Isolated internal iliac aneurysms are rare. We report a case of an uncommon presentation of perineal pain and tenesmus in a man caused by the pressure effects of the aneurysm. He had a successful endovascular exclusion and thrombosis of his aneurysm. On follow up of more than 3 years he remains free of all symptoms and no recurrence of the aneurysm.
Aneurysm

Objective: To analyse the clinical characteristics of patients with morbidly adherent placenta (MAP). Findings of this study will be used to identify patients at risk of MAP and to outline the best management strategy to deal with this devastating condition. Methods: Delivery records in Hospital Sultanah Nur Zahirah, Terengganu from 1st. January 2016 until 31st. December 2016 were reviewed and analysed. Results: Out of the 15,837 deliveries, eight cases of MAP were identified. Six out of eight patients had previous caesarean scar with concomitant placenta praevia, the other two patients had previous caesarean scar with history of placenta praevia in previous pregnancies. Seven out of eight cases were suspected to have MAP based on risk factors. Correct diagnosis was made by ultrasound in five patients, all with histologically confirmed moderate/severe degree of abnormal placentation. The other two cases of ‘unlikely MAP’, demonstrated segmental MAP intra-operatively with histologically confirmed milder degree of abnormal placentation. Total intraoperative blood loss ranged from 0.8 to 20 litres. Prophylactic internal iliac artery balloon occlusion was associated with significantly less blood loss. Conclusion: Antenatal diagnosis is essential in outlining the best management strategy in patients with MAP. Ultrasound may not be accurate in ruling out lower degree of MAP. Apart from having a scarred uterus with concomitant placenta praevia, history of having placenta praevia in previous pregnancy is also a risk factor for MAP. Prophylactic internal iliac artery balloon occlusion is associated with significantly less blood loss and should be considered in cases suspected with MAP.