凶险性前置胎盘并胎盘置入产前MRI检查的临床应用价值

目的探讨凶险性前置胎盘并胎盘置入产前MRI检查的临床应用价值。方法回顾性分析2018-01—2020-08间于西平县人民医院行产前MRI检查拟诊为凶险性前置胎盘并胎盘植入行剖宫产术的78例产妇的临床资料。以术前阴道超声联合术中所见或病理学(联合检查)结果为"金标准",统计术前MRI检查的灵敏度、特异性、准确率,以及阳性预测值和阴性预测值。结果 MRI诊断凶险性前置胎盘合并胎盘植入的灵敏度为93.44%,特异性为82.35%,准确率为93.59%。阳性预测值为95.16%,阴性预测值为87.50%。结论对拟诊为凶险性前置胎盘合并胎盘植入行剖宫产的产妇,术前行MRI检查有较高的灵敏度、特异性和准确率,尤其可协助评估胎盘置入子宫肌层的深度、宫旁侵犯,以及与周围器官的关系等,更有助于凶险性前置胎盘并胎盘植入的确诊。     

凶险型前置胎盘合并胎盘植入1例抢救体会

正凶险型前置胎盘是指既往有剖宫产史,此次妊娠为前置胎盘,胎盘附着于原子宫切口部位~([1])。不孕史、高龄孕妇、剖宫产增多是导致凶险型前置胎盘的因素。胎盘植入是指胎盘绒毛直接植入子宫肌层内。穿透性胎盘植入合并凶险型前置胎盘常发生严重的大出血,继发休克、凝血功能障碍,高达90%以     

超声诊断孕早中期胎盘植入

目的观察孕早中期超声诊断胎盘植入的价值。方法回顾性分析经引产手术证实的10例孕早中期胎盘植入的临床资料,观察孕早中期胎盘植入的超声声像图特点。结果 10例中,9例有剖宫产手术史。术前超声诊断胎盘植入6例,主要表现为胎盘低置,胎盘与子宫肌层间界限不清,胎盘后血流信号丰富、肌层变薄。术前超声漏诊4例。引产后48h复查超声,10例均见宫内胎盘植入残留表现。结论胎盘与子宫肌层间界限不清、胎盘后血流信号丰富及肌层变薄等二维超声图像特点对诊断孕早中期胎盘植入具有高度临床价值。     

宫腔镜联合B超检查对剖宫产切口憩室的诊断价值

B超检查是诊断子宫切口憩室最简捷、无创的方法,但有的子宫切口憩室狭小,仅靠超声容易漏诊。宫腔镜检查能直接观察子宫壁切口憩室的位置,但对于子宫憩室较深者有盲区。宫腔镜联合B超检查,能明确诊断子宫憩室的部位、大小、深度、窦道的方向以及子宫壁内膜肌层浆膜层的情况。     

植入性胎盘保留子宫治疗方法的探讨

胎盘植入是指胎盘绒毛植入子宫肌层，其发生率低，是妊娠严重的并发症之一，可引起严重的产后出血，子宫穿孔感染，甚至危及到产妇的生命，是产科子宫切除的重要原因。由于剖宫产率上升，刮宫次数增多，胎盘植入的发生率文献报道有明显上升趋势。本文比较分析我院2002年1月至2006年12月住院分娩的23例植入性胎盘病例，不同时期不同处理方案的治疗效果，探讨保留子宫的有效方法。     

剖宫产瘢痕妊娠：MRI与经阴道超声对照

目的评价MRI及经阴道超声诊断剖宫产瘢痕妊娠（CSP）的价值。方法回顾性分析经手术证实的28例CSP患者的MRI、经阴道超声表现,对比两种方法显示孕囊位置、大小、性质、对子宫肌层的浸润、是否合并囊内及宫腔出血、对卵黄囊显示及存活状况等情况。结果MRI及经阴道超声均可显示23例囊性孕囊和5例包块型孕囊。23例囊性孕囊中,MRI诊断孕囊内合并出血6例,经阴道超声发现囊内出血2例;MRI无法显示卵黄囊及判断胚胎是否存活;经阴道超声发现卵黄囊12例,其中胚胎存活10例。MRI显示孕囊位于瘢痕周围肌层内9例,位于瘢痕处向官腔方向延伸14例,经阴道超声诊断位于肌层8例,瘢痕及官腔内15例。5例包块型孕囊中,MRI均见包块内出血,经阴道超声诊断包块内出血3例;MRI诊断包块对子宫肌层浸润5例,经阴道超声无法判断孕囊对子宫肌层的浸润。MRI诊断官腔内积血18例,经阴道超声诊断8例。结论联合应用阴道超声与MRI有利于诊断CSP。     

