Fertility and obstetric outcome after conservative management of placenta accreta

Objective

To determine the fertility and obstetric outcomes after conservative management of placenta accreta.

Methods

A retrospective observational cohort study of all identified cases of placenta accreta from 1993 to 2007 in 2 tertiary university hospitals in France. For patients treated conservatively, maternal and fetal morbidity, reproductive function, fertility, and subsequent pregnancies were recorded.

Results

During the study period, 46 patients were treated by conservative management; 6 patients underwent a secondary hysterectomy. Of the remaining 40 patients, 35 were followed up for a median of 65 months (range 18-156 months). Patients resumed their menstrual cycles after a median of 130 days (range 48-176 days). Menses were irregular in 11 patients (31%), but none had amenorrhea. Twelve of the 14 patients desiring another pregnancy achieved a total of 15 pregnancies; 2 patients had recurrent placenta accreta. Five spontaneous abortions and 1 termination of pregnancy occurred during the first trimester. The median term at delivery was 37 weeks (range, 35-40 weeks). Four patients delivered prematurely.

Conclusion

Conservative management of placenta accreta can preserve fertility, although the risk of recurrent placenta accreta appears to be high.     

Risk factors and management patterns for emergency obstetric hysterectomy over 2 decades

Objective

To review the demographic characteristics of patients, risk factors, indications, and complications of emergency obstetric hysterectomy (EOH), and to determine the changing trends in EOH over the last 2 decades.

Methods

A retrospective review of all consecutive cases of EOH over the last 20 years at Mayday University Hospital, UK.

Results

There were 84 698 deliveries between January 1989 and January 2009. Fifty-two women had an EOH, with an incidence of 0.6 per 1000 deliveries. The underlying cause of EOH was uncontrolled primary hemorrhage in 50 (96.2%) women and severe sepsis leading to secondary hemorrhage in 2 (3.8%) women. A total of 38 (73%) EOHs were performed for intractable bleeding after cesarean delivery. Twenty-five EOHs were performed in the first decade, and 27 EOHs were performed in last decade.

Conclusion

Despite the introduction of pharmacologic agents and new surgical techniques to control postpartum hemorrhage, there was no reduction in the prevalence of EOH. Previous cesarean delivery with associated placenta previa or placenta accreta was a major contributor toward EOH.     

B-Lynch suture, intrauterine balloon, and endouterine hemostatic suture for the management of postpartum hemorrhage due to placenta previa accreta

Objective

To report our experience with a new conservative management approach to treat postpartum hemorrhage (PPH) due to placenta previa accreta.

Methods

A retrospective study of 9 patients with placenta previa accreta who underwent a conservative management protocol. The protocol consists of preventive radiological catheterization of the descending aorta, cesarean delivery, use of Affronti endouterine square hemostatic sutures, and placement of an intrauterine Bakri balloon in conjunction with B-Lynch suture. In the event of failure of the protocol, subsequent management employs ligation and/or reversible embolization of the uterine arteries followed by hysterectomy if unsuccessful.

Results

Conservative management of PPH was successful in all 9 patients evaluated and avoided the need for ligation and/or reversible embolization of the uterine arteries.

Conclusion

Management of PPH is dictated by several considerations including hemodynamic status and desire to preserve fertility. The initial results of this conservative protocol for treatment of PPH in high-risk patients with placenta previa accreta are encouraging.     

Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage

Objectives

The aims of this study are to determine the incidence and aetiology of major obstetric haemorrhage (MOH) in our population, to examine the success rates of medical and surgical interventions and to identify risk factors for peripartum hysterectomy and end organ dysfunction (EOD).

Study design

This prospective study from 2004 to 2007 was carried out in three Dublin maternity hospitals. Women were identified as having MOH if they received ≥5 units of red cell concentrate (RCC) acutely. Risk factors for hysterectomy or end organ dysfunction were calculated using logistic regression.

Results

One hundred and seventeen cases of MOH in 93,291 deliveries were identified (1.25/1000). The predominant cause was uterine atony. Haemostasis was achieved with medical therapy alone in 15% of cases. The hydrostatic balloon and the B-Lynch suture arrested bleeding in 75% and 40% of cases utilised respectively. Hysterectomy was required to arrest bleeding in 24% of women and 16% of women developed end organ dysfunction (11 had both). There was one maternal death. Independent risk factors for hysterectomy included the number of previous caesarean sections (OR 3.28, 95% CI 1.95-5.5), placenta praevia (OR 13.5, 95% CI 7.7-184), placenta accreta (OR 37.7, 95% CI 7.7-184), uterine rupture (OR 7.25, 95% CI 1.25-42) and the number of units of RCC transfused (OR 1.31, 95% CI 1.13-1.5). Independent risk factors for end organ dysfunction (EOD) were placenta accreta (OR 5, 95% CI 1.5-16.5), uterine rupture (OR 13.86, 95% CI 2.32-82), the number of RCC transfused (OR 1.31, 95% CI 1.13-1.5) and the minimum haematocrit recorded (OR 5.53, 95% CI 1.7-18).

