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“Placenta percreta (PP) is a condition in which the placenta abnormally penetrates entirely through the myometrium and into the uterine serosa. This might be complicated by attachment CP-868596 nmr of the placenta to surrounding structures or organs, such as the urinary bladder or rectum. PP is a potentially fatal condition,

and mortality rate is correlated to the extent of involvement of surrounding structures. When PP is complicated by bladder invasion, mortality rates have been estimated as high as 9.5% and 24% for mother and child, respectively.1 Knowledge of this condition and expectant management are especially important, as the incidence is on the rise—an estimated 50-fold increase in the last 50 years—attributed to the increased frequency of Caesarean deliveries.2 A 38-year-old woman (G6P3023) at 24 weeks gestation presented with vaginal bleeding. She reported that 1 week before she awoke in a “puddle of fluid.” She denied gross hematuria. She had a history of 3 Caesarean sections.

Fetal ultrasound showed complete placenta previa with placental vessels invading the bladder confirming PP (Fig 1). She was admitted for expectant management. Maternal fetal medicine, anesthesia, neonatal intensive care, and urology were all consulted. Magnesium sulfate, antibiotics, and steroids were administered prophylactically. On hospital day #2, the patient had an increased oxygen requirement and tachycardia. A computed tomographic scan www.selleckchem.com/products/KU-55933.html of the chest revealed extensive bilateral pulmonary emboli. She underwent inferior vena cava filter placement, was transferred to the surgical intensive care unit, and continuous heparin infusion was initiated. On hospital day #6, the patient went into labor and was taken to the operating room for a multidisciplinary procedure. She underwent exploratory laparotomy and repeat Caesarean section through a fundal uterine incision by the obstetrics team. A viable female neonate was delivered with Apgar scores of 9 and 9. A total abdominal hysterectomy and lysis

of adhesions were then performed by the gynecologic oncology service. The anterior uterine wall was then recognized to be affixed to the bladder. Dissection of the anterior uterine wall from the posterior bladder was accompanied by large posterior cystotomy. On routine inspection, decreased efflux was noted from the mafosfamide right ureteral orifice, and the right ureter was markedly dilated. At this point, intraoperative urology consultation was requested. The right ureter was secured, and a suture was identified that appeared to be constricting it. This was released with immediate return of urine from the ureteral orifice. A double-J ureteral stent was placed, and cystorrhaphy was performed. No leak was identified on bladder irrigation, and an omental flap was placed between the bladder and the vaginal cuff. A Jackson-Pratt drain and a Foley catheter were placed.