Placenta Accreta Spectrum with Ureteral Invasion

A 41-year-old woman presented with a spontaneous pregnancy. She had a history of three cesarean sections and two miscarriages.

Previously, a gestational sac was observed in the lower uterus, however, it not diagnosed as Cesarean Scar Pregnancy (CSP). She was later suspected with placenta previa and was referred to a hospital at 25 weeks gestation. 

At 26 weeks, cystoscopy revealed vascular protrusions in the bladder's mucosa. Ultrasonography at 30 weeks confirmed a bulging placenta within the scar, cervical canal deviation, and enlarged vessels towards the bladder. The patient was diagnosed with Placenta Accreta Spectrum (PAS) invading the bladder due to continued CSP, supported by MRI.

Considering the risk of uterine rupture and vascular protrusion, an elective cesarean hysterectomy was performed at 31 weeks and 6 days after interdisciplinary consultations. The newborn was delivered through a transverse uterine incision, and subsequent procedures included ureteral stent placement and uterine and bladder artery embolization. Cystectomy was considered unnecessary due to prior embolization. 

Intraoperative blood loss was substantial, requiring transfusions. Postoperatively, the ureteral stent was removed after resolving stenosis. 

This report underscores the need to anticipate placental invasion into the ureter in continued CSP, emphasizing the importance of preoperative hydroureter identification for confirming ureteral involvement. Collaborative efforts across multiple medical specialties are essential to manage intraoperative complications and prevent significant hemorrhage and organ damage.

Source: Yara N, Kinjyo Y, Chinen Y, Kinjo T, Mekaru K. Case Reports in Obstetrics and Gynecology. 2023 Oct 7;2023.