Placenta Accreta Causing Uterine Rupture in Second Trimester of Pregnancy after in vitro Fertilization: A Case Report
A 40-year old infertile woman was referred to our center for IVF program (oocyte donation and embryo transfer). She had two previous histories of dilatation and curettage, one after spontaneous abortion and another for diagnostic purposes.\nHysteroscopy was done prior to IVF cycle which revealed a band of adhesion running from anterior to posterior wall for which adhesiolysis was done in the same session. The patient conceived in the second cycle of embryo transfer (oocyte donation). Pregnancy was confirmed by beta-human chorionic gonandotrophin (β–hCG) levels and later on, by ultrasound which confirmed single intrauterine gestational sac with a beating heart. She was followed up regularly for her obstetric examination with no other risk factors except for advanced maternal age.\nLevel two obstetric ultrasound examination was done at eighteen weeks of gestation which ruled out gross congenital anomalies and suggested grade 0 left fundo-anterior placenta with normal invasion and normal amniotic fluid. In the nineteenth weeks of gestation, patient presented in the emergency department of our hospital with acute abdominal pain and signs of early shock (pulse rate 180/min, blood pressure 90/60 mmHg, hemoglobin 7.5 g% and hematocrit of 24%).\nInitially, the patient was revived from shock with adequate fluid replacement and other basic management procedures including central line placement for cental venous pressure (CVP) monitoring. Once the patient's condition was stable, she was sent for ultrasound and CT scan evaluations. Ultrasound examination revealed fresh intrauterine fetal death along with hemoperitoneum with no other gross finding.\nCT scan was done to rule out other causes of heamoperitoneum. Findings were suggestive of weakening of the uterine musculature at the left fundal region with fetus inside the cavity. Patient was taken up for emergency laprotomy and a heamoperitoneum of 3000 ml was found along with a dead fetus coming out of a large uterine fundal defect. Female fetus of approximately 700 g was extracted but the placental tissue could not be separated from the myometrium. Subtotal hysterectomy was performed in view of massive haemorrhage, while all other intraperitoneal organs were found to be intact. The patient was transfused one unit of packed cell intraoperatively and two units thereafter. She was intensively monitored postoperatively and was discharged on the sixth post-operative day in a perfectly stable condition.\nUterus () sent for biopsy and pathology report showed chorionic villi reaching the myometrium with absent decidua basilis which were consistent with the diagnosis of placenta accreta ().