Morbidly Adherent Placenta: A Critical Review

Objective

To evaluate the demographic profile, high risk factors, fetomaternal outcome and management options in morbidly adherent placenta (MAP).

Study Design

Retrospective analysis.

Methodology

Review of 20 case records of women with MAP during year 2001–2006.

Results

The mean age and parity of the women was 27.7 ± 4.2 years and 2.5 respectively. 70 % women had previous uterine scar, and similar number had placenta previa. 60 % women presented with antepartum hemorrhage and 20 % with retained placenta. 85 % women underwent hysterectomy with 5 % requiring internal iliac artery ligation, another 5 % partial cystectomy and 15 % bladder repair. Blood loss was between one and nine litres requiring an average of six units whole blood and 4 units FFP. There were six (30 %) maternal deaths. 55 % of the newborns were preterm and the perinatal mortality was 33.3 %.

Conclusion

Cesarean section and placenta previa are significant risk factors. MAP is associated with high fetomaternal morbidity and mortality.     

Morbidly Adherent Placenta: Its Management and Maternal and Perinatal Outcome

Objectives

The aim of the study was to identify the risk factors predisposing to morbidly adherent placenta and to study the different modes of management and the obstetric and neonatal outcome of these patients.

Methods

This was a retrospective cum prospective observational study conducted in the Department of Obstetrics and Gynaecology in a tertiary care referral hospital in Mumbai from January 2012 to November 2014.

Results

The incidence of morbidly adherent placenta was 1.32 per 1000 pregnancies with patient profile comprising second gravida in the age group 26–28 years; 90 % of the patients in this study had previous Caesarean section and co-existing placenta praevia was diagnosed in 63 %. Fifty-three per cent of the women delivered between 35 and 38 weeks and 40 % had elective deliveries. Caesarean section was the mode of delivery in 90 % of the patients. Prophylactic balloon placement in the internal iliac artery followed by classical Caesarean section, uterine artery embolization and post-operative methotrexate was done in 27 % which preserved the uterus and was associated the blood loss of 1000–2000 mL.

Conclusion

Antenatal diagnosis of morbidly adherent placenta allows for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality.

     

子痫前期并发脏器受累的孕妇血清及胎盘氧化应激损伤水平研究

目的:探讨分析并发不同脏器受累的子痫前期孕妇血清及胎盘氧化应激损伤水平。方法:选择2012年12月—2014年12月于福建医科大学附属协和医院产科住院分娩的30例子痫前期并发脏器受累的孕妇作为研究组,30例子痫前期未并发脏器受累的孕妇作为对照1组,另选同期正常晚期妊娠孕妇30例作为对照2组。应用紫外比色法检测血清及胎盘组织中谷胱甘肽过氧化物酶(GPX)活性、过氧化氢酶(CAT)活性、脂质过氧化终产物丙二醛(MDA)水平;WST法(Total Superoxide Dismutase Assay Kit with WST-1)检测血清及胎盘组织中超氧化物歧化酶(SOD)的活性水平。结果:1研究组及对照1组孕妇血清及胎盘组织中GPX、CAT、SOD活性水平均低于对照2组,且研究组均低于对照1组,差异均有统计学意义(P0.05)。2研究组及对照1组孕妇血清及胎盘组织中MDA水平均高于对照2组,且研究组高于对照1组,差异均有统计学意义(P0.05)。3研究组及对照1组孕妇血清及胎盘组织中MDA水平与GPX、CAT及SOD活性水平均呈负相关(P0.05);对照2组孕妇血清及胎盘组织中MDA水平与GPX、CAT及SOD活性水平未见明显相关性(P0.05)。结论:血清及胎盘氧化应激损伤增强可能是子痫前期发病的重要因素,且可能促使子痫前期孕妇并发脏器受累,血清及胎盘组织中抗氧化酶活性水平下降可能是血清及胎盘氧化应激损伤水平升高的原因。     

178例凶险性前置胎盘伴胎盘植入保留子宫手术方式探讨

目的:探讨降低凶险性前置胎盘伴胎盘植入出血风险和保留子宫的手术方式。方法:回顾性分析2015年4月—2017年11月在河南省人民医院进行手术的凶险性前置胎盘伴胎盘植入患者178例,根据患者的具体情况,采用相应的手术方式,包括双侧子宫动脉上行支结扎、宫颈提拉式缝合、子宫下段前壁部分切除、子宫下段双切口、宫腔球囊填塞以及腹主动脉球囊阻断等。结果:178例患者术中出血量为1 500(1 421.5,1 757.7)mL,其中未行腹主动脉球囊阻断者156例,术中出血量为1 600(1 461.3,1 707.2)mL;行腹主动脉球囊阻断者22例,术中出血量为1 800(1 761.9,1 912.7)mL,两者比较差异无统计学意义(Z=2.13,P=0.98);92例行Bakri球囊填塞术和86例未行宫腔填塞术患者术后感染发生率分别为23.9%(22/92)和18.6%(16/86),差异无统计学意义(χ~2=0.75,P=0.39)。1例患者因胎盘广泛植入切除子宫,所有患者均康复出院。结论:采用多种手术方式治疗凶险性前置胎盘伴胎盘植入患者,降低了术中出血量,多数子宫得以保留,取得了较好的治疗效果。     

Confidentiality in Pediatric and Adolescent Gynecology: When We Can,When We Can't,and When We're Challenged

Maintaining confidentiality is an important aspect of adolescent health care. Different states and provinces have laws around the provision of confidential health care to minors for specific health concerns such as reproductive health, mental health and substance abuse. However, there are situations where confidentiality cannot be assured, particularly if the adolescent is being abused. Educating teens and parents about the circumstances in which confidentiality is necessary is sometimes challenging for the clinician. Moreover, with the advent of electronic medical records, patient portals and other requirements to share health information with parents and the adolescent patient, confidentiality is sometimes not easy to assure. The following is the Elsevier Lecture from the 2015 Meeting of the North American Society for Pediatric and Adolescent Gynecology.     

