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.     

超声及MRI在胎盘植入诊断中的应用现状及评价

胎盘植入是胎盘绒毛因内膜缺陷而直接侵入子宫内膜,或胎盘直接种植到子宫肌层及浆膜层内。根据胎盘绒毛植入子宫肌层的深度,可将胎盘植入分为胎盘粘连、胎盘植入和胎盘穿通。超声和MRI是目前临床最常用于诊断胎盘植入的方法。超声已成为胎盘植入的首选检查方法;但当胎盘位于子宫后壁或需要判断胎盘植入深度时,超声检查结果不可靠。作为超声检查的辅助手段,MRI对于胎盘位于子宫后壁的患者具有较大优势,同时对于胎盘植入的分型(尤其对于胎盘穿通的患者)明显优于超声。对临床怀疑有胎盘植入高危因素的孕妇可先行超声检查;当超声诊断不明确、胎盘位于子宫后壁或不能判断其植入深度时,可进一步行MRI,以优化诊断率。     

Anestesia y reanimación en un caso de placenta pércreta

Placenta percreta is a sub-type of placenta accreta in which this organ invades the whole uterine wall and affects the adjacent organs. It is a condition with a high surgical risk which generally requires an obstetric hysterectomy.We present the case of a 36 year-old pregnant woman diagnosed with placenta percreta with bladder and intestinal invasion. She suffered a hypovolaemic shock during surgery which required a massive transfusion of blood products and inotropic support. Three further successive surgeries were required due to the bleeding, with selective embolisation of the hypogastric arteries being performed in one of them. She required 13 days in intensive care. The total volume of blood products transfused was, 43 units of red cells, 28 units of plasma, and 8 platelet pools.The importance of early prenatal diagnosis is emphasised in order to adequately plan the operation, and should include a multidisciplinary team (general surgeons, urologists, vascular surgeons), as well as experienced anaesthesiologists and obstetricians.     

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.     

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     

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.     

Multidisciplinary management of placenta percreta complicated by embolic phenomena

Hemorrhage and thrombosis are major causes of maternal mortality. This case discusses the management of a woman with placenta percreta complicated by intraoperative pulmonary embolism. A 39-year-old gravida 3 with two previous cesarean deliveries presented at 34 weeks of gestation with an antepartum hemorrhage. Magnetic resonance imaging confirmed placenta percreta. The multidisciplinary group including obstetricians, gynecological oncologists, interventional radiologists and anesthesiologists developed a delivery plan. Cesarean delivery was performed with internal iliac artery occlusion and embolization catheters in place. After the uterine incision our patient experienced acute hypotension and hypoxia associated with a drop in the end-tidal carbon dioxide and sinus tachycardia. She was resuscitated and the uterus closed with the placenta in situ. Postoperatively, uterine bleeding was arrested by immediate uterine artery embolization. With initiation of embolization, hypotension and hypoxia recurred. Oxygenation and hemodynamics slowly improved, the case continued and the patient was extubated uneventfully at the end of the procedure. Computed tomography revealed multiple pulmonary emboli. The patient was anticoagulated with low-molecular-weight heparin and returned six weeks later for hysterectomy. Placenta percreta with invasion into the bladder can be catastrophic if not recognized before delivery. The chronology of events suggests that this may have been amniotic fluid emboli. An intact placenta with abnormal architecture, such as placenta percreta, may increase the risk of amniotic fluid embolus. The clinical findings and co-existing filling defects on computed tomography may represent a spectrum of amniotic fluid embolism syndrome.     

Pregnant noncommunicating rudimentary uterine horn with placenta percreta.

BACKGROUND: To report a placenta percreta in a 7-week gestational rudimentary noncommunicating uterine horn pregnancy. METHODS: A 28-year-old woman with no complaints presented with a rudimentary uterine horn pregnancy at 7-weeks gestation. The diagnosis was suspected by ultrasonography and diagnosed by laparoscopy. Laparoscopic excision of the rudimentary uterine horn and ipsilateral salpingectomy were performed, as well as biopsy of several peritoneal endometriosis lesions. RESULTS: A 7-week gestation pregnancy with placenta percreta was identified in the rudimentary uterine horn. No communication was found with the right unicornuate uterus. Endometriosis was confirmed. Clinical outcome was favorable. CONCLUSION: Placenta percreta may occur in rudimentary uterine horn pregnancies, but accidents may be avoided by an early diagnosis and surgical management. However, in young women who desire pregnancy, planned laparoscopic resection of a rudimentary uterine horn revealed accidentally should be discussed.     