Conclusions

MOH is complicated by hysterectomy in 24% and end organ dysfunction in 16% of cases. The risk of peripartum hysterectomy is increased with the number of previous caesarean sections, the aetiology of the bleed, namely placenta praevia/accreta or uterine rupture and the volume of blood transfused. Critically, failure to maintain optimal haematocrit during the acute event was associated with end organ dysfunction.     

Placental pathology in fetal growth restriction

Objectives

One of the causes of intrauterine fetal growth restriction (FGR) can be pathology of the placenta. The aim of this study was to compare macroscopic and microscopic changes of the placentas from intrauterine growth restricted fetuses with those from normally developed fetuses, in order to test the hypothesis that vascular damage due to decreased maternal vascular perfusion may be responsible for FGR.

Study design

Between May 2007 and December 2008 we performed detailed macroscopic and histological examination of singleton placentas of 50 consecutive neonates with fetal growth restriction (FGR group) and compared them to 50 normal fetuses, born next to an FGR case, as a control group.

Results

Gestational age, birth weight, spontaneous delivery rate, mean weight of the placenta and the fetal-placental weight ratio were all lower in the FGR group than in the control group (p < 0.05). Thickening of the villous trophoblastic basal membrane, incidence of villous infarction, presence of thrombi or haematomas and the incidence of villitis were more common in the FGR group than in the controls (p < 0.05). There were, however, no significant differences in perivillous fibrin deposition, stromal fibrosis and cytotrophoblast proliferation between the groups. In FGR women who smoked, intervillous haematomas and villous infarction were more common (p < 0.05) than in controls.

Conclusions

All macroscopic and microscopic pathological changes associated with FGR were directly linked to reduction of placental blood flow. As smoking is a main risk factor for these placental abnormalities these results emphasize the need to persuade women to quit smoking not only during pregnancy, but even better long before pregnancy.     

Differences in the management of suspected cases of placenta accreta in France and Argentina

Objective

To compare the imaging procedures and surgical strategies used to treat placenta accreta at referral centers in France and Argentina.

Method

A total of 52 women suspected of having placenta accreta underwent ultrasound and placental magnetic resonance imaging evaluations at these centers between May 2003 and October 2006. Findings and management were recorded.

Results

The use of the 2 imaging technologies was similar in France and Argentina and conservative surgical treatment was predominant in both groups. The placenta was left in situ in 64.7% of cases at the French center whereas resection of the placenta and invaded area were performed in 91.4% of cases in Argentina.

Conclusion

The same diagnostic tools were used in the 2 groups, but there were differences in diagnostic accuracy and in the types of surgical procedures performed.     

Magnetic resonance imaging relaxation time measurements of the placenta at 1.5 T

Placental insufficiency is a major cause of fetal growth restriction (FGR) and accumulating evidence indicates several aspects of placental morphology are altered in this condition. MRI provides quantitative indices that may be used in non-invasive assessment of the human placenta, such as relaxation time measurements, T1 and T2. We hypothesised that placental relaxation times relate to alterations in placental tissue morphology and hence may be useful in identifying the changes associated with FGR. We report on the first phase of testing this hypothesis, in a study of women in normal pregnancy.

Aims

To assess relaxation time measurements in the placenta in normal pregnancy and correlate these with gestational age and stereological analyses of placental morphology following delivery.

Methods

30 women underwent MRI examination (1.5 T) between 20 and 41 weeks gestation. Placental T1 and T2 measurements were acquired from a mid-depth placental region, co-localised to a structural scan. Fixed, wax-embedded sections of these placentas collected at delivery were stained with hematoxylin/eosin and subjected to stereological analysis.

Results

Placental T1 and T2 show a significant negative correlation with gestation, (Pearson correlation p = 0.01, 0.03 respectively). 17 placentas were analysed stereologically. In the group as a whole there was no significant correlation between T1 and T2 and morphological features. However, in a subset of 7 pregnancies scanned within a week of delivery, a significant positive correlation was observed between the fibrin volume density and the ratio of fibrin: villous volume densities and T2 (Spearman correlation p = 0.02, 0.03 respectively).

