Maternal vascularisation of the human placenta: does the embryo develop in a hypoxic environment?

Compared to other mammals, implantation in the human establishes a precocious and intimate apposition between the maternal and fetal tissues. In the past it has been assumed that this relationship permits early onset of haemotrophic exchange, which in turn confers evolutionary advantage by supporting higher development. However, there is now strong evidence from a number of different disciplines to suggest that human pregnancy comprises two contrasting periods. During the first trimester there is little maternal bloodflow to the placenta, the oxygen tension within the feto-placental unit is low, and the uterine glands may provide much of the nutrient supply. At the start of the second trimester the maternal circulation within the intervillous space becomes fully established, the oxygen tension rises and haemotrophic nutrition becomes dominant. During the transition period there is a period of placental oxidative stress, and the response of the tissues to the changing oxygen concentration may play a pivotal role in determining the success or otherwise of the pregnancy.     

Laparoscopic sacrocolpopexy: results of a 100-patient series with 8 years follow-up

Objective Assess the feasibility, safety and results at mean term of laparoscopic promontofixation, and to describe the operative technique.Design Retrospective study.Setting Department of Gynaecology, Obstetrics and Reproductive Medicine, Caen University Hospital, France.Sample One hundred patients included from June 1993 to June 2001.Methods Pre- and post-operative clinical assessment of pelvic statics problems in accordance with the international POP-Q classification. Annual follow-up of patients and recording of any adverse effects.Main outcome measures The number of per-operative, immediate and late post-operative complications, together with the number of cases of recurrent prolapse.Results The mean follow-up was 43 months with one patient lost to follow-up. The rate of per operative complications was 11% (injuries: 6 bladder; 1 ureter; 1 vaginal; 1 rectal; 2 vascular) with a 4% rate of conversion to laparotomy. The rate of early post-operative complications was 9%, involving 7 patients (4 urinary infections, 3 occlusion syndromes, 1 eventration at a port site, 1 case of lumbo-sacral pain). The rate of late post operative complications was 25%, involving 24 patients (3 vaginal erosions, 2 volvulus of ileum, 5 cases of urinary stress incontinence, 14 cases of de novo constipation and 1 case of chronic pelvic pain). The success rate was 96% with 6 cases of partial recurrence (4 cystoceles and 2 rectoceles).Conclusions Laparoscopic promontofixation is feasible and safe. The rates of complications and recurrence are comparable to those reported in the literature for procedures carried out by laparotomy. The advantages connected with endoscopic surgery are the reduced trauma to the abdominal wall and the improved anatomical vision provided by the optic fibres; however, the long learning curve means that this procedure should be reserved for confirmed practitioners of laparoscopic surgery.     

The use of serial βHCG to plan surgical evacuation of retained placenta in a case of placenta accreta

Placenta accreta is a rare condition. Its management is always a dilemma. Traditionally, hysterectomy has been the treatment of choice. However, with appropriate case selection, conservative management is possible with or without using methotrexate. This case report describes conservative management of placenta accreta with serial monitoring of βHCG.     

Robotic Resection of a Symptomatic Parasitic Leiomyoma From the Obturator Fossa

Study Objective

To demonstrate a technique for robotically resecting a parasitic leiomyoma from the obturator fossa.

Dynamic contrast enhanced MRI of the placenta: A tool for prenatal diagnosis of placenta accreta?