腹部超声检查对子宫内膜病变的诊断价值

目的探讨腹部超声检查对子宫内膜病变的诊断价值。方法对89例阴道不规则出血或排液患者,行腹部超声检查,分别拟诊为子宫内膜息肉、内膜增生、黏膜下肌瘤和内膜癌,其中71例接受手术治疗,18例接受诊断性刮宫。将术前超声诊断与术后病理学检查结果进行比较。结果超声检查对子宫内膜息肉的诊断符合率为94.4%(17/18),内膜增生的符合率为90.9%(10/11),内膜癌的符合率88.0%(22/25),黏膜下肌瘤的符合率为82.9%(29/35)。结论根据子宫内膜病变的腹部超声图像特点,腹部超声检查能较准确测量内膜厚度、观察内膜形态、判断回声与肌层厚度的关系,宫腔内是否有团块及其性状。从而对子宫内膜病变进行较为准确的诊断。     

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...     

3.0T MRI诊断子宫少见原发恶性肿瘤

目的探讨子宫少见原发恶性肿瘤的MRI表现及特征,并与术后病理对照。方法回顾性分析11例子宫少见恶性肿瘤的MRI表现特点。结果 2例子宫内膜癌肉瘤、1例内膜间质肉瘤表现为宫腔内软组织肿块,伴不同程度出血、坏死及囊变;1例小细胞癌表现为宫颈肌层的巨大肿块,信号较均匀;1例横纹肌肉瘤、3例平滑肌肉瘤、3例淋巴瘤起源于子宫肌层,表现为肌层弥漫或局限性肿块,DWI中1例平滑肌肉瘤弥散受限不明显,淋巴瘤弥散受限显著。结论MRI有助于诊断子宫少见原发恶性肿瘤,可准确判断肿瘤部位及其与周围组织的关系,最终确诊需依靠病理检查。     

子宫肌腺症是难治性排卵障碍性异常子宫出血的潜在因素:病例系列研究

目的强调在诊治难治性排卵障碍性异常子宫出血(AUB-O)时考虑到子宫肌腺症(AM)可能性的重要性。方法回顾性总结2016年9月至2018年7月北京协和医院收治的6例难治性AUB-O患者的诊治经过。难治性AUB-O是指在除外子宫内膜恶性病变情况下,患者对激素治疗不敏感。主要评估手段包括超声和盆腔核磁共振(MRI)。结果根据MRI结果,6例患者均为内生型AM,可进一步被分为不对称性内生型AM和对称性内生型AM两组。在第1组患者中,超声虽可根据肌壁的不对称性增厚或栅栏样声像改变诊断AM,但MRI检查可提供蜂窝样病灶突向宫腔或"瑞士奶酪"征等特异影像学信息。在第2组患者中,超声和宫腔镜手术后的病理学检查均无阳性发现,而MRI检查发现结合带弥漫性增厚超过子宫肌层厚度的50%而得以明确诊断。6例患者均使用促性腺激素释放激素激动剂方可止血。结论在AUB-O的治疗过程中,如果常规药物治疗无效,内生型AM很有可能是潜在的致病因素,即使患者没有痛经的表现也应予以鉴别诊断。MRI对于AM的分型有利于个体化治疗的方案选择。     

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.     

Urological Manifestations of Placenta Percreta

Placenta percreta is a condition of pregnancy associated with abnormal decidua placenta. It is characterized by invasion of chorionic villi past the myometrium and serosa, towards urogenital organs. Complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. Reports suggest an increasing prevalence of this condition. From a urological perspective, this review suggests how early diagnostic modalities, effective treatment plans, and appropriate surgical methods may aid in decreasing the morbidity and mortality of placenta percreta. The importance of maintaining bladder integrity during hysterectomy is emphasized.Key Words: Abnormal placentation, Pregnancy, Hematuria, Placenta, Post postpartum hemorrhage, Shock, Placenta percreta, Pregnancy     

Placenta percreta invading the urinary bladder

The placenta, normally confined to the decidual lining of the uterine cavity, can in some circumstances invade the muscular wall of the uterus, a condition known as placenta accreta. Less common is placenta increta, in which placental cotyledons become intertwined with the muscular stroma of the uterus. Placenta percreta, in which the trophoblastic tissues penetrate the serosa of the uterus and may extend directly to adjacent structures, is even more rare and is potentially life-threatening. There have been only 10 reports of direct invasion of placenta percreta into the urinary bladder. We review these cases and report 3 recent patients, one of whom was diagnosed pre-operatively by ultrasonography.     

