Preservation of the Uterus in a Case of Late-Term Pregnancy with Placental Invasion and Omental Implantation

Preservation of the Uterus in a Case of Late-Term Pregnancy with Placental Invasion and Omental Implantation | 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 Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Preservation of the Uterus in a Case of Late-Term Pregnancy with Placental Invasion and Omental Implantation Yanling He, Weiwei Wang, Yubin Zhou, Yuping Wang, Yongna Sun, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4240325/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We report a unique case of a 27-year-old woman with a history of cesarean section, who presented with placental invasion and omental implantation at 39 weeks + 2 days of gestation. Preoperative ultrasound did not reveal signs of placenta accreta. Despite the challenges, we successfully preserved her uterus using a combination of surgical techniques, including manual placental removal, uterine artery ligation, and repair of the uterine fundus. This case highlights the importance of a multidisciplinary approach and preoperative preparation in managing such complex obstetric complications. Placenta invasion omental implantation uterine preservation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Case introduction A 27-year-old pregnant woman, at 39 weeks and 2 days of gestation, was admitted to our facility on June 3, 2023, for a scheduled cesarean section. This was due to a uterine scar resulting from a previous cesarean delivery at a local hospital in 2014, which was necessitated by fetal distress caused by amniotic fluid contamination. Her medical history includes a medical abortion in 2014. In addition, she underwent successful laparoscopic removal of a right tubal ectopic pregnancy in 2021. Upon admission, obstetric ultrasound estimated the fetal weight to be 3860g with a margin of error of 564g. The placenta was identified on the posterior uterine wall with no sonographic features indicative of placenta accreta or any disruption in the continuity of the uterine muscle wall. The surgical procedure entailed the extraction of the uterus from the abdominal cavity, which disclosed the fundal surface obscured by the greatest omentum(Figure1). Intraoperative assessment revealed that the placenta was deeply embedded in the omentum(Figure2), making its isolated removal impossible. Consequently, the segment of the omentum, inclusive of the implanted placenta, was excised, uncovering a sizable defect in the uterine fundus, measuring approximately 8cm by 7cm(Figures3-5). Following the removal of necrotic tissue from the fundal rupture site, the area was meticulously sutured in a continuous manner, and a Hyman suture was executed to reinforce the uterine fundus. To address the pervasive uterine bleeding, the ascending branches of the uterine arteries were ligated, and a dam suture was applied to the posterior uterine wall, effectively mitigating the hemorrhage. Persistent bleeding in the cervical canal was resolved with a cervical constriction technique. The uterine incision's myometrial and serosal layers were meticulously sutured, and a B-Lynch suture was utilized to augment uterine contraction and bolster the fundus（Figure8）. The right fallopian tube was identified as discontinuous, with a sizable 6cm by 5cm mesenteric cyst at the fimbriated end, which was thoroughly excised, followed by a salpingectomy of the right fallopian tube. The patient and their family were informed about the significant risks associated with the full-thickness spontaneous uterine rupture, which contraindicates future pregnancies. Considering the non-functional state of the right fallopian tube, the recommendation for long-term contraception was emphasized. Upon the patient's request, the left fallopian tube was securely ligated using the core-pulling and embedding technique. The surgery was deemed successful with an estimated blood loss of 1500ml, and the patient received an autologous blood transfusion of 500ml. Postoperative care focused on promoting uterine contraction, administering prophylactic antibiotics, and providing symptomatic treatment as necessary. Postoperatively, 2 units of RHD positive red blood cells and 400ml plasma were transfused.The patient was discharged on the fourth day after surgery with a well-healed incision. The surgical intervention was considered a success, with a calculated blood loss of approximately 1500 milliliters. To aid recovery, the patient received a 500ml autologous blood transfusion and, shortly after, two units of Rh-positive red blood cells and 400ml of plasma.Postoperative care focused on promoting uterine contraction, preventing infection with antibiotics, and addressing symptoms as needed, resulting in the patient's timely discharge on the fourth day due to good incision healing. Pathological analysis of the excised omentum and mesosalpingeal cyst showed decidual-like changes in the omentum and degenerated trophoblast cells（Figures 6 and 7）. These findings, along with intraoperative observations, confirmed a diagnosis of placenta percreta with extensive omental implantation. The patient was diagnosed with placenta percreta and significant omental involvement, as confirmed by both surgical findings and postpartum pathology. Discussion The term "placenta accreta" was coined by McCarthy and Nichols in 1950[1].It refers to the inadequate development of the uterine endometrium, either primary or secondary, resulting in the elimination of the physiological gap between the placenta and uterus during placental villous tissue growth. This leads to tight adherence of one or more maternal leaflets of the placenta to the basal layer of the endometrium, partial invasion into the uterine muscle layer, and even penetration through both the uterine muscle layer and serosal layer. Depending on how deeply placental villi invade into the uterine muscle layer, it can be classified as follows: 1. Adhesive placenta accreta: adhesion of placental villi to the surface of uterine muscles; 2. Placenta accreta: deep penetration of placental villi into spaces within uterine muscles; 3. Placenta percreta: passage and extension beyond both layers of uterine muscles by placental villi, including invasion into adjacent organs[2]. We utilized the keyword "placenta percreta" to