PMC8452425_01
3D ultrasound image. White arrow indicates normal bladder line; black arrow indicates the perimetrial interruption.
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fig1
Surprisingly, most of the PAS signs were absent: abnormal placental lacunae, bladder-line interruption, and myometrial thinning which was identified (Figure 1).
(a, b) Images of utero-bladder relationship. Graphic reconstruction (a) and 3D-ultrasound image (b) of the focal myometrial invasion without involvement of the bladder and integrity of the posterior bladder wall.
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fig2
The only ultrasound findings were the partial absence of the "clear zone," that is, the loss of the hypoechoic plane in the myometrium underneath the placental bed and a moderate uterovesical hypervascularity (Figure 2).
(a, b) Intraoperative images of vesicouterine peritoneum detachment (a) and evidence of placental "bulging" (b).
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fig3
In the meantime, an inspection of the placental site was carried out: after developing a bladder flap clearing the lower uterine segment, the bulging of the invasion of the placenta in a very thin myometrium with intense vascularization was evident on the anterior surface of the external anterior uterus (Figure 3); no parameters and bladder infiltration were present.