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.     

胎盘粘连98例临床分析

目的探讨引起胎盘粘连的相关因素,总结其预防及处理方法。方法回顾性分析2006年1月～2010年12月在笔者所在保健院住院分娩诊断为胎盘粘连（包括胎盘植入）的98例患者的产科情况。结果胎盘粘连的发生跟刮宫次数呈正相关,其发生可能与子宫内膜损伤、病变有密切关系。结论胎盘粘连可引起产后出血等严重并发症,临床工作者应严格宫腔操作,避免损伤子宫内膜,预防和减少胎盘粘连的发生。     

Laparoscopic-assisted vaginal hysterectomy in a patient with placenta percreta

Placenta percreta is a problem encountered with increasing frequency due to the rising rate of cesarean delivery. Conservative management of this condition is associated with decreased perioperative morbidity. When hysterectomy is necessary, a laparoscopic approach can provide additional benefits. We present the case of a woman with placenta percreta with bladder invasion who was undergoing conservative management and then required delayed hysterectomy. Laparoscopic-assisted vaginal hysterectomy was successfully performed. We review the techniques used to ensure a good outcome and the advantages of a minimally invasive approach to hysterectomy in this patient with placenta percreta.     

Placenta previa percreta with bladder invasion presenting as incarcerated hernia.

Placenta percreta is a rare complication of pregnancy in which the chorionic villi penetrate through the myometrium causing uterine rupture and life-threatening hemorrhage. Bladder invasion by the villi is unusual and may be associated with hematuria and low abdominal pain during midterm pregnancy.     

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。     

Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

Background

Placenta praevia and accreta are leading causes of major obstetric haemorrhage and peripartum hysterectomy. Detection is largely based on a high index of clinical suspicion, though the diagnostic accuracy of radiological imaging is improving. Interventional radiological techniques can reduce blood loss and the incidence of hysterectomy.

Methods

We have reviewed our experience with bilateral prophylactic uterine artery balloon occlusion in the management of women with suspected placenta accreta. Thirteen women at high risk of major haemorrhage due to placenta praevia or suspected placenta accreta were retrospectively studied. Uterine artery balloons were placed prophylactically under neuraxial anaesthesia in the angiography suite followed by caesarean delivery in the obstetric operating theatre.

Results

Intraoperative blood loss and transfusion requirements were low in our case series. There were no hysterectomies or admissions to the intensive care unit. Fetal bradycardia necessitating immediate caesarean delivery occurred in two women (15.4%).

Conclusion

In our case series in women with suspected placenta accreta, prophylactic use of uterine artery balloons was associated with a low requirement for blood transfusion but with possible increased risk of fetal compromise. Performing the interventional procedure at a different site from the operative room complicated management.     

A case report of placenta percreta with bladder invasion

A 33-year-old British woman who had undergone caesarean section at 31 years of age was admitted to our hospital at 28 weeks of gestation due to a large amount of genital hemorrhage induced by total placenta previa. Magnetic resonance imaging showed placenta percreta with bladder invasion. To control the sudden hemorrhage at 31 weeks of gestation, we performed an operation emergently. An occlusion ballon was inserted into the bilateral internal iliac arteries by radiologists, caesarian section followed by simple hysterectomy was performed by gynecologists, and then the bladder wall with placenta percreta was removed by urologists. Although the operation was carefully undertaken with multi-department cooperation, 11,550 ml of blood was lost during the 6.5-hour operation. There are few reports of placenta percreta with bladder invasion, about 30 cases including 3 cases in our country have been reported around the world until now.     