BackgroundUltrasound (US) is the primary imaging modality for the diagnosis of placenta accreta, but it is not sufficiently accurate. MRI morphologic criteria have recently emerged as a useful tool in this setting, but their analysis is too subjective. Recent studies suggest that gadolinium enhancement may help to distinguish between the stretched myometrium and placenta within a scar area. However, objective MRI criteria are still required for prenatal diagnosis of placenta accreta. The purpose of this study was to assess the diagnostic value of dynamic contrast gadolinium enhancement (DCE) MRI patterns for placenta accreta.Materials and methodsMR images were acquired with a 1.5-T unit at 30–35 weeks of gestation in women with a history of Caesarian section, a low-lying anterior placenta, and US features compatible with placenta accreta. Sagittal, axial and coronal SSFP (Steady State Free Precession) sequences were acquired before injection. Then, contrast-enhanced dynamic T1-weighted images were acquired through the entire cross-sectional area of the placenta. Images were obtained sequentially at 10- to 14-s intervals for 2 min, beginning simultaneously with the bolus injection. Functional analysis was performed retrospectively, and tissular relative enhancement parameters were extracted from the recorded images. The suspected area of accreta (SAA) was placed in the region of the previous scar, and a control area (CA) of similar size was placed on the same image plane, as far as possible from the SAA. Semi-quantitative analysis of DCE-MR images was based on the kinetic enhancement curves in these two regions of interest (ROI). Three tissular relative enhancement parameters were compared according to the pregnancy outcomes, namely time to peak, maximal signal intensity, and area under the enhancement curve.ResultsWe studied 9 women (43%) with accreta and 12 women (57%) with a normal placenta. All three tissular relative enhancement parameters differed significantly between the two groups (p < 10⁻³).ConclusionThe use of dynamic contrast-enhanced MRI at 30–35 weeks of gestation in women with a high risk of placenta accreta allows the extraction of tissular enhancement parameters that differ significantly between placenta accreta and normal placenta. It therefore provides objective parameters on which to base the diagnosis and patient management.     

Umbilical vein oxytocin in the management of retained placenta: an alternative to manual removal of placenta?

Purpose  

Retained placenta is potentially life threatening due to possible complications associated with manual removal. Our aim was to determine whether umbilical vein injection of oxytocin in saline reduces the need for manual removal of placenta.     

A case of ruptured uterus at 27 weeks of gestation complicated by placenta accreta

Introduction  

Placenta accreta is a rare complication, which can lead to maternal morbidity and mortality.     

Liver metastasis in a case of adenoid cystic carcinoma of the Bartholin’s gland: a rare presentation

Introduction  Adenoid cystic carcinoma of the Bartholin’s gland accounts for a minority of all Bartholin’s gland malignancies. Although local recurrences commonly occur distant metastasis is rare. Case report  We present the first reported case of Adenoid cystic carcinoma of the Bartholin’s gland with metastasis to the liver. Discussion  There is no consensus on the treatment of adenoid cystic carcinoma of the Bartholin’s gland. Wide local excision and/or vulvectomy and radiotherapy are advocated for treatment of this cancer. There is not much data on treatment of metastasis and it varies according to site. An erratum to this article can be found at     

Bilateral papillary cystadenoma of the mesosalpinx: a rare manifestation of Von Hippel–Lindau disease

We report a rare case of a woman with bilateral papillary cystadenomata of the broad ligament with von Hippel–Lindau disease (VHL) (other manifestations: capillary hemangioblastomas of the spinal cord). Patient surveillance is important, because in the course of VHL-associated tumors malignant lesions may arise that are relevant for the prognosis.     

Planned conservative management of placenta accreta – experience of a regional general hospital

Abstract

Objective: There are only a few series treating ≥10 cases of accreta conservatively, all from university teaching hospitals, with reported success rate of 60–85%. We reported the first series of accreta managed by planned uterine conservation in the setting of non-university district general hospital.

Methods: Women with placenta previa overlying previous cesarean scar who desired uterine conservation were included. For cases with accreta confirmed during cesarean delivery, placenta was purposefully left behind, followed immediately by uterine artery embolization. Cases were followed in our special postnatal clinic. Charts were reviewed to retrieve clinical details.

Results: Among 15 cases of placenta previa overlying cesarean scar opting for conservative management, 12 (80%) were confirmed to be accreta intra-operatively. They had 20–100% of the adherent placentae retained (median 90%) and their uterus preserved. Postpartum, abnormal vaginal bleeding and/or infection led to unscheduled readmission in 67% (8/12), all managed conservatively. Sonographic resolution of placenta took 2–13 months (median 6.6), and was later than menstrual return in 11 cases.

Conclusions: Successful planned conservative management of placenta accreta is feasible in the setting of district general hospital with facilities for interventional radiology.     

Vaginal birth of conjoined thoracopagus – a rare event

An extremely rare case of vaginal birth of preterm conjoined thoracopagus twins diagnosed after delivery is being described and brief review of literature discussed.     

Ascites in puerperium: a rare case of atypical pseudo-Meigs’ syndrome complicating the puerperium

Purpose  

We report the case of puerperal ascites, associated with elevated CA125 levels and secondary to a uterine myoma. The literature on pseudo-Meigs’ syndrome associated with pregnancy was reviewed.