenting as Retained Placenta: A Report of 3 Cases. Fetal Pediatr Pathol. 2019;38:215–25. Horgan R, Abuhamad A. Placenta Accreta Spectrum: Prenatal Diagnosis and Management. Obstet Gynecol Clin North Am. 2022;49:423–38. Ayati S, Leila L, Pezeshkirad M, Seilanian Toosi F, Nekooei S, Shakeri MT, et al. Accuracy of color Doppler ultrasonography and magnetic resonance imaging in diagnosis of placenta accreta: A survey of 82 cases. Int J Reprod Biomed. 2017;15:225–30. Tanaka YO, Shigemitsu S, Ichikawa Y, Sohda S, Yoshikawa H, Itai Y. Postpartum MR diagnosis of retained placenta accreta. Eur Radiol. 2004;14:945–52. Zuckerwise LC, Craig AM, Newton JM, Zhao S, Bennett KA, Crispens MA. Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum. Am J Obstet Gynecol. 2020;222:179.e1–179.e9. Marcellin L, Delorme P, Bonnet MP, Grange G, Kayem G, Tsatsaris V, et al. Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta. Am J Obstet Gynecol. 2018;219:193.e1–193.e9. Matsuzaki S, Yoshino K, Endo M, Kakigano A, Takiuchi T, Kimura T. Conservative management of placenta percreta. Int J Gynaecol Obstet. 2018;140:299–306. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jul, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 31 Jan, 2025 Reviews received at journal 17 Oct, 2024 Reviewers agreed at journal 06 Oct, 2024 Reviews received at journal 03 Oct, 2024 Reviewers agreed at journal 03 Oct, 2024 Reviews received at journal 24 Sep, 2024 Reviewers agreed at journal 24 Sep, 2024 Reviewers invited by journal 23 Sep, 2024 Editor invited by journal 28 Aug, 2024 Editor assigned by journal 27 Aug, 2024 Submission checks completed at journal 27 Aug, 2024 First submitted to journal 24 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4970998","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":358585257,"identity":"b879b695-125c-4bcf-97ae-c7d476daef2b","order_by":0,"name":"Qingge Zhang","email":"","orcid":"","institution":"The Second Hospital of Jilin University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qingge","middleName":"","lastName":"Zhang","suffix":""},{"id":358585258,"identity":"a78e3abc-0dca-4ca8-b1b7-a948cbd16505","order_by":1,"name":"Zongyu Liu","email":"","orcid":"","institution":"The Second Hospital of Jilin 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Fan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYBAC9gYGxgMMFWwyII4EUVp4DjAwHGA4w8ZDohbGNgZStLCfPXDo5jw+HoMDzAdv8zDY5RHWwpOXcDh3GxtQC1uyNQ9DcjFBLfYMOQZQLTxm0jwMBxIbCNrC/waoZQ5IC/83IrVIgGxpANvCRqwWoC05x9h4JA+zGVvOMUgmxmE5ho9zao7J8R1vfnjjTYUdYS1QcIyBgRlEGxCpHghqiFc6CkbBKBgFIw8AAN3qNkIymVTTAAAAAElFTkSuQmCC","orcid":"","institution":"The Second Hospital of Jilin University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Limei","middleName":"","lastName":"Fan","suffix":""}],"badges":[],"createdAt":"2024-08-25 02:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4970998/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4970998/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-07897-2","type":"published","date":"2025-07-19T16:04:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66904767,"identity":"d42a67a2-33f8-43e2-aee5-78aa4e32affa","added_by":"auto","created_at":"2024-10-17 17:40:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154689,"visible":true,"origin":"","legend":"\u003cp\u003eHypoechoic nodules were visible in the posterior uterine wall, with heterogeneous slightly hyperechoic areas being evident in the plasma layer of the right uterine horn\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-4970998/v1/d986238942ddac0e392400b7.png"},{"id":66904766,"identity":"ac47c08d-3768-4a4f-a03e-1d2b0b1640e6","added_by":"auto","created_at":"2024-10-17 17:40:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":160186,"visible":true,"origin":"","legend":"\u003cp\u003eMRI:\u003cstrong\u003eSagittal\u003c/strong\u003e: marked thickening of the anterior and basal walls.\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-4970998/v1/2c44276bfae34e0caa8be8d3.png"},{"id":66904765,"identity":"8c83c908-3bb0-47da-a3c2-bc32fb721c9b","added_by":"auto","created_at":"2024-10-17 17:40:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2160922,"visible":true,"origin":"","legend":"\u003cp\u003eThe uterine cavity was filled with a soft, grayish-red to grayish-yellow mass adhering primarily to the uterine fundus and locally saturating the uterine wall\u003c/p\u003e","description":"","filename":"Fig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-4970998/v1/93212830d684d14ca8d40fa9.png"},{"id":88506068,"identity":"6d8e34b4-c3ad-443c-9aca-2f734dd3d7b8","added_by":"auto","created_at":"2025-08-07 07:30:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3796354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4970998/v1/faef0adc-ba52-416a-aded-4de2578188d5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Uterine rupture and intestinal