Cesarean section in a pregnant patient with placenta percreta involving the urinary bladder

Placenta percreta involving adjacent structures is serious complication of pregnancy with a high mortality rate. A 32-year-old woman, gravida 4, para 3, who had previously undergone a cesarean section, was admitted to our hospital at 31 weeks' gestation for placenta previa. At 33 weeks' gestation, the diagnosis of placenta percreta with involvement of the urinary bladder was made by ultrasonography and magnetic resonance imaging. At 34 weeks' gestation, an elective cesarean section was scheduled. Anesthesia was maintained with sevoflurane in oxygen before delivery, and with nitrous oxide in oxygen, fentanyl and midazolam after delivery. During the operation, attempts to remove the placenta resulted in massive hemorrhage. Blood loss for the procedure was 13,800 g. Because of the extreme hemorrhage, we encountered hemorrhagic shock and postoperative complications despite the preoperative preparation. In case of placenta percreta, it is essential to prepare adequate volume of blood for transfusion at the start of surgery and secure large bore intravenous lines. A rapid transfusion device may be recommended. Regarding the anesthetic management, general anesthesia is preferable in consideration of the risk of hemorrhagic shock and the length of operation time. Furthermore, we need team approach and preoperative management to prevent the uncontrolled hemorrhage in such a severe case.     

Anaesthetic management of placenta accreta: use of a pre-operative high and low suspicion classification

Placenta accreta may be suspected prior to surgery, but the actual diagnosis is only confirmed at surgery. This prospective and observational study was performed to assess whether preparations should be made for potential massive blood loss prior to Caesarean surgery in all patients with suspected placenta accreta. Patients were classified as high or low suspicion for placenta accreta based on ultrasonography and clinical factors. Among 28 suspected cases of placenta accreta, diagnosis was confirmed at surgery in 50% (12/17 high and 2/11 low suspicion) cases. Hysterectomy was only performed in the 12 high suspicion patients with placenta accreta (p < 0.001). High suspicion patients required more blood transfusions: mean(SD) 6.5 (7.0) units vs 1.09 (1.1) units, p = 0.017. Anaesthetists should be prepared for major haemorrhage in all cases of suspected placenta accreta, although use of a system to grade level of suspicion may identify those at greater risk.     

胎盘植入62例临床分析

目的对北京协和医院胎盘植入病例的临床处理和结局进行分析。方法对2011年1月至2013年12月北京协和医院收治的胎盘植入病例62例进行回顾性病例分析。并对其中我院分娩的45例孕妇,根据超声或核磁共振结果,分为产前疑诊组和产前未疑诊组,比较两组患者一般情况及产科并发症发生情况。结果 62例胎盘植入病例中,24.2%合并剖宫产史,66.1%合并人工流产史。胎盘部分或全部残留占35.5%,合并产后出血51.6%,严重产后出血共7例。子宫切除共6例。产前疑诊胎盘植入病例合并剖宫产史者显著高于产前未疑诊病例(P=0.043);产前疑诊组合并前置胎盘、产后出血、胎盘穿透发生率均高于未疑诊组,但无统计学差异(P0.05)。6例子宫切除病例中有3例合并中央性前置胎盘,1例胎盘穿透,4例严重产后出血。结论剖宫产史和人工流产史是胎盘植入和胎盘穿透的高危因素,产前疑诊胎盘植入病例有助于制定分娩和抢救计划,以避免严重产科并发症的发生。     

Postpartum hemorrhage--an update

Postpartum hemorrhage remains a major cause of maternal morbidity and mortality. The incidence of postpartum hemorrhage appears to be increasing in developed countries due to an increased number of placenta accreta or percreta after previous Cesarean deliveries. The initial therapy of postpartum hemorrhage consists of uterotonic drugs and inspection of the uterine cavum. At the same time, optimization of the clotting potential should be initiated early. Tranexamic acid may be considered as a first line choice, followed by fibrinogen if necessary. If bleeding continues, fresh frozen plasma and packed red cells should be ordered in a ratio of 1:1, as this ratio has been shown to improve survival in trauma victims. All labor and delivery suites should have standard operating procedures for the management of postpartum hemorrhage in place with regular drills.