子宫动脉栓塞术用于胎盘植入性疾病

胎盘植入性疾病(PAS)属于产科危急重症,可致围产期难治性大出血、失血性休克、弥漫性血管内凝血,剖宫产手术出血量、输血量、子宫切除率及死亡率均较高。子宫动脉栓塞术(UAE)用于治疗PAS可有效栓塞子宫动脉主干及其分支,减少手术出血量及输血量,降低子宫切除率。本文对UAE用于PAS进展进行综述。     

胎盘植入性疾病分子机制和病理诊断研究进展

胎盘植入性疾病(placenta accreta spectrum disorders,PAS)是胎盘绒毛不同程度侵入子宫肌层的一组疾病.PAS是产科的高危并发症之一,在临床上可导致严重产后出血、休克、子宫切除,甚至产妇死亡.病理诊断是PAS诊断的"金标准",但目前仍存在争议.本文主要就PAS的分子机制和病理诊断两个方...     

超声检查新技术诊断胎盘植入性疾病研究进展

胎盘植入性疾病（PAS）早期临床表现隐匿,诊断困难,但产后并发症严重,甚至危及母亲和新生儿生命。以常规超声为基础,联合各种超声检查新技术,可提高PAS早期诊断准确率,有助于临床医师制订合理治疗方案以改善预后。本文对超声检查新技术诊断PAS研究进展进行综述。     

Massive obstetric haemorrhage on post caesarean subtotal hysterectomy due to late detection of occult placenta percreta: A case report

IntroductionPlacenta accreta syndrome is a significant cause of maternal mortality and morbidity. Therefore, a multidiscipline approach is essential to overcome this life-threatening disorder for the mother and fetus.Presentation of caseA 32-year-old women gravida 3 parity 2, 34 weeks gestation come due to recurrent antepartum haemorrhage. She had twice prior caesarean section. Ultrasound assessment suggests total placenta previa and elevating suspicion to placenta accreta. However, intraoperatively its sign is unavailable. Although we have done subtotal hysterectomy, massive bleeding still occurring. Therefore, we present management of unexpected placenta percreta.DiscussionManagement of unexpected placenta percreta involves prenatal diagnosis, haemoglobin optimization, surgical management anticipating haemorrhage, dedicated maternal ICU, blood bank providing massive transfusion and blood component.ConclusionClose monitoring is important in catastrophe management of Placenta Accreta Syndrome.     

Anaesthetic management of patients with placenta accreta

The management of a 28-year-old primigravida with placenta accreta diagnosed during Caesarean section is described. A hysterectomy was required to control massive haemorrhage, and the patient made a full recovery. The increased incidence of placenta accreta over the last three decades is thought to be associated with the concomitant increased frequency of Caesarean section, resulting in an increased incidence of placenta praevia (1.9 per cent to 3.9 per cent). Patients with placenta praevia who have had a previous Caesarean section have a remarkably increased risk of placenta accreta. Management of placenta accreta is primarily by control of haemorrhage on delivery of the placenta. Control can be assisted by infrarenal cross-clamping of the aorta and/or intra-myometrial injection of prostaglandin F2 alpha which produces myometrial and vascular contraction. Identification of patients at increased risk, preparation for treatment and effective treatment of placenta accreta will minimize maternal morbidity and mortality.     

Clinical analysis of 47 cases with placenta accreta

Objective: To explore the incidence, risk factors and treatment for placenta accreta.Methods: A retrospective analysis was carried out from May 1997 to May 2007 in Peking Union Medical College Hospital which involved 47 placenta accreta cases and 141 controls.Results: According to our study, the incidence of placenta accreta was 0.262%(47/17,918). The percentages of placenta previa in case group were significantly higher than those of control group (P<0.01). Ninety-five point seven four percent (95.74%) of the cases were cured with conservative methods. In the second trimester, the efficiency of dilatation and curettage was 42. 86%, uterine artery embolism (UAE) was 100%. In the third trimester, the efficiency of dilatation and curettage was 20.69%, tamping was 86.67%, and UAE was 100%.Conclusion: The incidence of placenta accreta in the second trimester seems increasing, which was higher than the incidence in the third trimester. The incidence of placenta accreta was only related to placenta previa. Uterine artery embolism was the best conservative management. While in the third trimester tamping was still the most effective conservative method. The majority of the cases could reserve their reproductive functions.     