injury resulting from postpartum penetrating placental implantation: a case report","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePlacental implantation is a serious pregnancy complication in which the placental villi invade the myometrium and may penetrate the uterine plasma layer, potentially impacting proximal organs including the bowel and bladder. In cases when the placenta penetrates the uterine plasma layer, the condition is referred to as penetrating placenta implantation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While rare, this condition is a clinical emergency that warrants prompt attention as it is associated with high rates of mortality and complications. Incomplete placental abruption during late pregnancy and labor can result in dangerous outcomes including hemorrhage, uterine rupture, infection, damage to pelvic organs, and even maternal death [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Risk factors for this adverse outcome include a history of cesarean sections or other procedures with the potential to cause uterine scarring [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The primary approach used for the diagnosis of placental implantation is ultrasonography, while magnetic resonance imaging (MRI) can provide complementary insight into the depth and extent of infiltration [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Hysterectomy is considered the standard treatment for placental implantation. In patients who are in stable condition without any active bleeding, conservative treatment is an option [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this report, we describe a case of penetrating placenta implantation that was not successfully diagnosed prenatally, ultimately leading to uterine rupture and small bowel injury following vaginal delivery. This case is published with the goal of providing a clinical reference for the management of similar cases.\u003c/p\u003e"},{"header":"2. Case Presentation","content":"\u003cp\u003eA 38-year-old patient, gravida 2 para 1 (G2P1), presented to our hospital with a 10-day history of irregular vaginal bleeding and a 1-day history of fever. She had previously undergone surgical treatment at a local hospital to remove multiple uterine smooth muscle tumors. Thirty-four days before presenting with these symptoms, she had given birth to a male infant at our hospital via vaginal delivery. After delivery, manual placental removal was necessary owing to the presence of adhesions and significant bleeding. Ultrasound-guided uterine evacuation was performed owing to the presence of dense placental adhesions. She had been discharged three days postoperatively. No significant abnormalities were detected by ultrasonography at 1-week postpartum. On day 28 postpartum, however, the patient began experiencing vaginal bleeding that was initially suspected to be menstrual in nature. The blood was bright red, contained clots, and exhibited a fetid odor, but did not coincide with any abdominal pain.\u003c/p\u003e \u003cp\u003eUltrasonography revealed the presence of a heterogeneous 7.4 x 4.5 cm slightly hyperechoic mass on the left side of the uterine cavity, protruding from the left uterine horn (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Subsequent MRI examination revealed the presence of an abnormal signal shadow within the myometrium that could not be clearly differentiated from the left uterine horn (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Routine blood test results on admission were as follows: white blood cell count, 25.9 x 10^9/L; neutrophil percentage, 89.0%; hemoglobin, 69 g/L; platelet count, 385.0 x 10^9/L, and blood human chorionic gonadotropin (hCG), 246.123 mIU/mL. As these findings were consistent with a severe infection, the patient was admitted for treatment, which initially consisted of symptomatic supportive care together with anti-inflammatory medications, blood transfusion, iron sucrose transfusion, and erythropoietin (EPO) to correct anemia.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter successfully controlling the patient\u0026rsquo;s anemia and infection, in light of the imaging results indicative of myometrial occupation, we opted to perform open exploratory surgery. During this procedure, the uterine corpus and most of the right adnexal region were found to be densely adherent to the small bowel, sigmoid colon, and rectum, with diffuse enlargement and softening. The severity of the adhesions also precluded the exposure of the left adnexal region, suggesting a potential case of placental implantation, and we asked our surgeon to perform the surgery with the same surgeon (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We treated the left adnexal area conservatively after carefully separating the adhesions. Additional intraoperative exploration led to the discovery