conduct a comprehensive search for case analyses conducted in the past few decades, both domestically and internationally. The prevalence of placenta accreta spectrum (PAS) has been documented in the literature, ranging from 0.25‰ in the 1970s [3]to 1.36‰~1.87‰ in contemporary studies[4-6]. Among these cases, adhesive placenta accreta, placenta accreta, and placenta percreta had respective prevalences of 0.23%, 0.03%, and 0.04%[7]. PAS can be further categorized into PAS with placenta previa and PAS without placenta previa[2]. Cases of PAS with placenta previa tend to garner more clinical attention and have higher detection rates compared to those without it. In this particular instance of PAS without placenta previa, a missed diagnosis occurred due to an ultrasound oversight on a uterine-bottom located placenta percreta. We observed several distinctive characteristics in our study's patient with placenta accreta compared to previous medical records: (1) It is uncommon for placenta percreta to persist until 39 weeks of gestation; (2) The diagnosis of placenta accreta was made during an elective cesarean section at 39 weeks of gestation. The patient did not experience any conscious discomfort prior to the procedure, and its identification was challenging preoperatively. (3) Among the previously documented cases of placenta percreta, our patient exhibited the largest area of placental implantation and uterine defect. It is exceptionally rare for successful preservation of the uterus without adequate preoperative preparation.（Figure8） The results of multivariate analysis revealed that patients with high-risk factors for placenta percreta, such as a history of uterine scar (caesarean section, uterine myomectomy, uterine perforation), infection following previous surgery, impaired wound healing, uterine malformation, multiple intrauterine operations (multiple abortions, history of hysteroscopic resection), and advanced maternal age were identified[8, 9]. Placenta percreta can occur in various locations within the uterus, including the uterine body and cornua, with a higher prevalence observed in the lower anterior wall of the uterus. The lower segment of the uterus or previous cesarean section scars lacks muscular tissue and exhibits poor blood supply and reduced elasticity; as pregnancy progresses, there is gradual stretching and thinning of the scar area on the lower anterior wall, thereby increasing the risk of uterine rupture. As gestational age progresses, the expansion of the uterine cavity occurs particularly during the initiation of contractions when tension in the myometrium gradually increases. This may lead to spontaneous rupture at any given time due to the “rags effect”.Meanwhile, ensuring adequate nutrient supply, placental tissue implants deeper and may even penetrate through the uterine serosa, resulting in damage to surrounding tissues and organs such as the bladder, intestines, and the greatest omentum. Sustaining pregnancy until third trimester becomes challenging as complete or incomplete uterine rupture along with severe postpartum hemorrhage and visceral injury can occur unpredictably. Consequently, placenta percreta contributes to a maternal mortality rate reaching up to 10%[10]. In our case, she underwent a cesarean section followed by medical abortion in 2014 with a short interval between pregnancies. Poor functional regeneration of her endometrium resulted in incomplete repair at sites where placental attachment occurred. Miscarriage further damaged her endometrium, particularly affecting its basal layer. In 2022, she became pregnant again with an embryo implanting at a compromised site within her damaged endometrium gradually developing into a case of placenta percreta. This patient presented with a rare occurrence of gestational sac in a weak area at the bottom of the uterus, accompanied by uterine rupture at the site of placenta percreta. This could be attributed to multiparity and thinning of the local uterine muscle layer. Regarding the sequence of uterine rupture and placenta percreta development in this case, I hypothesize that the gestational sac implants in the vulnerable region of the uterine basal layer and gradually forms placental tissue. The invasion depth and breadth increase as the spiral arteries of the uterus seek adequate nutrition, further compromising the weakened area at the uterine base. Subsequently, gradual implantation of the placenta into the greatest omentum occurs. As gestational weeks progress, increased pressure within the uterine cavity leads to heightened tension and ultimately ruptures at this weakened area. Prior placental implantation and subsequent self-repair by the greatest omentum contribute to reshaping of uterine muscle wall, maintaining relative integrity of uterus and sustaining pregnancy. However, during this process, changes occur in local microenvironment due to placental implantation leading to infiltration of inflammatory cells which results in increased tension on surface of uterus making it fragile. At this point, even slight coughing, sneezing or emotional excitement can cause spontaneous uterine rupture due to altered abdominal pressure caused by these actions. Similar to a case reported by Lucy M. Bradley where acute abdomen occurred at 22 weeks gestation with massive active internal bleeding causing hemorrhagic shock resulting in maternal-fetal death; autopsy findings indicated that previous cesarean scar was associated with placental implantation leading to uterine rupture[11]. Uterine rupture caused by placental implantation is characterized by sudden onset with concealed etiology but rapid progression and high mortality rate. This patient was undoubtedly fortunate as she did not experience internal bleeding or adverse pregnancy outcomes such as abdominal pregnancy or fetal demise inside uterus. Placenta accreta presents with a range of clinical manifestations, and the severity of the disease is correlated with the extent of implantation and presence of uterine rupture. It necessitates differentiation from acute abdomen. The primary symptoms encompass varying degrees of abdominal pain, chest tightness accompanied by lower backache, abdominal distension, rectal fullness, changes in fetal heart rate, pelvic and abdominal fluid accumulation, anemia, hemorrhagic shock, and infection [5]. Placenta