Neuraxial anesthesia and postoperative opioid administration for cesarean delivery in patients with placenta accreta spectrum disorder: a retrospective cohort study

BackgroundThere is no consensus on optimal anesthetic and analgesic management of patients presenting for cesarean delivery with suspected placenta accreta spectrum disorder. Neuraxial anesthesia is preferred for uncomplicated procedures, but general anesthesia may be indicated for those at risk of hemorrhage and hysterectomy. We compared the effect of anesthesia techniques on postoperative maternal opioid administration and neonatal respiratory distress.MethodsA single-center retrospective study from 2016 to 2019 using electronic records to identify singleton pregnancies with a high index of suspicion of placenta accreta spectrum disorder. Patients were categorized by the anesthetic technique they received: general, neuraxial, or neuraxial with conversion to general anesthesia following delivery. Postoperative maternal opioid administration (oral morphine in mg equivalents) and risk of neonatal respiratory distress were compared using linear mixed models.ResultsThirty-nine records were analyzed. Mean-adjusted oral morphine mg equivalents were 192 for patients receiving general anesthesia vs. 90 for neuraxial anesthesia only (P=0.009) and 104 for neuraxial with conversion to general anesthesia (P=0.052). Neonates delivered under general anesthesia had a 3.5 times relative risk (95% CI 1.3 to 9.8, P=0.017) of respiratory distress compared with those exposed to neuraxial anesthesia alone.ConclusionPatients receiving general anesthesia alone were administered more opioids than those undergoing neuraxial anesthesia or neuraxial with conversion to general anesthesia. This finding was maintained when accounting for whether or not the patient underwent hysterectomy. Deciding on anesthetic management requires consideration of patient comorbidities, severity of placenta accreta spectrum pathology, and surgical requirements.     

Interventional radiology in women with suspected placenta accreta undergoing caesarean section

Placenta praevia in the presence of a previous uterine scar is associated with increased risk of placenta accreta, which could lead to major haemorrhage at delivery. Major haemorrhage is one of the leading causes of maternal mortality in the UK. Interventional radiology with trans-catheter balloon occlusion or arterial embolisation is a recognised technique for the management of intractable obstetric haemorrhage. Between December 2002 and May 2007 thirteen women in our institution with sonographic findings of anterior placenta praevia and suspected placenta accreta or percreta underwent caesarean sections with peri-operative bilateral internal iliac artery catheterization with or without balloon occlusion or embolisation. This case series describes our experience of anaesthetic and radiological techniques, surgical procedures and outcomes. The obstetricians and anaesthetists in our institution are of the impression that the use of peri-operative, preferably pre-operative, internal iliac artery catheterization with or without balloon occlusion or embolisation, in women with placenta accreta or percreta, improves the operative field and potentially reduces blood loss and transfusion requirements. We were unable to find evidence that this technique reduces the need for caesarean hysterectomy. Through our experience, we have developed a unit protocol for the management of women with suspected placenta accreta undergoing caesarean section.     

Perioperative outcomes of placenta accreta spectrum Cesarean delivery in a hybrid vs labour and delivery operating room

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Use of temporary aortic balloon occlusion of the abdominal aorta was useful during cesarean hysterectomy for placenta accreta

We describe the use of an abdominal aortic occlusion balloon catheter to control excessive blood loss at cesarean hysterectomy for placenta accreta. Prophylactic abdominal aortic occlusion balloon catheter was placed in the angiography suite under local anesthesia before surgery. The 38-year-old parturient was anesthetized with propofol, sevoflurane, ketamine, remifentanil and fentanyl under close monitoring and appropriate respiratory management. The occlusion balloon was inflated after the infant had been delivered, and bleeding at the placenta required cesarean hysterectomy. There was a sudden and dramatic reduction in blood loss, and hysterectomy was performed uneventfully. An aortic occlusion was sustained for 25 min. Intraoperative blood loss was 1,800 g, and 300 g of autologous blood and 4 units of red cell concentrates were transfused. The postoperative course was uneventful. The present case suggests that prophylactic insertion of an aortic occlusion balloon catheter seems to be a safe and an effective method in controlling anticipated bleeding for caesarean hysterectomy in a parturient with placenta accreta.     

Emergency obstetric hysterectomy in eastern Nigeria

This study was undertaken to determine the incidence of morbidity and mortality of emergency obstetric hysterectomy at the University of Nigeria Teaching Hospital, Enugu, and also the modalities for reducing these complications. Of the 84 cases of emergency obstetric hysterectomy carried out at the Teaching Hospital between January 1979 and December 1988, 43 had antenatal care at the Teaching Hospital while the remaining 41 were referred cases. Sixty patients were operated upon for ruptured uterus while the remaining 24 were as a result of post partum causes such as uterine atony, adherent placenta, lacerated cervix and sepsis. The leading post-operative complications were fever, haemorrhagic shock and sepsis. A maternal mortality rate of 29.8% was recorded, with the referred patients contributing 68% of the mortality. Better supervision of antenatal care in the community studied, improved blood transfusion facilities in the Teaching Hospital and adequate prophylaxis with antibiotics are recommended to reduce morbidity and mortality in operated cases.     

