Alternative management of placenta accreta

A 27-year-old lady presented at 32 weeks gestation complaining of shortness of breath, headache, palpitations and feeling generally unwell for 1 day. Her current pregnancy was complicated by major placenta praevia. Because she developed worsening symptoms of pre-eclampsia and raised blood pressure, a decision was made to deliver her by an elective Caesarean section. The Caesarean section was complicated by a morbidly adherent placenta. There was no plane of cleavage between the placenta and the uterine wall. She had severe haemorrhages of 2.5 l following delivery, and to stem the bleeding, a B-lynch suture was placed and a Rusch tamponade balloon was inserted to achieve haemostasis. Although her condition improved and she did not have any further bleeding, she developed infection 3 weeks later and had a hysterectomy. We present this case to demonstrate that balloon tamponade and B-lynch suture are valuable developments in management of obstetric haemorrhage due to placenta accreta.     

Conservative management of placenta percreta invading the bladder: be patient

We report a case of placenta percreta with bladder invasion in a multiparous woman with five previous cesarean sections. At 25 weeks of gestation, because of severe hematuria, antenatal diagnosis was easy. A multidisciplinary management was carried out with conservative treatment. Three repeated artery embolizations were necessary because of placenta volume and collateral vessels. None surgical treatment was realized to avoid hemorrhage and morbidity secondary to hysterectomy and partial cystectomy.     

Controversies in the management of placenta accreta

Obstetric hemorrhage is one of the most common causes of maternal morbidity and mortality worldwide, and abnormal placentation, including placenta accreta, is currently the most common indication for peripartum hysterectomy. Prenatal identification of these cases and early referral to centers with the capability to manage them will likely result in improved outcomes. Interventions that may limit transfusion requirements include normovolemic hemodilution, selective embolization of pelvic vessels by interventional radiology, conservative management of accretism in a few selected cases, and the use of the cell saver intraoperatively. Current understanding of the mechanisms of acute coagulopathy has questioned the current transfusion guidelines, leading to a tendency to apply massive transfusion protocols based on hemostatic resuscitation. Prospective trials are required to validate the efficacy of this approach. Obstetricians should be familiar with current transfusion protocols, as the incidence of placental accretism is expected to increase in the future.     

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.     

Conservative versus extirpative management in cases of placenta accreta

OBJECTIVE: To compare the impact of conservative and extirpative strategies for placenta accreta on maternal morbidity and mortality. METHODS: We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta admitted to our tertiary center from January 1993 through December 2002. Two consecutive periods, A and B, were compared. During period A (January 1993 to June 1997), our written protocol called for the systematic manual removal of the placenta, to leave the uterine cavity empty. In period B (July 1997 to December 2002), we changed our policy by leaving the placenta in situ. The following outcomes over the 2 periods were compared: need for blood transfusion, hysterectomy, intensive care admission, duration of stay in intensive care, and postpartum endometritis. RESULTS: Thirty-three cases of placenta accreta were observed among 31,921 deliveries (1.03/1,000). During period B, there was a reduction in the hysterectomy rate (from 11 [84.6%] to 3 [15%]; P <.001), the mean number of red blood cells transfused (3,230 +/- 2,170 mL versus 1,560 +/- 1,646 mL; P <.01), and disseminated intravascular coagulation (5 [38.5%] versus 1 [5.0%]; P =.02), compared with period A. There were 3 cases of sepsis in period B and none in period A (P =.26). At least 2 women with conservative management subsequently had successful pregnancies. CONCLUSION: Leaving the placenta accreta in situ appears to be a safe alternative to removing the placenta.     

Anesthesia management of complete versus incomplete placenta previa: a retrospective cohort study

Purpose: Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management.

Methods and materials: This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases.

Results: Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p?=?.017), higher mean estimated blood loss (p?p?p?p?p?=?.02), a longer median postoperative care unit (PACU) (p?=?.02), ICU (p?=?.002), and overall length of stay in the hospital (p?Conclusions: Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.     