Discussion

The correlations between placental T1 and T2 and gestation show that these variables are clearly influenced by changes in placental structure. Fibrin might be a key component but further work is needed to fully elucidate the major structural influences on placental T1 and T2.     

Assessment of ischemia-modified albumin level in patients with recurrent pregnancy loss during the first trimester

Objective

The finding that ischemia-modified albumin (IMA) is increased in pre-eclamptic pregnancy suggests a role for IMA as a potential biomarker for abnormal placental development related to miscarriage. This study was undertaken to evaluate IMA levels in women with recurrent pregnancy loss (RPL).

Study design

This case-control study was performed between March 2008 and September 2009, at the Department of Obstetrics and Gynecology of Meram School of Medicine. Serum IMA and albumin concentrations were assessed in 43 women with a history of two or more unexplained first trimester miscarriages (group 1), and 42 healthy pregnant women (group 2) in the first trimester. IMA, adjusted IMA and albumin concentrations were compared between the groups. Statistical analysis was performed using Student's t-test and Mann-Whitney U test.

Results

IMA and adjusted IMA levels were significantly higher in women with RPL (1.11 + 0.08 and 1.09 + 0.09, respectively) compared to women in group 2 (0.88 + 0.10 and 0.88 + 0.11, respectively). Albumin levels in group 1 were significantly lower compared with group 2. There was a negative correlation between IMAand albumin levels in each group.

Conclusion

Maternal IMA levels appear to be elevated in women with early RPL. This finding may suggest that an abnormally high hypoxic intrauterine environment may be associated with abnormal placental development that contributes to early miscarriage.     

Amenorrhea and resumption of menstruation after uterine artery embolization for fibroids

Objectives

To determine whether women will experience permanent amenorrhea following uterine artery embolization for fibroids, and whether rates of onset differ in the long term according to age at the time of the procedure.

Methods

Over 77 months, 211 consecutive eligible women were grouped by age (group A, < 40 years [n = 39]; group B, 40-44 years [n = 98]; and group C, ≥ 45 years [n = 74]) and the cumulative rates of onset of permanent amenorrhea were compared between the groups.

Results

The likelihood of incurring permanent amenorrhea was significantly higher in group C. The cumulative rates in groups A, B, and C were 0%, 1.4%, and 19.7% at 3 years and 0%, 11.2%, and 40.4% at 6 years.

Conclusion

The rates of onset of permanent amenorrhea changed over time and differed according to age at the time of the procedure, with little likelihood of permanent amenorrhea at 6 years for women younger than 40 years at the time of the procedure.     

A double-blind, randomized, placebo-controlled trial of misoprostol and routine uterotonics for the prevention of postpartum hemorrhage

Objective

To assess the effects of 400-μg sublingual misoprostol plus routine uterotonics on postpartum hemorrhage.

Methods

A double-blind, placebo-controlled, randomized study was performed. After delivery of the child, eligible women received routine uterotonics and were randomly allocated to receive 400-μg misoprostol or placebo sublingually. The primary outcome measure was blood loss of at least 500 mL within 1 hour of taking the trial tablets.

Results

In total, 672 women received misoprostol and 673 received placebo. The baseline data were similar for both groups. Misoprostol plus routine uterotonics reduced postpartum blood loss, but the effect was not significant for blood loss of at least 500 mL (relative risk [RR] 0.96; 95% confidence interval [CI], 0.63-1.45) or blood loss of at least 1000 mL (RR 0.50; 95% CI, 0.15-1.66). Misoprostol also reduced the need for non-routine oxytocin, manual removal of the placenta, and hysterectomy, but these differences were not significant either. Misoprostol was associated with pyrexia and moderate/severe shivering. There was no death in either group.

Conclusion

Misoprostol plus routine uterotonics resulted in modest reductions of blood loss in the third stage of labor, but the effects did not reach statistical significance. Larger studies are recommended.     

Home administration of misoprostol for early medical abortion in India

Objective

To assess the efficacy and acceptability of home administration of misoprostol for early medical abortion in Indian family planning clinics.

Methods

In this prospective cohort study, consenting pregnant women (n = 599) with amenorrhea of 8 weeks or less seeking termination of pregnancy received 200 mg of oral mifepristone followed 48 hours later with 400 µg of oral misoprostol, administered either at home or at the clinic.

Results

Almost all women (88.4%) chose to take misoprostol home. There was no statistical difference in success rates between home and clinic users (89.0% vs 92.4%, Pearson χ² = 0.7; P = 0.395). Most women in both the home (90.7%) and clinic (92.3%) groups were satisfied or very satisfied with the procedure.