埃兹蛋白在早孕自然流产患者蜕膜、绒毛的表达

目的探讨埃兹蛋白在胎盘形成过程中是否有作用及其与自然流产的关系。方法采用免疫组织化学方法检测自然流产组及正常妊娠组蜕膜和绒毛中埃兹蛋白的表达。结果在蜕膜及绒毛组织的蜕膜细胞以及滋养层细胞的胞膜和胞浆内均可见深浅不一的棕黄色颗粒沉着。与正常妊娠组相比,自然流产组蜕膜组织中埃兹蛋白的表达降低,差异有统计学意义(P<0.05);与正常妊娠组相比,自然流产组绒毛组织中埃兹蛋白的表达降低,差异有统计学意义(P<0.05)。结论自然流产组较正常妊娠组蜕膜及绒毛组织中埃兹蛋白的表达减弱,推测埃兹蛋白低表达可能与胚泡植入过程中胚泡不易黏附、滋养层细胞侵袭力下降、胎盘形成不良有关,提示埃兹蛋白可能在胎盘形成及妊娠的维持过程中起作用。     

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.     

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.     

Acute urinary bladder tamponade with hypovolemic shock due to placenta percreta with bladder invasion. Case report

A rare case with residual tissue of placenta previa invading posterior parts of the bladder as placenta percreta complicated by massive late hematuria with hypovolemic shock two months after gynecologic-obstetric operation is presented. The patient was finally treated by emergency bladder resection. If a grand multipara with a history of hysterotomies, such as cesarean sections, presents lower abdominal pain involving hematuria during pregnancy, placental invasion of the bladder may be suspected. The primary treatment by hysterectomy should be complemented by bladder resection. This placental type may have high steroidogenesis.     

Ureter injury in obstetric hysterectomy with placenta accreta spectrum: Case report

Introduction and importancePlacenta accreta spectrum (PAS) is a state of abnormal attachment of the placenta, including placenta accreta, placenta increta, and placenta percreta. This condition can be life-threatening due to the placenta cannot spontaneously separated, resulting in continuous bleeding. Cesarean section followed by hysterectomy is one of the treatment options for PAS. There was a great liability for urinary tract injuries during the operation of PAS patient.Case presentationWe present the case of ureter injury during subtotal hysterectomy in patient with PAS. A 30-years-old female patient was diagnosed with recurrent antepartum hemorrhage due to placenta previa accreta spectrum on G2P1 33 weeks of gestational age, singleton live breech presentation, previous c-section 1×. After uterine transverse incision, the baby was delivered. We decided to perform subtotal hysterectomy. There was severe adhesion. On the exploration after subtotal hysterectomy was performed, we found ruptured of the right ureter.Clinical discussionHysterectomy peripartum is one of the treatment of PAS, either to prevent or to control postpartum hemorrhage. In pregnant women with morbid placental adherence, there was a great liability for urinary tract injuries. Distal ureters are the most commonly injured while hysterectomy. Injuries to the ureters in this patient occurred due to severe adhesions and unclear visual organ.ConclusionAlthough it is rare, ureter injury may occur during subtotal hysterectomy in patient with placenta accreta spectrum. To prevent that condition, inserting ureter stent can be perform before the operation. Multidisciplinary approach is carried out so that patient outcomes are good.     

Resuscitative endovascular balloon occlusion of the aorta deployed by acute care surgeons in patients with morbidly adherent placenta: a feasible solution for two lives in peril

Morbidly adherent placenta (MAP), which includes accreta, increta, and percreta, is a condition characterized by the invasion of the uterine wall by placental tissue. The condition is associated with higher odds of massive post-partum hemorrhage. Several interventions have been developed to improve hemorrhage-related outcomes in these patients; however, there is no evidence to prefer any intervention over another. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular intervention that may be useful and effective to reduce hemorrhage and transfusions in MAP patients. The objective of this narrative review is to summarize the evidence for REBOA in patients with MAP. We posit that acute care surgeons can perform REBOA for patients with MAP.