Uterine rupture due to placenta accreta at 28 weeks of pregnancy]

The authors report the case of uterine rupture occurring after 28 weeks of amenorrhea and related to placenta accreta and treated by means of hysterectomy. They stress the diagnostic problems and discuss possible conservative treatment.     

Management of placenta accreta

Placenta accreta occurs when a defect of the decidua basalis results in abnormally invasive placental implantation. Main risk factors include placenta previa and previous caesarean section. The conventional sonographic criteria for abnormally adherent placenta have a good diagnostic value that has to be assessed. MRI should improve the diagnosis when sonography is inconclusive. The choice of the treatment results of medical staff and the women's choice. It implies centers with adequate equipment and resources. Radical strategy consists in caesarean hysterectomy according to American recommendations or in an attempt of complete placental delivery associated with trial haemostasis and hysterectomy if this fails. A conservative approach whereby the placenta is left in place may however be proposed in selected cases if the woman wishes to continue to be fertile. This strategy needs a rigorous follow-up until complete resorption of the placenta. In case of major hemorrhage, hysterectomy should not be delayed to prevent major maternal complications or even maternal death.     

Uterine inversion secondary to placenta accreta in a diethylstilbestrol-exposed parturient. A case report

The potential for a poor reproductive outcome is particularly pronounced in women with cervicovaginal changes related to diethylstilbestrol (DES). A women with documented DES exposure and cervicovaginal abnormalities developed an acute postpartum uterine inversion requiring a hysterectomy.     

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 treatment of placenta accreta

Prolonged retained placenta causing a delayed postpartum hemorrhage is a relatively common occurrence. However, there is a dearth of medical literature describing fertility-preserving treatments when standard therapy fails. We present two cases in which protracted retained placenta due to placenta accreta was successfully treated by hysteroscopic resection. Two nulliparous women had spontaneous vaginal deliveries requiring manual placental extraction. Both experienced delayed postpartum hemorrhage and underwent suction curettage with ultrasound guidance. Both patients were found to have persistent products of conception with imaging consistent with placenta accreta. Both patients failed expectant management and subsequently underwent hysteroscopic resection with complete resolution of their symptoms. We conclude that hysteroscopic resection is a conservative therapeutic option for placenta accreta in stable patients.     

胎盘植入患者的大量输血策略

胎盘植入的发生率随着剖宫产率的增加呈平行增长趋势。胎盘植入是造成严重产后出血的主要因素之一,据报道,胎盘植入尤其是胎盘位于子宫前壁瘢痕部位的患者平均出血量为3 000～5 000 ml,其中约有90%需要输血,有40%的患者输血超过10 U红细胞悬液。输血是严重产后出血中降低孕产妇死亡率的重要手段。本文主要对胎盘植入患者大量输血的评估、准备和成分输血治疗进行介绍,以指导临床合理输血治疗,改善胎盘植入患者的预后。     

Risk factors for placenta accreta

OBJECTIVE: To identify risk factors associated with placenta accreta in a large cohort study. METHODS: Data for this study came from the Taiwan Down Syndrome Screening Group, an ongoing project on feasibility of serum screening in an Asian population. Women who had serum screening for Down syndrome at 14-22 weeks' gestation using alpha-fetoprotein (AFP) and free beta-hCG between January 1994 and June 1997, and delivered in the same institution, were included (n = 10,672). Those who had multiple gestations (n = 200), overt diabetes (n = 11), or fetal malformations (n = 101) were excluded. If a woman was involved more than once, one randomly selected pregnancy was included in the analysis (n = 9349). Twenty-eight pregnancies were complicated by placenta accreta, diagnosed by clinical presentation (n = 26) or histologic confirmation (n = 2). Multiple logistic regression with adjustment for potentially confounding variables was used to identify independent risk factors for placenta accreta. RESULTS: Women who had placenta previa (odds ratio [OR] 54.2; 95% confidence interval [CI] 17.8, 165.5) and second-trimester serum levels of AFP and free beta-hCG greater than 2.5 multiples of the median (OR 8.3; 95% CI 1.8, 39.3 and OR 3.9; 95% CI 1.5, 9.9, respectively), and were 35 years and older (OR 3.2; 95% CI 1.1, 9.4) were at increased risk of having placenta accreta. CONCLUSION: Risk factors for placenta accreta include placenta previa, abnormally elevated second-trimester AFP and free beta-hCG levels, and advanced maternal age.     

胎盘植入患者的麻醉管理

胎盘植入是产科严重并发症之一,术中易发生难以控制的大出血,临床风险极高。手术的麻醉方法、麻醉管理,对于母胎安全尤为重要。本文提倡风险关口前置与多学科协作,术前充分评估病情,选择符合抢救需要的麻醉方法及术中合理的液体复苏。     

胎盘植入患者血管栓塞治疗

胎盘植入是严重威胁母胎健康的疾病,其治疗手段尚未统一,目前血管栓塞治疗为治疗手段之一。胎盘植入患者预防与治疗产后出血的血管栓塞方法包括：术前预防性血管球囊闭塞术、术中及术后血管栓塞术。血管栓塞的优势为减少手术失血量与输血量,术后并发症及住院时间等。但同时也存在发生一定并发症的风险,包括盆腔内感染、器官缺血、发热、白细胞升高、组织神经疼痛、血管栓塞等。血管栓塞的应用还有待临床大样本的研究进一步评价。     

Uterine artery embolization and hysteroscopic resection to treat retained placenta accreta: A case report

Retained placenta is a serious cause of postpartum hemorrhage. Compounding this problem is the rare finding of a retained placenta accreta. Different authors have presented management options for retained placenta accreta that include methotrexate, uterine artery embolization, dilation and curettage, hysteroscopic loop resection, and hysterectomy. We report here on a patient who was diagnosed with a retained placenta accreta and underwent successful conservative treatment with uterine artery embolization followed by hysteroscopic morcellation. Whereas other methods have failed due to bleeding and/or infection, this case illustrates a potential new means of addressing this challenging obstetrical complication.     

The antenatal diagnosis of placenta accreta

The antenatal diagnosis of placenta accreta is invaluable in planning an approach to delivery or to management of an early intrauterine demise. The women most at risk are those who have had uterine surgery and have placenta previa, but placenta accreta can occur in any pregnancy. In early pregnancy the most useful ultrasound finding is implantation of the sac over a uterine scar. Vascular sinuses, appearing as early as 15 weeks, are irregularly shaped, have obvious blood flow when evaluated with color Doppler, and have the highest sensitivity for placenta accreta. Loss of the usual retroplacental clear space as a sole finding will usually be false positive. Magnetic resonance imaging diagnosis is in its infancy and has not yet been proven to add information unless the placenta is posterior. In the future it will hopefully aid in distinguishing placenta accreta from percreta.