Conclusion

Home administration of misoprostol is safe and feasible for introduction into medical abortion services in India.     

Perioperative cesarean delivery morbidity among HIV-infected women under highly active antiretroviral treatment: a case-control study

Objective

To compare post-cesarean complications between HIV-infected women on highly active antiretroviral therapy (HAART) and a matched group of non-HIV-infected women, and to evaluate predisposing risk factors for these complications in the HIV group.

Study design

We performed a retrospective study of 160 HIV-infected women and 320 non-infected women who underwent cesarean section in a single reference center from 1997 to 2007. All HIV patients were under high active antiretroviral therapy (HAART). The women were assessed for a large number of major and minor postoperative complications. Selected risk factors for perioperative morbidity were analyzed in the HIV-positive group and data were analyzed using logistic regression.

Result(s)

Overall postoperative complications did not differ significantly between the two groups (26.9% in HIV patients vs. 22.8% in controls; OR = 1.24; 95% confidence interval [CI] = 0.8-1.92). Anemia was the most frequent morbidity observed, affecting 17.5% of HIV-positive women and 11.8% of controls. Major complications were associated with a CD4+ cell count of <500 cell/ml (OR = 3.28, 95% CI = 1.04-10.31) and prematurity <34 weeks (OR = 9.76, 95% CI = 1.99-47.71).

Conclusion(s)

Post-cesarean complications were not significantly increased in HIV-infected women on HAART compared to non-HIV-infected women. Prematurity and low CD4+ cell count were risk factors for major complications.     

Intravenous nitroglycerin for controlled cord traction in the management of retained placenta

Objective

To determine the effect of 200 μg of intravenous nitroglycerin in the release of retained placenta by controlled cord traction.

Methods

In this randomized controlled study, 40 women with a placenta retained for 30 minutes received intravenously 200 μg of nitroglycerin or a normal saline solution before umbilical cord traction was initiated. The rates of successful removal of the retained placenta in the study (n = 20) and control (n = 20) groups were compared, as were blood pressure, pulse rate, blood loss, and adverse effects.

Results

The placenta was released in only 15% and 20% of the participants in the study and control group, respectively. The remainder of the participants required general anesthesia and manual removal of the retained placenta regardless of group assignation. Blood pressure fell in significantly more women in the study group, but there were no differences in estimated blood loss or minor adverse effects.

Conclusion

Intravenously administered nitroglycerin did not facilitate the release of retained placenta by umbilical cord traction. However, cord traction may be performed longer than 30 minutes to attempt releasing the placenta before operative manual removal is initiated.     

Domestic violence against infertile women in a Turkish setting

Objective

To investigate the prevalence of domestic violence against infertile women in a Turkish setting.

Methods

A total of 122 women with primary infertility attending an obstetrics and gynecology outpatient clinic were interviewed using the Abuse Assessment Screen questionnaire to investigate their experiences of domestic violence.

Results

In total, 41 (33.6%) women had experienced domestic violence because of their infertility. Of these women, 32 (78%) had experienced domestic violence for the first time in the relationship with the current partner following diagnosis of female factor infertility. The percentage of nonabused and abused infertile women who were mostly satisfied with their sexual lives was 56.87% and 29.2%, respectively (P < 0.05).

Conclusion

Routine screening for domestic violence in infertility clinics is necessary to give affected women an opportunity to access appropriate health care and support services.     

Oxidized low-density lipoproteins in cord blood from neonates with intra-uterine growth restriction

Objective

We verified whether oxidative stress indices (oxidized low-density lipoproteins and malondialdehyde) and inflammatory biomarkers (circulating C-reactive protein, interleukin-6, tumour necrosis factor-α, serum amyloid A and soluble intercellular vascular cell adhesion molecule) are increased in the umbilical vein of placental insufficiency induced intra-uterine growth restricted neonates.

Study design

The prospective cohort study, involving 3 tertiary care centers, consists of 200 consecutively recruited pregnant women carrying twins. We chose the twin pregnancy model because both fetuses share the same maternal environment, thereby avoiding potential confounding factors when comparing oxidative stress and inflammation biomarkers. We analysed only twin pairs with one with intra-uterine growth restriction (N = 38) defined as fetal growth < 10th percentile with abnormal Doppler of the umbilical artery. Blood samples were taken at birth from the umbilical vein. Intra-pair comparisons on the biomarkers were performed using the Student paired t-test.

Results

We observed increased cord blood levels of oxidized low-density lipoproteins, (2.394 ± .412 vs 1.296 ± .204, p = .003) but not of malondialdehyde in growth restricted neonates when compared to their normal counterparts. Although indices of inflammation tended to be increased in cord blood from growth restricted newborns, the difference did not reach statistical significance.