accreta frequently coexists with placenta previa and can result in recurrent vaginal bleeding during pregnancy. Placenta accreta spectrum (PAS) poses significant risks for both maternal and fetal health. The heterogeneity in clinical presentations may lead to misdiagnosis or underdiagnosis. This case's recollection does not include any mention of experiencing mild abdominal pain during pregnancy or transient changes in fetal heart rate or other subtle discomfort symptoms.These factors significantly contributed to the preoperative oversight of placenta percreta. Ultrasound examination plays a crucial role in obstetrics, serving as the "eyes" of this field and facilitating the identification of uterine rupture. Adequate bladder filling is essential, along with careful attention to placental position, parenchymal echo, retroplacental space, and smoothness of the posterior bladder wall. In cases where there is incomplete myometrium, uterine rupture should be considered. Sonographers should be reminded to thoroughly examine the placental attachment site for patients with high risk factors for uterine rupture. Color Doppler flowmetry can provide valuable insights into blood vessels and flow within the placenta as well as blood flow distribution between the placenta and myometrium, aiding in early diagnosis of placenta accreta. The following characteristics are observed in color Doppler flow imaging of placenta increta: ① The placenta exhibited several vascular cavities and a break in the uterine serosa- bladder connection; ②The color Doppler study revealed turbulent blood flow within the placental lacunae and enhanced vascularization beneath the placenta ; ③placenta previa [12, 13]. (Figure9，10and11)Ultrasonography in the second and third trimesters has been reported to exhibit sensitivities and specificities ranging from 80% to 90% for the identification of placenta accreta spectrum[12, 13]. A meta-analysis encompassing 23 studies involving 3707 pregnancies revealed that ultrasound exhibited approximately 90.72% sensitivity in diagnosing PAS while maintaining an impressive specificity rate of up to 96.94%[14]. These may be overestimates, however, because data are derived from experts who possess a comprehensive understanding of the significant risks associated with placenta accreta. Considerable interobserver variability exists in the identification of the condition[15], and accuracy significantly decreases when clinicians are unaware of pertinent clinical information[16].Preoperative ultrasound failed to detect uterine rupture in this patient due to the absence of typical clinical manifestations, as well as the atypical location of placental attachment on the bottom of the uterine rather than at the atomic uterine incision scar. Pelvic MRI is a feasible modality for assessing depth of placental invasion among patients with this condition while also providing guidance for surgical planning during cesarean section[17].However, MRI is a costly modality that necessitates specialized expertise for the diagnosis of accreta, which remains limited in availability. Furthermore, there is currently no evidence to suggest that MRI enhances diagnostic accuracy or improves outcomes when used in conjunction with ultrasonography alone[18, 19]. Although the patient experienced a catastrophic obstetric event, specifically placenta accreta leading to uterine rupture, fortunately, no adverse outcomes were observed for both the mother and fetus. However, it is imperative to draw lessons from this experience and consider planned delivery for patients diagnosed with placenta accreta as an effective approach to minimize blood loss and reduce complications such as uterine rupture, uncontrollable antepartum hemorrhage, and fetal distress while ensuring optimal fetal safety. The choice of gestational age for clinical delivery remains a topic of debate; however, delivering between 34-36 weeks of pregnancy is recommended in order to enhance maternal and neonatal outcomes [1]. Preoperative blood preparation, autologous blood transfusion techniques, vascular occlusion methods during surgery, and controlled hemostasis can significantly contribute towards reducing ICU admission rates among critically ill patients. Retrospective analysis on twelve cases of placental accreta indicated that the median gestational age at onset of uterine rupture was observed at around week 29 (range 18weeks and 3days-36weeks and 3days), with the maximum gestational age reaching 36weeks and 3 days[20]. In conclusion, uterine rupture is a catastrophic event in obstetrics, and placenta accreta is a serious obstetrical complication that can jeopardize the lives of both the mother and fetus. For patients with high-risk factors, the role of preoperative ultrasound in detecting uterine rupture and placenta accreta is critical, but its limitations must be acknowledged and addressed with alternative diagnostic methods when necessary. In this patient, a multidisciplinary team approach and meticulous surgical planning were crucial to the successful preservation of the uterus and the avoidance of hysterectomy. From an upstream perspective, it is imperative to strengthen education efforts aimed at protecting women's health by promoting contraception methods effectively while reducing unplanned pregnancies and unnecessary abortions or uterine surgeries. To safeguard women's well-being holistically, let us begin with prioritizing uterine protection. Declarations Ethics approval The study was approved by the Ethics Committee of The Affiliated Yantai Yuhuangding Hospital of Qingdao University (Yantai, China). Consent for publication This case report has obtained written informed consent from the patient for publication. The patient has fully understood the purpose, scope, and potential risks and benefits of the publication Availability of data and materials The data and materials used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This work was supported by the Shandong Provincial Natural Science Foundation (ZR2021MH223). Authors’ contributions YL.H., YB.Z., WW.W. and YP.W. are responsible for the for the writing of this manuscript; YN.S., YF.Z., and XM.Y. are responsible for the imagine processing; HM.Q., LP.Q. and L.L. are surgeons of this patient; HM.Q. support the funding for this study. All authors reviewed and approved the manuscript. YL.H, YB.Z., WW.W. and YP. W. contributed equally to the article. HM.Q., LP.Q, and L.L. are co-corresponding authors. References Mc CE, Nichols EO Jr.. Ruptured uterus due to placenta percreta. Am J Surg. 1950;80(4):485–6. Jauniaux E, et al. