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World Journal of Clinical Cases Dec 2023For the past few years, preventive interventional therapy has been widely used domestically and overseas, bringing great benefits to pregnant women at high-risk for...
BACKGROUND
For the past few years, preventive interventional therapy has been widely used domestically and overseas, bringing great benefits to pregnant women at high-risk for complications, such as pernicious placenta previa (PPP) and placenta accreta. Nevertheless, there are still few reports on surgical complications related to interventional therapy, and its safety should be a concern.
CASE SUMMARY
We report a 36-year-old pregnant woman with PPP who underwent balloon implantation in the lower segment of the abdominal aorta before caesarean section. However, the balloon shifted during the operation, which damaged the arterial vessels after filling, resulting in severe postpartum haemorrhage in the patient. Fortunately, after emergency interventional stent implantation, the patient was successfully relieved of the massive haemorrhage crisis.
CONCLUSION
It seems that massive postoperative bleeding has been largely avoided in preventive interventional therapy in high-risk pregnant women with placenta-related diseases, but surgical complications related to intervention therapy can also cause adverse consequences. It is equally important for clinical doctors to learn how to promptly identify and effectively treat these rare complications.
PubMed: 38188213
DOI: 10.12998/wjcc.v11.i36.8574 -
American Journal of Obstetrics and... Dec 2023The rising rate of cesarean deliveries has led to an increased incidence of long long-term complications, including niche formation in the uterine scar. Niche...
BACKGROUND
The rising rate of cesarean deliveries has led to an increased incidence of long long-term complications, including niche formation in the uterine scar. Niche development is associated with various gynecologic complaints and complications in subsequent pregnancies, such as uterine rupture and placenta accreta spectrum disorders. Although uterine closure technique is considered a potential risk factor for niche development, consensus on the optimal technique remains elusive.
OBJECTIVE
We aimed to evaluate the effect of single-layer vs double-layer closure of the uterine incision on live birth rate at a 3-year follow-up with secondary objectives focusing on gynecologic, fertility, and obstetrical outcomes at the same follow-up.
STUDY DESIGN
A multicenter, double-blind, randomized controlled trial was performed at 32 hospitals in the Netherlands. Women ≥18 years old undergoing a first cesarean delivery were randomly assigned (1:1) to receive either single-layer or double-layer closure of the uterine incision. The primary outcome of the long-term follow-up was the live birth rate; with secondary outcomes, including pregnancy rate, the need for fertility treatment, mode of delivery, and obstetrical and gynecologic complications. This trial is registered on the International Clinical Trials Registry Platform www.who.int (NTR5480; trial finished).
RESULTS
Between 2016 and 2018, the 2Close study randomly assigned 2292 women, with 830 of 1144 and 818 of 1148 responding to the 3-year questionnaire in the single-layer and double-layer closure. No differences were observed in live birth rates; also there were no differences in pregnancy rate, need for fertility treatments, mode of delivery, or uterine ruptures in subsequent pregnancies. High rates of gynecologic symptoms, including spotting (30%-32%), dysmenorrhea (47%-49%), and sexual dysfunction (Female Sexual Function Index score, 23) are reported in both groups.
CONCLUSION
The study did not demonstrate the superiority of double-layer closure over single-layer closure in terms of reproductive outcomes after a first cesarean delivery. This challenges the current recommendation favoring double-layer closure, and we propose that surgeons can choose their preferred technique. Furthermore, the high risk of gynecologic symptoms after a cesarean delivery should be discussed with patients.
PubMed: 38154502
DOI: 10.1016/j.ajog.2023.12.032 -
The Journal of Maternal-fetal &... Dec 2024Pelvic artery embolization (PAE) is a uterus-saving treatment for postpartum hemorrhage (PPH); however, subfertility or abnormal placentation for subsequent pregnancy...
OBJECTIVE
Pelvic artery embolization (PAE) is a uterus-saving treatment for postpartum hemorrhage (PPH); however, subfertility or abnormal placentation for subsequent pregnancy has been a concern in several previous reports. This study aimed to investigate the impact of PAE on subsequent pregnancies in women with a history of PPH.
METHODS
A retrospective cohort study was conducted on women transferred to the tertiary center for PPH and delivered for the next pregnancy at the same center later. The study group was divided into two groups based on PAE application to treat previous PPH.
RESULTS
Of the 62 women included, 66% (41/62) had received PAE for the previous PPH, while 21 had not. Pregnancy outcomes for subsequent pregnancies were compared between the PAE and non-PAE groups. The PAE group had a higher estimated blood loss volume for the present delivery than the non-PAE group (600 vs. 300 mL, = 0.008). The PAE group also demonstrated a higher incidence of placenta previa (4.8% vs. 24.4%, = 0.080) and placenta accreta (0% vs. 14.6%, = 0.082) than the non-PAE group, although the difference was not statistically significant.
CONCLUSION
These findings suggest that the use of PAE to treat PPH may increase the risk of bleeding, placenta previa, and placenta accreta spectrum in subsequent pregnancies.