Conclusion

In the twin model, intra-uterine growth restriction is associated with low-density lipoprotein oxidation without apparent dysregulation of inflammation biomarkers.

Condensation

Increased oxidized low-density lipoproteins are observed in growth restricted twins compared to their co-twins with normal growth at birth.     

A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term

Objective

To determine the factors associated with the success rate of external cephalic version (ECV) for breech presentation at term.

Methods

A prospective analysis of 500 ECV maneuvers. The variables maternal age, maternal weight, body mass index, previous cesarean delivery, gestational age, parity, amount of amniotic fluid, placental location, and type of breech were studied using logistic regression analysis.

Results

The success rate of ECV was 52.2% (n = 261). The variables significantly associated with success were parity, placental location, amount of amniotic fluid, and type of breech (P < 0.05). A parity of 2 had a 3.74-times higher probability of success than nulliparity (95% CI, 2.37-5.90); a posterior placenta increased the success rate by 2.85 times compared with an anterior placenta (95% CI, 1.87-4.36); and double footling breech presentation had a 2.77-times higher success rate compared with a frank breech presentation (95% CI, 1.16-6.62). The area under the ROC curve showed a predictive ability of 73.6% (95% CI, 69.2%-77.9%) for these 3 variables.

Conclusion

Parity, placental location, amount of amniotic fluid, and type of breech presentation were associated with the success rate of ECV.     

CA 125 normalization with chemotherapy is independently predictive of survival in advanced endometrial cancer

Objective

Changes in CA 125 with chemotherapy predict outcome for epithelial ovarian cancer. There is no such data for advanced endometrial cancer.

Method

Retrospective review of all women receiving carboplatin and paclitaxel for advanced endometrial cancer at any of the institutions of the British Columbia Cancer Agency between September 1995 and September 2006.

Results

185 newly diagnosed women were treated. Univariable analysis for progression-free survival identified as adverse predictors: grade 3, positive residual, age > 60, deep myometrial invasion, increasing stage/substage, papillary serous subtype, presence of cervical involvement, ECOG 1 or greater, CA 125 above 35 either preoperatively or at start of cycle 1 and CA 125 greater than 24 at the start of cycle 3. Upon multivariate analysis, CA 125 above 24 at cycle 3, grade 3 and positive residual remained as independent predictors. The single most important factor identified by decision tree analysis was CA 125 level at cycle 3.

Conclusion

As with epithelial ovarian cancer, changes in CA 125 are highly predictive of outcome for advanced, chemotherapy treated endometrial cancer.     

Prevalence and risk factors for domestic violence against infertile women in an Iranian setting

Objective

To determine the prevalence of and risk factors for domestic violence against women with female factor infertility in an Iranian setting.

Methods

In this cross-sectional survey conducted from August 1, 2009 to January 31, 2010, 400 women with primary infertility attending Valiasr Reproductive Health Research Center in Tehran, Iran, were interviewed using the Revised Conflict Tactics Scales questionnaire (CTS₂). This instrument was developed to investigate the presence domestic violence.

Results

A total of 247 women (61.8%) reported having experienced domestic violence because of their infertility. The most common type of violence was psychological (n = 135 [33.8%]), followed by physical (n = 56 [14%]) and sexual (n = 32 [8%]), with 24 women (6%) reporting injuries. All women reported their husbands to be the perpetrators.

Conclusion

Domestic violence against infertile women is a considerable yet unreported problem. Clinicians should identify the abused women and provide them with medical care and supportive counseling.     

Effect of clindamycin treatment on vaginal inflammatory markers in pregnant women with bacterial vaginosis and a positive fetal fibronectin test

Objective

To compare the levels of interleukin (IL)-1β, IL-6, and matrix metalloproteinase (MMP)-8 in the vaginal secretions of pregnant women with a positive fetal fibronectin (fFN) test result with or without asymptomatic bacterial vaginosis (BV) before and after treatment with oral clindamycin.

Methods

A prospective cohort study was conducted among 43 pregnant women with a positive fFN test result. All patients were treated with clindamycin, and the pre- and post-treatment levels of IL-1β, IL-6, and MMP-8 were compared.

Results

Before treatment, levels of IL-1β and MMP-8 were significantly higher in women with BV compared with women without BV (P < 0.05). Vaginal levels of IL-1β and IL-6, but not MMP-8, decreased after treatment in pregnant women with BV.

Conclusions

The inability of clindamycin to decrease MMP-8 vaginal levels may explain why it is ineffective in reducing preterm birth in pregnant women with positive fFN and BV.