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;146(1):20–4. Read JA, Cotton DB, Miller FC. Placenta accreta: changing clinical aspects and outcome. Obstet Gynecol. 1980;56(1):31–4. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997;177(1):210–4. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192(5):1458–61. Bailit JL, et al. Morbidly adherent placenta treatments and outcomes. Obstet Gynecol. 2015;125(3):683–9. Matsuzaki S et al. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am J Obstet Gynecol, 2021. 225(5): p. 534 e1-534 e38. Imafuku H, et al. Clinical factors associated with a placenta accreta spectrum. Placenta. 2021;112:180–4. Baldwin HJ, et al. Antecedents of Abnormally Invasive Placenta in Primiparous Women: Risk Associated With Gynecologic Procedures. Obstet Gynecol. 2018;131(2):227–33. Giouleka S, et al. Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv. 2022;77(11):665–82. Bradley LM, Addas JAK, Herath JC. Maternal and fetal death at 22 weeks following uterine rupture at the site of the placenta percreta in a C-section scar. Forensic Sci Med Pathol. 2019;15(4):658–62. Berkley EM, Abuhamad AZ. Prenatal diagnosis of placenta accreta: is sonography all we need? J Ultrasound Med. 2013;32(8):1345–50. Comstock CH, Bronsteen RA. The antenatal diagnosis of placenta accreta. BJOG, 2014. 121(2): p. 171 – 81; discussion 181-2. D'Antonio F, Iacovella C, Bhide A. Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2013;42(5):509–17. Bowman ZS, et al. Interobserver variability of sonography for prediction of placenta accreta. J Ultrasound Med. 2014;33(12):2153–8. Bowman ZS, et al. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol. 2014;211(2):e1771–7. Huang L, et al. Accuracy of MRI-Based Radiomics in Diagnosis of Placenta Accreta Spectrum: A PRISMA Systematic Review and Meta-Analysis. Med Sci Monit. 2024;30:e943461. Riteau AS, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. PLoS ONE. 2014;9(4):e94866. Balcacer P, et al. Magnetic Resonance Imaging and Sonography in the Diagnosis of Placental Invasion. J Ultrasound Med. 2016;35(7):1445–56. Li XF, et al. [Clinical analysis of 12 cases of spontaneous uterine rupture caused by placenta percreta]. Zhonghua fu chan ke za zhi. 2020;55(10):691–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board 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-4240325","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":292370917,"identity":"f7a1bb76-58ea-4f99-84f9-6773b846d0e7","order_by":0,"name":"Yanling He","email":"","orcid":"","institution":"Yuhuangding Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Yanling","middleName":"","lastName":"He","suffix":""},{"id":292370918,"identity":"bb448178-2e76-40fe-a574-d115c4731b67","order_by":1,"name":"Weiwei Wang","email":"","orcid":"","institution":"Yuhuangding Hospital of Qingdao 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involvement.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/4b6010001e61a1018f5d3a42.png"},{"id":55250394,"identity":"79e8e869-1111-4bca-97b4-6e675f3a39ad","added_by":"auto","created_at":"2024-04-24 17:33:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":572036,"visible":true,"origin":"","legend":"\u003cp\u003eIntrauterine exploration revealing a significant uterine fundus defect with placental invasion into the surrounding omentum.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/0e3eb8af7166c1d82ab6b3da.png"},{"id":55250396,"identity":"395f2bfb-b1ef-4c11-a4fa-97303dd3d9d1","added_by":"auto","created_at":"2024-04-24 17:33:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":529254,"visible":true,"origin":"","legend":"\u003cp\u003eDecomposition of adhesion\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/c6c1df45a0b604af0ec855b0.png"},{"id":55250393,"identity":"c8fc13d7-e894-47f7-be68-08b10e3d2729","added_by":"auto","created_at":"2024-04-24 17:33:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":519596,"visible":true,"origin":"","legend":"\u003cp\u003eExcision of the omentum engrafted within the placenta\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/f292a1a9d2e79519cac6ddc5.png"},{"id":55250401,"identity":"1e708d46-df8b-4038-bfe9-6cb5927faf8c","added_by":"auto","created_at":"2024-04-24 17:33:48","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":575587,"visible":true,"origin":"","legend":"\u003cp\u003eResect the omentum and placenta completely to expose the defect on the uterine fundus.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/05209890aa31a81ee3500866.png"},{"id":55251637,"identity":"d90a4f16-f339-40d6-ac0f-34dac757fa46","added_by":"auto","created_at":"2024-04-24 17:41:47","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":473326,"visible":true,"origin":"","legend":"\u003cp\u003ePathological results: placental tissue in the omentum.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/9b12a6c65eacd94da9b8344a.png"},{"id":55251638,"identity":"07bd9597-79c4-4691-b236-7317f7639a54","added_by":"auto","created_at":"2024-04-24 17:41:47","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":436351,"visible":true,"origin":"","legend":"\u003cp\u003ePathological results: syncytiotrophoblast in the omentum.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/29b7bb1c2f0767afbf80d7ae.png"},{"id":55250399,"identity":"53526261-19b3-4347-8c52-69fd11a6465e","added_by":"auto","created_at":"2024-04-24 17:33:47","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":377536,"visible":true,"origin":"","legend":"\u003cp\u003eRepairing the Ruptured Uterus:\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/9cce317b4a04079f4a6391f1.png"},{"id":55250402,"identity":"26ba324f-f04d-4bf9-854f-36f39a659878","added_by":"auto","created_at":"2024-04-24 17:33:48","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":143404,"visible":true,"origin":"","legend":"\u003cp\u003eFigure8: Schematic representation of placental implantation in our case.\u003c/p\u003e","description":"","filename":"81.