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Placenta percretaFrom: Steve & Eryl Raymond (eryl@intekom.co.za)Sun Jun 13 23:49:31 2004
In 30 years of Obstetrics I have never encountered a true case of percreta until this weekend. The patient aged 30 with two previous Lower Segment Caesars presented on Friday at 24 weeks with bleeding, at a district hospital near here. The fetal heart was still present and the uterus tender, with ultrasound evidence of a "haematoma" in the anterior low-lying placenta, and estimated fetal weight about 700 grams. Initial advice to the resident was to rupture the membranes and deliver - that this was essentially a mid-trimester miscarriage. About five hours later they rang again to say that she had not dilated beyond 3cm and this time it was a new doctor who had seen the patient and informed me that the previous doctor had missed the fact that she had had two caesars, and had given Cytotec. The bleeding was minimal but I asked him to transfer to our hospital as the progress was unsatisfactory. Overnight she made a few more centimetres dilatation progress and the fetal heart disappeared. On opening the abdomen the placenta was found to have gone right through the lower segment into the bladder and down into the anterior vaginal wall. It was impossible to see the anatomy properly as the bleeding from this area was just horrendous. I had to excise a strip of bladder wall along with the uterus, and then try to get sutures around the top of the vagina which would be haemostatic. The control of bleeding from this area was particularly tenuous. In the end we packed and came out. She has had six units of cross-matched blood and three of ONEG, and has produced about 50 ml urine all day today! I was very glad I had put on a long apron and gumboots! But I fear that the prolonged hypotension and hypovolaemia indicate a very poor prognosis. Just to remind me that Obstetrics can be fun I rushed to a ruptured uterus this afternoon, and spent another happy hour and a half performing another hysterectomy and packing of pelvis, because the rupture went through the Left uterine artery pedicle and I couldn't locate the torn ends. Even a ligation of internal Iliac didn't seem to slow down the bleeding much. Steve Raymond
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