Case Report of Spontaneous Uterine Rupture Due to Placenta Percreta at 18 Weeks: An Emergency Medicine Perspective.

BACKGROUND: Placenta accreta spectrum (PAS), or abnormal trophoblastic invasion of the placental villi into uterine myometrium at varying depths, is often diagnosed around the time of delivery. The incidence of PAS is rising, likely due to increasing cesarean section frequency, placing patients at increased risk of PAS-related uterine rupture in subsequent pregnancies. Current obstetric guidelines support ultrasound investigation around 20 weeks, however, prior case reports have noted an incidence of uterine rupture as early as the ninth week of pregnancy.

CASE REPORT: A 34-year-old 18-week pregnant patient presented with acute abdominal pain, unstable vital signs, and a diffusely peritonitic abdominal examination. Significant abdominal free fluid was noted on bedside ultrasound, as well as a single live intrauterine pregnancy. The patient was transfused four units of blood while arranging transport to the operating room with the Trauma Surgery and Obstetric teams. She was found to have hemoperitoneum from a uterine rupture secondary to placenta percreta, and underwent hysterectomy. She required initiation of massive transfusion protocol for ongoing hemodynamic instability during surgery, but ultimately recovered and was discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Uterine rupture secondary to PAS is a rare, life-threatening diagnosis that requires emergent intervention. Given the increasing frequency of PAS, the emergency physician should consider uterine rupture in any pregnant patient with symptoms such as abdominal pain, vaginal bleeding, or hematuria. By making a timely diagnosis, some patients may avoid hysterectomy, or even experience fetal survival in some cases.