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/983b13b5777c4e924c753db4.png"},{"id":55250398,"identity":"cafc254c-0456-4c95-bbc0-31a941f76e6b","added_by":"auto","created_at":"2024-04-24 17:33:47","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":254075,"visible":true,"origin":"","legend":"\u003cp\u003eFigure9: The placenta exhibited several vascular cavities ( green arrow) and a break in the uterine serosa- bladder connection.（white arrow）\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/3f89a4dd6f5b5d121bfc0c6b.png"},{"id":55251639,"identity":"ea979591-91ec-434f-90cf-69120e7f2950","added_by":"auto","created_at":"2024-04-24 17:41:47","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":312323,"visible":true,"origin":"","legend":"\u003cp\u003eFigure10:The color Doppler study revealed turbulent blood flow within the placental lacunae（yellow arrow） and enhanced vascularization beneath the placenta（red arrow）.\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/15f0957e006a32e6941d1585.png"},{"id":55250403,"identity":"bf53cfb8-e342-4ff6-a66f-1af1d1c91395","added_by":"auto","created_at":"2024-04-24 17:33:48","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":444242,"visible":true,"origin":"","legend":"\u003cp\u003eFigure11:placenta previa (blue arrow)\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/caf4096f455ebcb844562845.png"},{"id":58101479,"identity":"789cb2f1-d301-4d29-9b55-73983b364ab1","added_by":"auto","created_at":"2024-06-11 06:41:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5185625,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4240325/v1/25cac3ac-10a1-4594-92f6-bbbb2b212e99.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preservation of the Uterus in a Case of Late-Term Pregnancy with Placental Invasion and Omental Implantation","fulltext":[{"header":"Case introduction","content":"\u003cp\u003eA 27-year-old pregnant woman, at 39 weeks and 2 days of gestation, was admitted to our facility on June 3, 2023, for a scheduled cesarean section. This was due to a uterine scar resulting from a previous cesarean delivery at a local hospital in 2014, which was necessitated by fetal distress caused by amniotic fluid contamination.\u0026nbsp;Her medical history includes a medical abortion in 2014. In addition, she underwent successful laparoscopic removal of a right tubal ectopic pregnancy in 2021.\u003c/p\u003e\n\u003cp\u003eUpon admission, obstetric ultrasound estimated the fetal weight to be 3860g with a margin of error of 564g. The placenta was identified on the posterior uterine wall with no sonographic features indicative of placenta accreta or any disruption in the continuity of the uterine muscle wall.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe surgical procedure entailed the extraction of the uterus from the abdominal cavity, which disclosed the fundal surface obscured by the greatest omentum(Figure1). Intraoperative assessment revealed that the placenta was deeply embedded in the omentum(Figure2), making its isolated removal impossible. Consequently, the segment of the omentum, inclusive of the implanted placenta, was excised, uncovering a sizable defect in the uterine fundus, measuring approximately 8cm by 7cm(Figures3-5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing the removal of necrotic tissue from the fundal rupture site, the area was meticulously sutured in a continuous manner, and a Hyman suture was executed to reinforce the uterine fundus. To address the pervasive uterine bleeding, the ascending branches of the uterine arteries were ligated, and a dam suture was applied to the posterior uterine wall, effectively mitigating the hemorrhage. Persistent bleeding in the cervical canal was resolved with a cervical constriction technique. The uterine incision\u0026apos;s myometrial and serosal layers were meticulously sutured, and a B-Lynch suture was utilized to augment uterine contraction and bolster the fundus（Figure8）.\u003c/p\u003e\n\u003cp\u003eThe right fallopian tube was identified as discontinuous, with a sizable 6cm by 5cm mesenteric cyst at the fimbriated end, which was thoroughly excised, followed by a salpingectomy of the right fallopian tube. The patient and their family were informed about the significant risks associated with the full-thickness spontaneous uterine rupture, which contraindicates future pregnancies. Considering the non-functional state of the right fallopian tube, the recommendation for long-term contraception was emphasized. Upon the patient\u0026apos;s request, the left fallopian tube was securely ligated using the core-pulling and embedding technique.\u003c/p\u003e\n\u003cp\u003eThe surgery was deemed successful with an estimated blood loss of 1500ml, and the patient received an autologous blood transfusion of 500ml. Postoperative care focused on promoting uterine contraction, administering prophylactic antibiotics, and providing symptomatic treatment as necessary. Postoperatively, 2 units of RHD positive red blood cells and 400ml plasma were transfused.The patient was discharged on the fourth day after surgery with a well-healed incision.\u003c/p\u003e\n\u003cp\u003eThe surgical intervention was considered a success, with a calculated blood loss of approximately 1500 milliliters. To aid recovery, the patient received a 500ml autologous blood transfusion and, shortly after, two units of Rh-positive red blood cells and 400ml of plasma.Postoperative care focused on promoting uterine contraction, preventing infection with antibiotics, and addressing symptoms as needed, resulting in the patient\u0026apos;s timely discharge on the fourth day due to good incision healing.\u003c/p\u003e\n\u003cp\u003ePathological analysis of the excised omentum and mesosalpingeal cyst showed decidual-like changes in the omentum and degenerated trophoblast cells（Figures 6 and 7）. These findings, along with intraoperative observations, confirmed a diagnosis of placenta percreta with extensive omental implantation.\u003c/p\u003e\n\u003cp\u003eThe patient was diagnosed with placenta percreta and significant omental involvement, as confirmed by both surgical findings and postpartum pathology.