Novel Technique for Assessing Amniotic Fluid Volume: Use of a Three-Dimensional Bladder Scanner

Objective: Abnormalities of amniotic fluid (AF) volume are associated with significant perinatal morbidity and mortality. Although current ultrasound techniques provide a linear amniotic fluid index (AFI) or 2-D area of AF, these indices have limited correlation with actual AF volume. The bladder volume instrument (BVI) 2500 ultrasound (Diagnostic Ultrasound Corp., Redmond, WA) utilizes a rotating 2 MHz transducer, a computer-defined fluid interface, and computer integration of 12 cross-sectional images to calculate 3-D fluid volume. In term pregnancies with normal AF volume, we previously demonstrated a correlation between the AFI and the 3-D volume as determined by BVI. In the present study, we sought to establish normative gestational values for BVI-determined 3-D volume and the relation to simultaneous AFI determinations.

Methods: Following written informed consent, 73 gravidas (17-41 weeks) with uncomplicated pregnancies and normal AF volume were prospectively studied with BVI and an ATL Ultramark 6 sector scan. The largest vertical fluid pocket in each quadrant of the abdomen was identified with the sector scan and vertical measurements for AFI recorded. Simultaneous AF 3-D volume measurements of each pocket were performed three times with BVI and maximum values were utilized. Gestational changes in the 3-D volume were correlated with measured AFI as well as known changes in AF volume.

Results: The mean ± SD 3-D volume and AFI for all patients was 369 ± 172 ml and 12.4 ± 4-5 cm, respectively. One AFI centimeter was equivalent to a volume of approximately 30 ml and did not change significantly by gestational age. The 3-D AF volume demonstrated a parabolic pattern throughout gestation and significantly correlated with known changes in AF volume.

Conclusions: The BVI scanner provides a useful measure of AF volume as the BVI values are correlated with known changes in AF volume. 3-D volume assessment with BVI may aid in diagnosing oligo- and/or polyhydramnios.     

清除胎盘后子宫重建术与胎盘原位保留在胎盘植入治疗中的对比研究

目的:比较清除胎盘后子宫重建术与胎盘原位保留+子宫动脉栓塞术对于胎盘植入患者保留子宫的优劣。方法:回顾2011年1月至2013年12月我院胎盘植入病例,分别接受清除胎盘后子宫重建术(PEUR组)和胎盘原位保留后子宫动脉栓塞术(PIS-UAE组),比较两组患者的临床结局。结果:共纳入61例,其中PEUR组35例,PIS-UAE组26例。与PEUR组相比,PIS-UAE组手术时间更短(107分钟vs 154分钟,(印)P(正)<0.05);但产褥感染率[10例(38.5%) vs 2例(5.7%),(印)P(正)<0.05]及晚期产后出血率[16例(61.5%) vs 2例(5.7%),(印)P(正)<0.001]显著升高,且住院时间更长(7.5天vs 5天)。两组患者穿透型植入占比及术中膀胱损伤率无差异((印)P(正)>0.05)。PIS-UAE组因术后出血需进一步手术止血者(开腹清除胎盘、再次UAE、子宫切除)占比显著高于PEUR组。PIS-UAE组子宫保留率84.6%,PEUR组97.1%。随访至2019年6月,共有17例(17/56,30.4%)再次妊娠,1...     

Teaching Pediatric Straddle Injury Repair with Use of a 3D Printed Model

Study ObjectiveTo determine the utility of a 3D vulvar model for teaching pediatric straddle injury repair.DesignProspective study.SettingTwo academic hospitals.ParticipantsTwenty obstetrics and gynecology residentsInterventions and Main Outcome MeasuresKnowledge score on the basis of a 7-question pre/post test. Likert scale questions evaluated the 3D model as a teaching tool.ResultsTwenty residents participated; 2 (10%) had ever repaired a straddle injury. Knowledge scores increased after model use and didactic session from 3.05 of possible 7 to 6.35; P = .001. Only 2/20 (10%) residents “agreed” or “strongly agreed” with the statement, “I am comfortable repairing a straddle injury” before the intervention, compared with 19/20 (95%) afterward (P < .001). Of 20 residents, 19 (95%) believed that it simulated surgical experience “very well” or “well.”ConclusionThe use of a 3D pediatric vulvar model can simulate surgical experience and can be an effective teaching tool when combined with a didactic session on pediatric straddle injury.     

Placenta percreta with bladder involvement: case report and review of literature

The authors present a very infrequent case of invasive placenta in a 33-year-old caucasian primigravida, admitted in our Department because of labor. In the course of a cesarean section performed for failure of progress, the presence of a highly adherent placenta located in the anterior part of the lower uterine segment which affected the posterior vesical wall was discovered. Recommendations for management are discussed.