Placenta percreta is a rare and potentially life-threatening complication of pregnancy. Its incidence has been increasing and is reported to be one in 533 deliveries. Risk factors include history of previous cesarean/scarred uterus, placenta previa, history of manual extraction of placenta, multiple pregnancies, dilatation and curettage, endometriosis, high parity, and advanced maternal age. Intestinal obstruction in pregnancy is rare and occurs in one in 3,000 deliveries. Symptoms are often nonspecific, and fetal and maternal mortality rates are higher during pregnancy as diagnosis can be delayed due to symptoms mimicking typical pregnancy-associated complaints. Significant morbidity or mortality is associated with both complications. Concern for fetal outcomes while managing these two complications raises therapeutic, ethical, moral, and social dilemmas.
A 32-year-old multigravida with a history of extensive adhesions of the small bowel into the anterior abdominal wall and significant hemoperitoneum was admitted at 28-week gestation for sudden sharp abdominal pain, nausea, and elevated blood pressure. The fetal heart rate was 147 and a Category I strip. Routine and pregnancy-induced hypertentions labs were within normal limits. Sonogram and MRI showed a small bowel obstruction and placenta percreta. The patient was scheduled for cesarean and hysterectomy at 32 weeks. A multidisciplinary team including the patient's obstetrician, gynecologic oncologist, maternal fetal medicine specialist, neonatologist, anesthesiologist, interventional radiologist, representative from blood bank, clinical nurse specialist, and managers from labor and delivery and the operating room met and planned for the delivery. At 31-week gestation, the patient's pain worsened and her hemoglobin and hematocrit dropped. The patient delivered a viable infant girl via repeat cesarean the patient went to the intensive care unit (ICU) for recovery and the infant was admitted to the neonatal ICU. The postpartum course was significant for fluctuating blood pressure that was treated intermittently with medications. The patient was discharged home on postoperative day 7.
The presence of two rare complications necessitated extensive planning for the anticipated delivery and well-being of the mother and infant. Significant lessons learned from this case included education and support for nursing staff on a variety of diagnoses uncommon to daily obstetric practice and a multidisciplinary team approach to care. Daily high-risk multidisciplinary planning rounds and strong collegial relationships that focused on the patient and infant's welfare facilitate evidence-based care of critically ill mothers and infants.