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe term \u0026quot;placenta accreta\u0026quot; was coined by McCarthy and Nichols in 1950[1].It refers to the inadequate development of the uterine endometrium, either primary or secondary, resulting in the elimination of the physiological gap between the placenta and uterus during placental villous tissue growth. This leads to tight adherence of one or more maternal leaflets of the placenta to the basal layer of the endometrium, partial invasion into the uterine muscle layer, and even penetration through both the uterine muscle layer and serosal layer. Depending on how deeply placental villi invade into the uterine muscle layer, it can be classified as follows: 1. Adhesive placenta accreta: adhesion of placental villi to the surface of uterine muscles; 2. Placenta accreta: deep penetration of placental villi into spaces within uterine muscles; 3. Placenta percreta: passage and extension beyond both layers of uterine muscles by placental villi, including invasion into adjacent organs[2].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe utilized the keyword \u0026quot;placenta percreta\u0026quot; to conduct a comprehensive search for case analyses conducted in the past few decades, both domestically and internationally. The prevalence of placenta accreta spectrum (PAS) has been documented in the literature, ranging from 0.25\u0026permil; in the 1970s [3]to 1.36\u0026permil;~1.87\u0026permil; in contemporary studies[4-6]. Among these cases, adhesive placenta accreta, placenta accreta, and placenta percreta had respective prevalences of 0.23%, 0.03%, and 0.04%[7]. PAS can be further categorized into PAS with placenta previa and PAS without placenta previa[2]. Cases of PAS with placenta previa tend to garner more clinical attention and have higher detection rates compared to those without it. In this particular instance of PAS without placenta previa, a missed diagnosis occurred due to an ultrasound oversight on a uterine-bottom located placenta percreta.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We observed several distinctive characteristics in our study\u0026apos;s patient with placenta accreta compared to previous medical records: (1) It is uncommon for placenta percreta to persist until 39 weeks of gestation; (2) The diagnosis of placenta accreta was made during an elective cesarean section at 39 weeks of gestation. The patient did not experience any conscious discomfort prior to the procedure, and its identification was challenging preoperatively. (3) Among the previously documented cases of placenta percreta, our patient exhibited the largest area of placental implantation and uterine defect. It is exceptionally rare for successful preservation of the uterus without adequate preoperative preparation.（Figure8）\u003c/p\u003e\n\u003cp\u003eThe results of multivariate analysis revealed that patients with high-risk factors for placenta percreta, such as a history of uterine scar (caesarean section, uterine myomectomy, uterine perforation), infection following previous surgery, impaired wound healing, uterine malformation, multiple intrauterine operations (multiple abortions, history of hysteroscopic resection), and advanced maternal age were identified[8, 9]. Placenta percreta can occur in various locations within the uterus, including the uterine body and cornua, with a higher prevalence observed in the lower anterior wall of the uterus. The lower segment of the uterus or previous cesarean section scars lacks muscular tissue and exhibits poor blood supply and reduced elasticity; as pregnancy progresses, there is gradual stretching and thinning of the scar area on the lower anterior wall, thereby increasing the risk of uterine rupture. As gestational age progresses, the expansion of the uterine cavity occurs particularly during the initiation of contractions when tension in the myometrium gradually increases. This may lead to spontaneous rupture at any given time due to the\u0026nbsp;\u0026ldquo;rags effect\u0026rdquo;.Meanwhile, ensuring adequate nutrient supply, placental tissue implants deeper and may even penetrate through the uterine serosa, resulting in damage to surrounding tissues and organs such as the bladder, intestines, and the greatest omentum. Sustaining pregnancy until third trimester becomes challenging as complete or incomplete uterine rupture along with severe postpartum hemorrhage and visceral injury can occur unpredictably. Consequently, placenta percreta contributes to a maternal mortality rate reaching up to 10%[10].\u003c/p\u003e\n\u003cp\u003eIn our case, she underwent a cesarean section followed by medical abortion in 2014 with a short interval between pregnancies. Poor functional regeneration of her endometrium resulted in incomplete repair at sites where placental attachment occurred. Miscarriage further damaged her endometrium, particularly affecting its basal layer. In 2022, she became pregnant again with an embryo implanting at a compromised site within her damaged endometrium gradually developing into a case of placenta percreta. This patient presented with a rare occurrence of gestational sac in a weak area at the bottom of the uterus, accompanied by uterine rupture at the site of placenta percreta. This could be attributed to multiparity and thinning of the local uterine muscle layer.\u003c/p\u003e\n\u003cp\u003eRegarding the sequence of uterine rupture and placenta percreta development in this case, I hypothesize that the gestational sac implants in the vulnerable region of the uterine basal layer and gradually forms placental tissue. The invasion depth and breadth increase as the spiral arteries of the uterus seek adequate nutrition, further compromising the weakened area at the uterine base. Subsequently, gradual implantation of the placenta into the greatest omentum occurs. As gestational weeks progress, increased pressure within the uterine cavity leads to heightened tension and ultimately ruptures at this weakened area. Prior placental implantation and subsequent self-repair by the greatest omentum contribute to reshaping of uterine muscle wall, maintaining relative integrity of uterus and sustaining pregnancy. However, during this process, changes occur in local microenvironment due to placental implantation leading to infiltration of inflammatory cells which results in increased tension on surface of uterus making it fragile. At this point, even slight coughing, sneezing or emotional excitement can cause spontaneous uterine rupture due to altered abdominal pressure caused by these actions. Similar to a case reported by Lucy M. Bradley where acute abdomen occurred at 22 weeks gestation with massive active internal bleeding causing hemorrhagic shock resulting in maternal-fetal death; autopsy findings indicated that previous cesarean scar was associated with placental implantation leading to uterine rupture[11]. Uterine rupture caused by placental implantation is characterized by sudden onset with concealed etiology but rapid progression and high mortality rate. This patient was undoubtedly fortunate as she did not experience internal bleeding or adverse pregnancy outcomes such as abdominal pregnancy or fetal demise inside uterus.