that the placental tissue had penetrated the myometrium and invaded the small bowel. Intraoperative rapid pathology results confirmed that degenerated chorionic tissue was present between the myometrial walls with localized chorionic invasion throughout the myometrium, consistent with a case of penetrating placenta implantation. To ensure that the lesion was fully removed in order to abrogate associated bleeding, a subtotal hysterectomy was performed. Given the limited amounts of necrosis observed in some of the small bowel lesions, the surgeon also performed the partial resection and anastomosis of the affected portion of the small bowel. The procedure was successful, and was completed with good intraoperative hemostasis and no significant complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient underwent routine postoperative antibiotic treatment and received symptomatic care with nutritional support. Her intestinal function gradually recovered after the procedure, and her hemogloblin levels gradually rebounded. On day 9 postoperatively, she met the criteria for discharge as she had experienced good recovery without any apparent complications. Follow-up examination performed 1-month post-discharge revealed no apparent abnormalities, and the patient reported no further bleeding or any other symptoms.\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eRising uterine surgery rates in recent years have contributed to a corresponding rise in the incidence of placental implantation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While placental implantation can occur anywhere within the uterus, it is particularly common in the lower portions of the uterus, and cases of uterine body implantation resulting in uterine rupture are rare [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The diagnosis of uterine rupture is generally fairly straightforward, as it is characterized by severe abdominal pain and fetal heart deceleration during the antepartum and postpartum periods. Uterine rupture typically causes the mother to experience a sharp, sudden abdominal pain that lessens over time together with the cessation of uterine contractions. If not promptly treated, internal bleeding can lead to shock and the absence of fetal heart sounds even though the fetal body can still be palpated through the abdominal wall. Postpartum uterine rupture, in contrast, is primarily characterized by vaginal bleeding, shock, or blood loss that is not consistent with the vital signs exhibited by the affected patient, with intra-abdominal hemorrhage occurring in some cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The patient in the present case did not exhibit any clear signs or symptoms of uterine rupture prior to, during, or following delivery. This is likely attributable to the fact that uterine rupture in this case was a consequence of penetrating placenta implantation rather than another cause. One potential explanation is that placental penetration of the uterine plasma membrane layer can result in continuous bleeding from the uterine fissure, but the blockage of this fissure by the placental implantation limits the ability of blood to enter the abdominal cavity [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In such cases, if the fissure is small, it can be difficult to detect via ultrasonography, complicating diagnostic efforts and contributing to a high risk of a missed diagnosis of uterine rupture.\u003c/p\u003e \u003cp\u003eEfforts to diagnose placental implantation are currently dependent on ultrasonography and MRI [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. As a complementary approach to ultrasonography, MRI can offer insight into the depth and lateral extension of myometrial infiltration while being less prone to diagnostic error stemming from factors including the position of placental attachment and maternal size. Ashraf et al. confirmed the superior sensitivity, specificity, and positive predictive value of MRI relative to ultrasonography when diagnosing cases of low-lying adherent placenta [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. As in the present case, the ultrasonographic findings were not clearly indicative of placental implantation, but MRI results were suggestive of the significant thickening of the anterior and fundal uterine walls. These findings provided a clinical foundation for the diagnosis of placental implantation and the selection of an appropriate treatment plan.However, in patients with typical penetrating placenta implantation, although ultrasound examination did not clearly indicate the presence of placenta implantation, but in conjunction with the clinical manifestations of the highly suspected combination of uterine rupture, it may be a waste of time to carry out nuclear magnetic examination to clarify the diagnosis at this time. Therefore, the diagnosis of placental implantation cannot be completely excluded in patients with obvious clinical manifestations that cannot be confirmed by ultrasound.