1. Patient is a 28y.o G3P2002 @262/7 weeks by 24wk U/S with a h/o 2 prior c-sections who p/w vaginal bleeding and in stable condition. Abdominal U/S performed at OSH indicating some degree of placenta previa and possible placental invasion into the uterine wall. Age 28 Repeat US here showed abnormal focal increased vascularity of the myometrium posterior to the bladder and increased placental lakes and loss of the hypoechoic subplacental zone (Nitabuch’s layer). (All possible sonographic signs of placental accreta. Obtained pelvic MRI to confirm extent of invasion. Differential Dx.- placenta previa, abruptio placentae, vaginal or cervical trauma

2. Quick review Placenta accreta- abnormal placental implantation when the anchoring placental villi attach to the myometrium instead of being contained by decidual cells. Placental percreta- chorionic villi penetrate to or through the uterine serosa and may invade surrounding organs. Placenta increta- chorionic villi invade into the myometrium. Accreta Incidence- increased from before, 1/533 deliveries - higher risk if have prior c-sections -accreta occurs in 15-20% of women with previa and one prior section Outcome risks- postpartum hemorrhage and subsequent hysterectomy

3. Dx. w/u 1. U/S has 85% sensitivity and specificity for detecting placenta accreta. 2. Color Doppler shows placental lacunar flow, hypervascularity of the bladder uterine serosa, prominent subplacental venous complex, and loss of subplacental Doppler vascular signals. 3. MRI- when the diagnosis is uncertain, the placenta is posterior or to better see depth of invasion. -can lead to modifications in clinical management such as prophylactic ureteral catheterization. Management Scheduled delivery at 36wks after confirm fetal lung development. Followed by cesarean hysterectomy with the placenta left in situ Balloon catheterization of internal iliac arteries into the uterine arteries preoperatively or intraoperatively if possible.

4. MRI signs- 1. thinning of myometrium at site of implantation 2. irregularity along the uterine wall at placental site

7. Hospital Course Patient was placed on moderate bedrest, given 2 doses of BMTZ, and placed on continual fetal monitoring. Patient has remained stable on the antepartum floor while under close observation. She continues to have light vaginal spotting but with reassuring FHT. Now moved to postpartum floor with TID monitoring. Plan to do C/S if starts to labor or bleed more heavily. Primary team has decided to only wait until 34wks. to deliver d/t possible percreta. Patient is currently 29 5/7 weeks. Getting another pelvic MRI on Monday. Have not considered balloon catheterization.

8. References Maldijan, C. et al. MRI appearance of placenta percreta and placenta accreta. Magn Reson Imaging. 1999 Sep;17(7):965-71. Radiology Recall; Spencer B. Gay and Richard J. Woodcock, Jr. Squire’s Fundamentals of Radiology, fifth edition; Robert Novelline. UptoDate, Placenta Acreata. March 21, 2006. By Tovia Martirosian MS4