\u003c/p\u003e\n\u003cp\u003ePlacenta accreta presents with a range of clinical manifestations, and the severity of the disease is correlated with the extent of implantation and presence of uterine rupture. It necessitates differentiation from acute abdomen. The primary symptoms encompass varying degrees of abdominal pain, chest tightness accompanied by lower backache, abdominal distension, rectal fullness, changes in fetal heart rate, pelvic and abdominal fluid accumulation, anemia, hemorrhagic shock, and infection [5]. Placenta accreta frequently coexists with placenta previa and can result in recurrent vaginal bleeding during pregnancy. Placenta accreta spectrum (PAS) poses significant risks for both maternal and fetal health. The heterogeneity in clinical presentations may lead to misdiagnosis or underdiagnosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis case\u0026apos;s recollection does not include any mention of experiencing mild abdominal pain during pregnancy or transient changes in fetal heart rate or other subtle discomfort symptoms.These factors significantly contributed to the preoperative oversight of placenta percreta.\u003c/p\u003e\n\u003cp\u003eUltrasound examination plays a crucial role in obstetrics, serving as the \u0026quot;eyes\u0026quot; of this field and facilitating the identification of uterine rupture. Adequate bladder filling is essential, along with careful attention to placental position, parenchymal echo, retroplacental space, and smoothness of the posterior bladder wall. In cases where there is incomplete myometrium, uterine rupture should be considered. Sonographers should be reminded to thoroughly examine the placental attachment site for patients with high risk factors for uterine rupture. Color Doppler flowmetry can provide valuable insights into blood vessels and flow within the placenta as well as blood flow distribution between the placenta and myometrium, aiding in early diagnosis of placenta accreta. The following characteristics are observed in color Doppler flow imaging of placenta increta: ① The placenta exhibited several vascular cavities and a break in the uterine serosa- bladder connection; ②The color Doppler study revealed turbulent blood flow within the placental lacunae and enhanced vascularization beneath the placenta ; ③placenta previa \u0026nbsp;[12, 13]. (Figure9，10and11)Ultrasonography in the second and third trimesters has been reported to exhibit sensitivities and specificities ranging from 80% to 90% for the identification of placenta accreta spectrum[12, 13]. A meta-analysis encompassing 23 studies involving 3707 pregnancies revealed that ultrasound exhibited approximately 90.72% sensitivity in diagnosing PAS while maintaining an impressive specificity rate of up to 96.94%[14]. These may be overestimates, however, because data are derived from experts who possess a comprehensive understanding of the significant risks associated with placenta accreta. Considerable interobserver variability exists in the identification of the condition[15], and accuracy significantly decreases when clinicians are unaware of pertinent clinical information[16].Preoperative ultrasound failed to detect uterine rupture in this patient due to the absence of typical clinical manifestations, as well as the atypical location of placental attachment on the bottom of the uterine rather than at the atomic uterine incision scar.\u003c/p\u003e\n\u003cp\u003ePelvic MRI is a feasible modality for assessing depth of placental invasion among patients with this condition while also providing guidance for surgical planning during cesarean section[17].However, MRI is a costly modality that necessitates specialized expertise for the diagnosis of accreta, which remains limited in availability. Furthermore, there is currently no evidence to suggest that MRI enhances diagnostic accuracy or improves outcomes when used in conjunction with ultrasonography alone[18, 19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the patient experienced a catastrophic obstetric event, specifically placenta accreta leading to uterine rupture, fortunately, no adverse outcomes were observed for both the mother and fetus. However, it is imperative to draw lessons from this experience and consider planned delivery for patients diagnosed with placenta accreta as an effective approach to minimize blood loss and reduce complications such as uterine rupture, uncontrollable antepartum hemorrhage, and fetal distress while ensuring optimal fetal safety. The choice of gestational age for clinical delivery remains a topic of debate; however, delivering between 34-36 weeks of pregnancy is recommended in order to enhance maternal and neonatal outcomes [1]. Preoperative blood preparation, autologous blood transfusion techniques, vascular occlusion methods during surgery, and controlled hemostasis can significantly contribute towards reducing ICU admission rates among critically ill patients. Retrospective analysis on twelve cases of placental accreta indicated that the median gestational age at onset of uterine rupture was observed at around week 29 (range\u0026nbsp;18weeks and 3days-36weeks and\u0026nbsp;3days), with the maximum gestational age reaching\u0026nbsp;36weeks and 3 days[20].