\u003c/p\u003e \u003cp\u003eHysterectomy is currently the standard approach to treating cases of placental implantation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, conservative treatment is a viable option for stable patients without any other complications [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], particularly for women with long-term fertility requirements and a strong preference for uterine preservation. The International Federation of Gynecology and Obstetrics (FIGO) has proposed four conservative treatment approaches [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], allowing for the management of placental implantation on an individualized basis. In the present case, the patient had already given birth and had no future reproductive requirements. As such, a subtotal hysterectomy was performed after comprehensive consideration.\u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003eIn summary, while cases of penetrating placenta implantation combined with uterine rupture are rare, when they manifest they need to be urgently treated as the condition of affected patients is often poor. Given the limited auxiliary examination options for this condition, there is a pressing need to raise awareness of this condition and to adopt effective, active interventional strategies to treat affected patients in an effort to reduce maternal mortality. The overall quality of prenatal and perinatal healthcare for pregnant women should also be improved where possible by detecting potential risk factors in a timely manner to mitigate potential prenatal, perinatal, and postnatal health risks.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participant\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Second Hospital of Jilin University[SB(2024) Annual Review No. (114)].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhao H, Wang Q, Han M, Xiao X. Current state of interventional procedures to treat pernicious placenta previa accompanied by placenta accreta spectrum: A review. Medicine (Baltimore). 2023;102:e34770.\u003c/li\u003e\n\u003cli\u003eSilver RM. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Obstet Gynecol. 2015;126:654\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eJauniaux E, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, et al. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. Bjog. 2019;126:e1\u0026ndash;e48.\u003c/li\u003e\n\u003cli\u003eZhu L, Yang X, Sun W, Qian L, Li S, Li D. Myomectomy scar pregnancy: a case report and review of the literature. J Int Med Res. 2020;48:300060520924542.\u003c/li\u003e\n\u003cli\u003eTimor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, et al. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol. 2014;43:383\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eGulati A, Anand R, Aggarwal K, Agarwal S, Tomer S. Ultrasound as a Sole Modality for Prenatal Diagnosis of Placenta Accreta Spectrum: Potentialities and Pitfalls. Indian J Radiol Imaging. 2021;31:527\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eSawant R, Patil S, Warghade SS, Shirsat SY. The Role of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of the Adherent Placenta: An Observational Study. Cureus. 2024;16:e53856.\u003c/li\u003e\n\u003cli\u003eSentilhes L, Seco A, Azria E, Beucher G. Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study. Am J Obstet Gynecol. 2022;226:839.e1\u0026ndash;839.e24.\u003c/li\u003e\n\u003cli\u003eJauniaux E, Ayres-de-Campos D. FIGO consensus guidelines on placenta accreta spectrum disorders: Introduction. Int J Gynaecol Obstet. 2018;140:261\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eSilver RM, Fox KA, Barton JR, Abuhamad AZ, Simhan H, Huls CK, et al. Center of excellence for placenta accreta. Am J Obstet Gynecol. 2015;212:561\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eMiller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997;177:210\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eToppenberg KS, Block WA Jr. Uterine rupture: what family physicians need to know. Am Fam Physician. 2002;66:823\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eCramer S, Hatem F, Heller DS. Placenta Increta Presenting as Retained Placenta: A Report of 3 Cases. Fetal Pediatr Pathol. 2019;38:215\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eHorgan R, Abuhamad A. Placenta Accreta Spectrum: Prenatal Diagnosis and Management. Obstet Gynecol Clin North Am. 2022;49:423\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eAyati S, Leila L, Pezeshkirad M, Seilanian Toosi F, Nekooei S, Shakeri MT, et al. Accuracy of color Doppler ultrasonography and magnetic resonance imaging in diagnosis of placenta accreta: A survey of 82 cases. Int J Reprod Biomed. 