Comparison between 1.5-T and 3.0-T MRI for the diagnosis of placenta accreta spectrum disorders

PurposeAccurate antenatal diagnosis of placenta accreta spectrum (PAS) is important for optimal management. The purpose of this study was to compare the respective capabilities of 1.5-T and 3.0-T MRI in the diagnosis of PAS.Materials and methodsBetween March 2016-March 2021, 190 pregnant women at high risk for PAS underwent dedicated prenatal MRI with either 1.5-T or 3.0-T units at a tertiary imaging center. Cesarian section and MRI were performed less than 6 weeks from each other. Prospectively collected data were evaluated by two experienced genitourinary radiologists for presence and extent of PAS. A comparative study was designed to investigate differences in predictive ability between 1.5-T and 3.0-T MRI groups. Sensitivity, specificity, accuracy, negative and positive prognostic values relative to intraoperative/histological findings, were computed for both groups and were compared with chi-square (χ 2) test. Interobserver agreement was estimated using Kappa test.ResultsOne hundred-eighty-two gravid women were included in the study; of these, 91/182 (50%) women were evaluated with 1.5-T (mean age, 35 ± 5.1 [SD] years; mean gestational age: 32.5 weeks) and 91/182 (50%) with 3.0-T MRI (mean age, 34.9 ± 4.9 [SD] years; mean gestational age, 32.1 weeks). 1.5-T MRI yielded 95.7% sensitivity (95% CI: 87.8–99.1) and 81.8% specificity (95% CI: 59.8) and 3.0-T MRI 93.8% sensitivity (95% CI: 86.0–97.9) and 83.3% specificity (95% CI: 48.2–97.7) for PAS identification, with no differences between the two groups (P = 0.725 and P >0.999, respectively). MRI showed excellent predictive ability for detecting extrauterine placental spread with 100% sensitivity (95% CI: 89.4–100.0), 96.7% specificity (95% CI: 88.1–99.6) for 1.5-T and 97% sensitivity (95% CI: 84.2–99.9), 96.7% specificity (95% CI: 88.1–99.6) for 3.0-T without differences between the two groups (P > 0.999). Interobserver agreement was excellent for both groups. The most frequently detected MRI signs of PAS for both 1.5-T and 3.0-T groups were placental heterogeneity (n = 85, 93.5% vs. n = 90, 98.9%; P = 0.413), and intraplacental fetal vessels (n = 64, 70.3% vs. n = 65, 71.4%; P = 0.870).ConclusionThis study suggests that 3.0-T MRI and 1.5-T MRI are equivalent for the diagnosis of PAS.     

Massive obstetric haemorrhage in a patient with placenta percreta

We present a case of a 38 year-old patient with prenatal diagnosis of placenta praevia. When the elective caesarean began it was found a placenta accreta. In spite of an emergency hysterectomy, embolisation using interventional radiography was needed after a massive obstetric haemorrhage. The post-operative period progressed without incidents.     

Laparoscopic-assisted vaginal hysterectomy in a patient with placenta percreta

Placenta percreta is a problem encountered with increasing frequency due to the rising rate of cesarean delivery. Conservative management of this condition is associated with decreased perioperative morbidity. When hysterectomy is necessary, a laparoscopic approach can provide additional benefits. We present the case of a woman with placenta percreta with bladder invasion who was undergoing conservative management and then required delayed hysterectomy. Laparoscopic-assisted vaginal hysterectomy was successfully performed. We review the techniques used to ensure a good outcome and the advantages of a minimally invasive approach to hysterectomy in this patient with placenta percreta.     

Case report: high sympathetic block with ptosis after lumbar epidural analgesia in an obstetric patient

Following lumbar epidural analgesia, a 26 year old primigravida developed right ptosis and other signs of paralysis of the right sympathetic supply to the head and neck. The case is discussed and compared with cases of Horner's syndrome which have followed epidural analgesia. It was probably due to differential sympathetic blockade.     

输血相关性急性肺损伤一例

输血相关性急性肺损伤(transfusion-related acute lung injury,TRALI)指发生在输血过程中或输血后6h内出现的缺氧或双侧肺水肿,排除左房高压,排除循环超负荷并且输血前没有预先存在的急性肺损伤.报道l例女性患者,36岁,全麻术中发生TRALI,经治疗后患者康复出院.     

Cesarean hysterectomy for placenta percreta invading the anterior abdominal wall: anesthetic considerations--a case report

Placenta accreta is defined as an abnormal adherence of the placenta to the uterine wall owing to a faulty or an absent decidua basalis. Placenta accreta is further subdivided into placenta accreta vera, increta and percreta, depending on the level of invasion of the uterine wall and surrounding structures. Placenta percreta represents invasion to the serosa and/or other pelvic structures. We herein present the case of a pregnant patient with placenta percreta invading anterior abdominal wall and review the perioperative (Cesarean hysterectomy) anesthetic management of this complication.