84例胎盘植入患者的治疗与结局

目的分析不同类型胎盘植入患者的合理治疗方法选择。 方法回顾性分析中山大学附属第一医院妇产科2000年1月1日至2009年6月30日治疗的84例胎盘植入病历资料,根据分娩时胎盘是否完全清除分为根治性治疗组(54例)和保守性治疗组(30例)。两组病例一般资料的比较、子宫体部胎盘植入和前置胎盘植入子宫切除率的比较采用卡方检验,出血量组间差异比较采用秩和检验。 结果84例胎盘植入中,根治性治疗54例(64%),其中子宫切除9例(17%),产后出血25例(46%)。保守性治疗30例(36%),其中4例(13%)治疗失败切除子宫,产后出血14例(47%),晚期产后出血4例(13%),产褥感染1例(3%);保留子宫的26例中,14例(54%)残留胎盘需后续手术清除。前置胎盘并胎盘植入保守治疗失败率高,出血量大,子宫切除率(36.36%),显著高于宫体部胎盘植入的子宫切除率(1.96%),χ²＝16.409,P<0.05。 结论产后出血是胎盘植入的常见并发症,治疗方案的选择应以控制子宫出血为前提,治疗的难点是前置胎盘植入和穿透性植入者,前置胎盘植入根治性治疗优于保守治疗,植入范围>10 cm且穿透性植入的前置胎盘宜切除子宫。     

Placenta accreta and percreta: a review of 5 cases

Five cases of placenta accreta and percreta are reviewed. Three cases, one a recurrence in the same patient, presented with acute abdominal pain; in one case perforation resulting from placenta percreta was discovered at laparotomy. In another case, placenta accreta was recognized during cesarean delivery. Total or subtotal hysterectomy was performed in three cases; piecemeal removal of placental tissue and closure of the tear was performed in two of the patients. There were no maternal deaths, but the infants were stillborn in three cases of perforation or uterine rupture.     

Management of placenta accreta: morbidity and outcome

OBJECTIVE: The aim of the study was to evaluate our results in the management of placenta accreta. STUDY DESIGN: In a retrospective study we reviewed cases of placenta accreta diagnosed in two university teaching hospitals between 1993 and 2003. For a subgroup of patients a conservative approach was attempted. In this procedure placenta was left in place until spontaneous resorption. RESULTS: Fifty cases (0.12%) of placenta accreta were observed in 41, 119 deliveries during the study period. Of the 50 cases, 24 patients (48%) were managed by the standard approach and 26 patients (52%) underwent conservative treatment. Additional surgical or medical treatment was performed in 35 of the 50 patients (70%). There was no maternal death. Overall hysterectomy rate was 40%, 10 patients were transferred to intensive care unit (20%), 7 had fever (14%), 5 had endometritis (10%) and 19 patients had blood transfusion (38%). Conservative treatment did not lead to hysterectomy in 21 cases (80.7%) and failed in 5 (19.3%). During the follow-up period, 3 women had successful pregnancy. CONCLUSION: Analysis of management of placenta accreta shows that for a subgroup of selected patients a conservative approach could preserve subsequent fertility without evident increase in morbidity.     

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.     

Parallel vertical compression sutures to control bleeding in cases of placenta previa and accreta

Objective: To evaluate the effectiveness of full-thickness vertical compression suture and intrauterine catheter in cases with placenta previa/accreta.

Study design: This study was conducted on Obstetrics and Gynecology emergency unit of Sohag University Hospital. Two longitudinal parallel full-thickness suture was taken using delayed absorbable suture (No. 2 Vicryl…) the entry of needle through anterior wall of lower uterine segment just above the internal os 2–3?cm medial to lateral aspect of lower uterine segment then completely piercing the posterior wall and then return from posterior wall to anterior wall 1–2?cm below incision line of the uterus. Another suture was taken in other side in the same manner. The Foley’s catheter was inserted through the incision line into the cervix and balloon was inflated by 20–30?cc saline.

Results: Two hundred and seventy-eight cases were included in the research. There were 107 cases without significant bleeding from lower uterine segment and no maneuver was needed. The remaining 171 cases were managed by vertical compression suture and intrauterine Foley’s catheter which was successful in 168 cases (98.2%) to stop the bleeding. Only three cases cesarean total hysterectomy was needed.