2017;15:225\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eTanaka YO, Shigemitsu S, Ichikawa Y, Sohda S, Yoshikawa H, Itai Y. Postpartum MR diagnosis of retained placenta accreta. Eur Radiol. 2004;14:945\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eZuckerwise LC, Craig AM, Newton JM, Zhao S, Bennett KA, Crispens MA. Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum. Am J Obstet Gynecol. 2020;222:179.e1\u0026ndash;179.e9.\u003c/li\u003e\n\u003cli\u003eMarcellin L, Delorme P, Bonnet MP, Grange G, Kayem G, Tsatsaris V, et al. Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta. Am J Obstet Gynecol. 2018;219:193.e1\u0026ndash;193.e9.\u003c/li\u003e\n\u003cli\u003eMatsuzaki S, Yoshino K, Endo M, Kakigano A, Takiuchi T, Kimura T. Conservative management of placenta percreta. Int J Gynaecol Obstet. 2018;140:299\u0026ndash;306.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"penetrating placental implantation, subtotal hysterectomy, intestinal tract injury, vaginal delivery","lastPublishedDoi":"10.21203/rs.3.rs-4970998/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4970998/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe refractory obstetric hemorrhage that can occur as a result of placental implantation remains a major cause of maternal mortality. Abnormal placental implantation rates have risen markedly in recent years, with the increasing frequency of cesarean sections and other procedures such as myomectomy having contributed to uterine scarring. Penetrating placental implantation resulting in uterine rupture, however, is far less common. This report describes a case of postpartum penetrating placenta implantation leading to uterine rupture and intestinal injury.\u003c/p\u003e\u003ch2\u003eCase:\u003c/h2\u003e \u003cp\u003eA 38-year-old G2P1 female presented to the hospital 34 days following a normal delivery with symptoms including 10 days of irregular vaginal bleeding and a 1-day history of fever. She had previously undergone surgical treatment for multiple smooth muscle uterine tumors. Ultrasound and magnetic resonance imaging findings were indicative of myometrial occupancy, prompting speculation that placental implantation may have occurred. Following anti-infection treatment and the correction of anemia, open exploratory surgery was performed. During this procedure, the placenta was found to have penetrated the uterus and caused small bowel erosion. A subtotal hysterectomy and partial small bowel resection were performed, and postoperative pathology confirmed a case of penetrating placenta implantation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePenetrating placenta implantation is a rare complication for which few additional testing options are available, complicating the diagnostic process. Greater awareness of this condition should thus be emphasized to minimize the incidence of adverse pregnancy outcomes.\u003c/p\u003e","manuscriptTitle":"Uterine rupture and intestinal injury resulting from postpartum penetrating placental implantation: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-17 17:40:32","doi":"10.21203/rs.3.rs-4970998/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-31T16:32:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-17T16:37:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255949571663259737092462686882857966264","date":"2024-10-06T21:57:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-03T23:21:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33957593173730617789151265949052178680","date":"2024-10-03T04:10:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-24T15:53:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168831178664994297646202112109386731968","date":"2024-09-24T09:54:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-24T03:44:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-28T09:35:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-27T22:35:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-27T22:34:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-08-25T02:43:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe22cada-a6bf-44bc-86e1-def4368c80df","owner":[],"postedDate":"October 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T07:12:33+00:00","versionOfRecord":{"articleIdentity":"rs-4970998","link":"https://doi.org/10.1186/s12884-025-07897-2","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-07-19 16:04:53","publishedOnDateReadable":"July 19th, 2025"},"versionCreatedAt":"2024-10-17 17:40:32","video":"","vorDoi":"10.1186/s12884-025-07897-2","vorDoiUrl":"https://doi.org/10.1186/s12884-025-07897-2","workflowStages":[]},"version":"v1","identity":"rs-4970998","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4970998","identity":"rs-4970998","version":["v1"]},"buildId":"re_ckhLnmML6MCF96OHNJ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}