The incidence of PAS has significantly increased with rising rates of uterine surgeries; however, cases of placenta percreta complicated by uterointestinal injury remain rare [10, 11]. This case is important due to its unique presentation: the patient sought medical attention 34 days postpartum with fever and vaginal bleeding. Imaging revealed a myometrial mass and surgical exploration confirmed placental penetration through the uterine corpus with associated small bowel injury. Such delayed diagnoses often occur because placental tissue overlying uterine defects obscures signs of intra-abdominal hemorrhage [12], and the insidious clinical manifestations pose significant challenges for early detection.
In this case, neither prenatal nor early postpartum ultrasonography definitively indicated placenta percreta. Although a 1-week postpartum ultrasound revealed no abnormalities, the emergence of fetid vaginal bleeding and elevated hCG levels at 28 days postpartum suggested retained viable placental tissue. Subsequent MRI showed abnormal thickening of the anterior uterine wall and fundus but lacked classic signs of placenta percreta (e.g., disruption of the serosal layer). These observations align with the reported literature: Horgan et al. emphasized the limited sensitivity of ultrasound in detecting small uterine defects obscured by placental tissue [13], while placental obstruction of the defect may restrict intra-abdominal hemorrhage, resulting in atypical imaging manifestations [12]. Similar to a case described by O’Connor et al., the asymptomatic progression in this patient underscores the necessity for increased clinical vigilance in high-risk populations [14].
The patient’s history of surgical myomectomy for multiple uterine smooth muscle tumors is a critical factor underpinning the development and severity of this complication. Uterine surgery, including myomectomy, creates scar tissue that disrupts the normal endometrial-myometrial interface. This scar tissue provides a potential nidus for abnormal placental adherence, significantly elevating the risk for PAS disorders [3, 6]. In this case, the extensive dense adhesions encountered intraoperatively between the uterus, omentum, bowel, and bladder were likely a direct consequence of the prior myomectomy. These adhesions not only complicated the surgical exploration and increased the technical difficulty of the procedure but also potentially masked early signs of placental penetration and facilitated the adherence and subsequent erosion of the placental tissue into the adjacent small bowel. The location and depth of the myomectomy scars likely dictated the site of placental penetration, ultimately leading to the rare but serious bowel injury observed.
Furthermore, the attempted manual placental removal in the context of suspected PAS warrants careful analysis. While retained placenta necessitates clinical intervention, mechanical disruption in PAS-affected uteri may potentially exacerbate myometrial defects [12]. This could facilitate deeper placental penetration into adjacent structures, as suggested by the bowel injury in this case. Current guidelines recommend that in suspected PAS, gentle extraction techniques and avoidance of forceful traction should be prioritized to minimize iatrogenic injury [3, 9].
Placenta percreta can be clinically challenging to be differentiated from retained placental tissue or gestational trophoblastic neoplasia (GTN) due to overlapping manifestations (e.g., vaginal bleeding, infection). In this case, definitive differentiation was achieved through the integration of imaging features, hCG levels, and intraoperative pathological findings, reducing the risk of misdiagnosis. The low hCG level (246 mIU/mL) and its rapid postoperative decline to undetectable levels within one week, combined with the absence of trophoblastic proliferation on histopathology, definitively excluded GTN. Furthermore, the absence of classic uterine rupture symptoms (e.g., sudden-onset abdominal pain) further complicated diagnostic efforts. Consistent with reported cases, Zuckerwise et al. documented that only 3% of PAS-related uterine ruptures are associated with sepsis, mainly associated with delayed diagnosis [15]. The patient’s fever and leukocytosis align with these characteristics, emphasizing the critical need for prompt recognition in atypical presentations.
Intraoperatively, placental penetration through the uterine corpus with dense adhesions to the small bowel resulted in partial bowel wall necrosis. Such intestinal injuries occur in only 2–3% of PAS cases [16], yet Marcellin et al. emphasize that bowel involvement is strongly associated with multi-organ injury and increased risks of postoperative complications [16]. However, bladder invasion is more frequently reported due to its anatomical proximity to the lower uterine segment [3]. In this case, the lesion was successfully addressed via subtotal hysterectomy and partial bowel resection. Postoperative pathology confirmed extensive villous infiltration into the myometrium and small bowel serosal necrosis, highlighting the need for multidisciplinary collaboration in managing complex PAS. Further, extensive adhesions between the uterus, omentum, and bowel—likely attributable to the patient’s previous myomectomy—further corroborate uterine surgical history as a core risk factor for PAS [3, 6].
Although FIGO proposes conservative management for patients without active bleeding [9], this patient underwent definitive surgery due to completed childbearing, severe infection, and anemia. Zuckerwise et al. demonstrated that delayed surgical intervention increases sepsis risk [15]. In this case, timely surgery after infection control prevented clinical deterioration. The management of bowel injury (partial resection with anastomosis) adhered to individualized therapeutic principles: despite limited bowel involvement, localized necrosis suggested that conservative repair might elevate postoperative enterocutaneous fistula risk, justifying aggressive resection as a judicious approach.