Conclusions: Vertical lateral compression sutures with inserting inflated balloon of Foley’s catheter is an effective method for controlling bleeding in cases of placenta previa/accreta.     

Multiple repeat cesareans and the threat of placenta accreta: incidence, diagnosis, management

Placenta accreta is a significant source of obstetric morbidity and mortality. Its incidence is increasing as a direct consequence of the increasing cesarean section rate, which reflects increased rates of maternal obesity, increased numbers of multiple gestations secondary to assisted reproductive technology, physician concern about litigation for adverse obstetric outcome, and a decline in the use of operative vaginal delivery for both cephalic and breech presentations. Optimum management for most cases requires elective cesarean hysterectomy, ideally performed at about 34?weeks' gestation. A multidisciplinary approach produces the best outcomes.     

母血中胎儿DNA预测前置胎盘合并粘连的探讨

目的:通过实时荧光定量PCR方法测定孕妇外周血中胎儿DNA量,初步探讨前置胎盘合并胎盘粘连孕妇外周血中胎儿DNA量与正常对照组有无统计学差异;母血中胎儿DNA定量能否预测前置胎盘合并胎盘粘连。方法:收集35例孕28~34周且胎儿为男性,经我院B超诊断为前置胎盘的单胎孕妇作为研究组,其中合并胎盘粘连8例经手术确诊,称为前置胎盘粘连组,未合并胎盘粘连27例称为前置胎盘未粘连组。收集30例孕28~34周,且胎儿为男性,正常单胎妊娠孕妇作为对照组,通过实时荧光定量PCR方法测定3组孕妇外周血中胎儿DNA量,比较3组结果的异同。结果:前置胎盘粘连组孕妇外周血中胎儿DNA量高于对照组,差异有统计学意义(P<0.05)。前置胎盘未粘连组孕妇外周血中胎儿DNA量与对照组差异无统计学意义(P>0.05)。前置胎盘粘连组孕妇外周血中胎儿DNA量高于未合并胎盘粘连组,差异有统计学意义(P<0.05)。孕妇外周血中胎儿DNA量与前置胎盘类型无关,差异无统计学意义(P>0.05)。结论:孕妇外周血中胎儿DNA量与胎盘粘连与否有关,即与胎盘组织的功能状态有关。因此测定孕妇外周血中胎儿DNA量可能有助于预测前置胎盘合并胎盘粘连。     

预防性双髂内动脉球囊闭塞术在13例凶险型前置胎盘伴胎盘植入患者中的应用效果

目的 探索预防性双髂内动脉球囊闭塞术在凶险型前置胎盘伴胎盘植入治疗中的作用.方法 采用回顾性分析方法.2010年1月至2012年12月,就诊于广州市妇女儿童医疗中心的41例凶险型前置胎盘伴胎盘植入患者纳入研究.13例患者在剖宫产术前行预防性双髂内动脉球囊闭塞术(双髂内动脉球囊置管+术中取胎后球囊扩张),作为研究组;另28例患者没有接受预防性双髂内动脉球囊闭塞术,作为对照组.采用两独立样本t检验及x2检验比较2组术中出血量、输血量、术前术后血红蛋白变化情况、手术时间、是否子宫切除、住院时间、相关并发症的差异. 结果 研究组术中出血量为(1429±875) ml,输血量为(920±438) ml,明显少于对照组[分别为(4600±2090) ml和(3600±1225) ml],差异均有统计学意义(t分别为6.840和10.251,P均=0.000).研究组手术时间和术后住院时间均短于对照组,差异有统计学意义[(197±45) min与(284±44)min,t=5.850,P=0.000;(6.7±1.3)d与(8.2±2.2)d,t=2.272,P=0.029].但研究组子宫切除率与对照组比较差异没有统计学意义[11 13与 89％(25/28)·x2=0.181,P=0.670].对照组中需要二次开腹手术者2例,发生肺水肿1例,凝血功能障碍2例,下肢静脉栓塞1例,同时并发肺水肿及肾功能损害1例;研究组中无一例发生以上并发症.结论 预防性双髂内动脉球囊闭塞术可减少凶险型前置胎盘伴胎盘植入患者的术中出血量、输血量及相关并发症.