Ureter injury in obstetric hysterectomy with placenta accreta spectrum: Case report

Placenta accreta spectrum (PAS) is a state of abnormal attachment of the placenta, including placenta accreta, placenta increta, and placenta percreta. This condition can be life-threatening due to the placenta cannot spontaneously separated, resulting in continuous bleeding. Cesarean section followed by hysterectomy is one of the treatment options for PAS. There was a great liability for urinary tract injuries during the operation of PAS patient.

We present the case of ureter injury during subtotal hysterectomy in patient with PAS. A 30-years-old female patient was diagnosed with recurrent antepartum hemorrhage due to placenta previa accreta spectrum on G2P1 33 weeks of gestational age, singleton live breech presentation, previous c-section 1×. After uterine transverse incision, the baby was delivered. We decided to perform subtotal hysterectomy. There was severe adhesion. On the exploration after subtotal hysterectomy was performed, we found ruptured of the right ureter.

Hysterectomy peripartum is one of the treatment of PAS, either to prevent or to control postpartum hemorrhage. In pregnant women with morbid placental adherence, there was a great liability for urinary tract injuries. Distal ureters are the most commonly injured while hysterectomy. Injuries to the ureters in this patient occurred due to severe adhesions and unclear visual organ.

Although it is rare, ureter injury may occur during subtotal hysterectomy in patient with placenta accreta spectrum. To prevent that condition, inserting ureter stent can be perform before the operation. Multidisciplinary approach is carried out so that patient outcomes are good.