Unexpected placenta accreta spectrum in an unscarred uterus causing catastrophic post-partum hemorrhage: a case report and review of the literature

Background: Placenta accreta spectrum (PAS) disorder is a fatal condition responsible for obstetric haemorrhage, which contributes to increased feto-maternal morbidity and mortality. The main contributing factor is a scarred uterus, often from a previous cesarean delivery, myomectomy, or uterine instrumentation. The occurrence of PAS in an unscarred uterus is extremely rare, with only anecdotal cases reported so far in the literature. We document one such case of unexpected placenta increta without identifiable risk factors presenting with severe postpartum hemorrhage. The management is often challenging, especially in low-middle-income countries like India with limited access to healthcare, where most cases are identified only at the time of delivery.

Case presentation: We narrate a case of a 25-year-old woman of North Indian ethnicity, para 2 live 2, who presented to our emergency in shock with retained placenta and severe postpartum haemorrhage. She had undergone a normal vaginal delivery at 37 weeks and 2 days of pregnancy at a local hospital around 2 h before. The patient had not undergone antenatal checkups or sonography during her pregnancy. Manual removal of the placenta was attempted under anaesthesia, which was unsuccessful. So, keeping the diagnosis of the morbidly adherent placenta in mind and the deteriorating condition of the patient, an emergency laparotomy followed by a supracervical hysterectomy was performed after the conservative methods failed to control the haemorrhage. Simultaneously, she was given four units of packed red cells and fresh frozen plasma in a ratio of 1:1, along with vasopressors and fluid replacement therapy to attain hemodynamic stability. Post-operatively, the patient was shifted to the intensive care unit (ICU) for close monitoring. She was discharged after five days in satisfactory condition. A histopathological examination later on revealed placenta increta.

Conclusion: Although very rare, PAS in an unscarred uterus with no other known risk factors is associated with a significant rate of maternal morbidity and mortality. This case highlights the importance of screening for radiological signs of adherent placenta during prenatal visits, even in low-risk populations. Any patient suspected of PAS should be referred to a well-equipped centre for optimal care. Also, young obstetricians should be imparted skill-based training to manage such emergencies with a multidisciplinary team approach.