\u003c/p\u003e\n\u003cp\u003eIn conclusion, uterine rupture is a catastrophic event in obstetrics, and placenta accreta is a serious obstetrical complication that can jeopardize the lives of both the mother and fetus. For patients with high-risk factors, the role of preoperative ultrasound in detecting uterine rupture and placenta accreta is critical, but its limitations must be acknowledged and addressed with alternative diagnostic methods when necessary. \u0026nbsp;In this patient, a multidisciplinary team approach and meticulous surgical planning were crucial to the successful preservation of the uterus and the avoidance of hysterectomy. \u0026nbsp;From an upstream perspective, it is imperative to strengthen education efforts aimed at protecting women\u0026apos;s health by promoting contraception methods effectively while reducing unplanned pregnancies and unnecessary abortions or uterine surgeries. To safeguard women\u0026apos;s well-being holistically, let us begin with prioritizing uterine protection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of The Affiliated Yantai Yuhuangding Hospital of Qingdao University (Yantai, China).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report has obtained written informed consent from the patient for publication. The patient has fully understood the purpose, scope, and potential risks and benefits of the publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data and materials used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Shandong Provincial Natural Science Foundation (ZR2021MH223).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYL.H., YB.Z., WW.W. and YP.W. are responsible for the for the writing of this manuscript; \u0026nbsp; YN.S., YF.Z., and XM.Y. are responsible for the imagine processing; HM.Q., LP.Q. and L.L. are surgeons of this patient; HM.Q. support the funding for this study. All authors reviewed and approved the manuscript. YL.H, YB.Z., WW.W. and YP. W. contributed equally to the article. HM.Q., LP.Q, and L.L. are co-corresponding authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMc CE, Nichols EO Jr.. Ruptured uterus due to placenta percreta. Am J Surg. 1950;80(4):485\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, et al. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;146(1):20\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRead JA, Cotton DB, Miller FC. Placenta accreta: changing clinical aspects and outcome. Obstet Gynecol. 1980;56(1):31\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997;177(1):210\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192(5):1458\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBailit JL, et al. Morbidly adherent placenta treatments and outcomes. Obstet Gynecol. 2015;125(3):683\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsuzaki S et al. \u003cem\u003eTrends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States.\u003c/em\u003e Am J Obstet Gynecol, 2021. 225(5): p. 534 e1-534 e38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImafuku H, et al. Clinical factors associated with a placenta accreta spectrum. Placenta. 2021;112:180\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaldwin HJ, et al. Antecedents of Abnormally Invasive Placenta in Primiparous Women: Risk Associated With Gynecologic Procedures. Obstet Gynecol. 2018;131(2):227\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiouleka S, et al. Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv. 2022;77(11):665\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradley LM, Addas JAK, Herath JC. Maternal and fetal death at 22 weeks following uterine rupture at the site of the placenta percreta in a C-section scar. Forensic Sci Med Pathol. 2019;15(4):658\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerkley EM, Abuhamad AZ. Prenatal diagnosis of placenta accreta: is sonography all we need? J Ultrasound Med. 2013;32(8):1345\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eComstock CH, Bronsteen RA. The antenatal diagnosis of placenta accreta. BJOG, 2014. 121(2): p. 171\u0026thinsp;\u0026ndash;\u0026thinsp;81; discussion 181-2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Antonio F, Iacovella C, Bhide A. Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2013;42(5):509\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowman ZS, et al. Interobserver variability of sonography for prediction of placenta accreta. J Ultrasound Med. 2014;33(12):2153\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowman ZS, et al. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol. 2014;211(2):e1771\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang L, et al. Accuracy of MRI-Based Radiomics in Diagnosis of Placenta Accreta Spectrum: A PRISMA Systematic Review and Meta-Analysis. Med Sci Monit. 2024;30:e943461.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiteau AS, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. PLoS ONE. 2014;9(4):e94866.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalcacer P, et al. Magnetic Resonance Imaging and Sonography in the Diagnosis of Placental Invasion. J Ultrasound Med. 2016;35(7):1445\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi XF, et al. [Clinical analysis of 12 cases of spontaneous uterine rupture caused by placenta percreta]. Zhonghua fu chan ke za zhi. 2020;55(10):691\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Placenta invasion, omental implantation, uterine preservation","lastPublishedDoi":"10.21203/rs.3.rs-4240325/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4240325/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report a unique case of a 27-year-old woman with a history of cesarean section, who presented with placental invasion and omental implantation at 39 weeks\u0026thinsp;+\u0026thinsp;2 days of gestation. Preoperative ultrasound did not reveal signs of placenta accreta. Despite the challenges, we successfully preserved her uterus using a combination of surgical techniques, including manual placental removal, uterine artery ligation, and repair of the uterine fundus. This case highlights the importance of a multidisciplinary approach and preoperative preparation in managing such complex obstetric complications.\u003c/p\u003e","manuscriptTitle":"Preservation of the Uterus in a Case of Late-Term Pregnancy with Placental Invasion and Omental Implantation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-24 17:33:42","doi":"10.21203/rs.3.rs-4240325/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7ff78a22-0c2b-4e70-8dbe-07c553d34562","owner":[],"postedDate":"April 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-11T06:33:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-24 17:33:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4240325","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4240325","identity":"rs-4240325","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}