From Focal to Near Fatal: Recurrent Placenta Accreta Spectrum Resulting in Early Second Trimester Uterine Rupture

Background: Placenta accreta spectrum (PAS) is a life-threatening

obstetric condition defined by abnormal placental adherence to or invasion into the myometrium. Though exceedingly rare, uterine rupture in the setting of PAS has been reported in both the first and second trimesters. We present a case of placenta percreta complicated by uterine rupture at 14 weeks and 4 days gestation in a patient with multiple prior uterine surgeries and a history of conservatively managed PAS.

Case: A 34-year-old G5P3013 presented at 13 weeks and 6 days with right lower quadrant pain and nausea. Her obstetric history included two low transverse cesarean sections and a classical cesarean section complicated by placenta previa with focal accreta managed conservatively. Initial workup revealed tachycardia, leukocytosis, elevated lactate, and MRI evidence of myometrial thinning. She was discharged after symptomatic improvement, then returned one week later in hemorrhagic shock. Emergent laparotomy revealed fundal uterine rupture at the prior scar site with 4 liters of hemoperitoneum. Supracervical hysterectomy and bilateral salpingectomy was performed by Complex Benign Gynecology, Gynecological Oncology, General Surgery, and OB hospitalist teams. Pathology confirmed placenta percreta with omental extension.

Conclusion: Uterine rupture secondary to PAS can present in the first trimester with a prodrome mimicking other diagnoses. In our patient, abdominal pain, lactic acidosis, and omental thickening preceded hemodynamic collapse by one week. Providers should maintain a high index of suspicion for this complication in patients with prior uterine scars presenting with abdominal pain in pregnancy, regardless of gestational age. Collaboration amongst hospital providers, from the emergency room to the operating room, is invaluable in the care of patients presenting with this complex pathology.