Topics: Pregnancy; Female; Humans; Postpartum Hemorrhage; Retrospective Studies; Placenta Previa; Pelvis; Placenta Accreta; Arteries
PubMed: 38146176
DOI: 10.1080/14767058.2023.2296360 -
Gynecologic Oncology Reports Dec 2023Placenta accreta spectrum (PAS) disorders are increasing in incidence and represent a significant contributor to severe maternal morbidity in the US. Prior uterine...
BACKGROUND
Placenta accreta spectrum (PAS) disorders are increasing in incidence and represent a significant contributor to severe maternal morbidity in the US. Prior uterine surgeries other than cesarean section are important, yet less common, risk factors for PAS.
CASE
This is a case of a 43-year-old woman with a prior history of cervical cancer necessitating radical trachelectomy. She was subsequently diagnosed with a complete placenta previa with a high degree of suspicion for PAS. Multidisciplinary teams convened to plan for delivery. A cesarean hysterectomy was performed at 32 weeks. Final surgical pathology confirmed the presence of morbidly adherent placenta invading the vaginal cuff.
CONCLUSION
Patients who are diagnosed with early-stage cervical cancers have the option of fertility-preserving surgical management. Serial ultrasound evaluations, specifically looking for PAS, might be warranted in post-trachelectomy pregnancies.
PubMed: 38144573
DOI: 10.1016/j.gore.2023.101307 -
Revista Brasileira de Ginecologia E... Dec 2023To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a...
OBJECTIVE
To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT).
METHODS
Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes.
RESULTS
During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units.
CONCLUSION
After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.
Topics: Pregnancy; Female; Humans; Retrospective Studies; Placenta Accreta; Portugal; Cesarean Section; Patient Care Team; Hysterectomy
PubMed: 38141594
DOI: 10.1055/s-0043-1772482 -
Cureus Nov 2023Expectant management of cesarean scar pregnancy (CSP) in patients who refuse termination of pregnancy and continue with placenta accreta spectrum (PAS) is possible with...
OBJECTIVE
Expectant management of cesarean scar pregnancy (CSP) in patients who refuse termination of pregnancy and continue with placenta accreta spectrum (PAS) is possible with multidisciplinary care and careful monitoring in a tertiary care center. Doctors with the relevant expertise in managing PAS use highly accurate ultrasound as a tool to diagnose, monitor, and manage this disorder, which enables them to determine appropriate surgical strategies and techniques to achieve optimum maternal and fetal outcomes with minimal blood loss and no major maternal mortality and morbidity. In this study, we aim to evaluate expectant management in such patients.
MATERIALS AND METHODS
This is a retrospective study of 10 patients with a previous history of a uterine scar. Diagnosed with CSP in the first trimester, they refused to terminate their pregnancy and continued with PAS. We studied them over a period of four years from 2018 to 2022 and managed them at Latifa Hospital, Dubai, UAE.
RESULTS
Of the 10 patients, nine delivered in the third trimester (around 34 weeks gestation), seven underwent elective surgery, and three underwent emergency surgery. Four patients were exogenous cases and six were endogenous cases at diagnosis during early gestation. Seven patients had a cesarean hysterectomy, and three (with focal placenta accreta) had uterine wall reconstruction surgery. Four patients needed blood transfusions. The average duration of surgery was between 2.5 and 5 hours. There were no miscarriages, no maternal and neonatal deaths, and no significant obstetric complications such as rupture of the uterus or major obstetric hemorrhage.
CONCLUSION
Even though CSP is a potentially life-threatening condition because of serious complications such as PAS if continued, expectant management is possible under multidisciplinary care where the team strictly adheres to clinical protocols and accurate surgery to reduce obstetric hemorrhage.
PubMed: 38106794
DOI: 10.7759/cureus.48921 -
Scanning 2023[This retracts the article DOI: 10.1155/2022/1050029.].
[This retracts the article DOI: 10.1155/2022/1050029.].
PubMed: 38093777
DOI: 10.1155/2023/9760954 -
International Journal of Surgery Case... Jan 2024Postpartum hemorrhage (PPH) can be defined as excessive bleeding (>500 ml) from the genital tract after the delivery of baby upto 6 weeks. PPH accounts for major cause...
INTRODUCTION AND IMPORTANCE
Postpartum hemorrhage (PPH) can be defined as excessive bleeding (>500 ml) from the genital tract after the delivery of baby upto 6 weeks. PPH accounts for major cause of maternal mortality rate. Prevention and early intervention can prevent this complication of delivery. However condition like placenta accreta leads to retention of placenta and makes PPH inevitable.
CASE SUMMARY
We present the case of massive postpartum hemorrhage secondary to Placenta accreta in young primigravida with RH negative pregnancy. Clinical findings and investigations were not significant during her admission. She delivered the baby via vaginal route but placenta was not expelled till 30 min. Due to failed manual removal of placenta patient was shifted to OT.Manual vacuum aspiration was done in OT setting and chunks of placenta along with blood clots were obtained.Uterine balloon tamponade was inserted. Due to persistent PV bleeding subtotal hysterectomy was carried out in line for placenta accreta.
DISCUSSION
Placenta accreta being one of the life threatening obstetric condition, it should be diagnosed as early as possible and need prompt management so as to prevent maternal mortality. Due to increasing number of cesarean delivery the cases of placenta accreta has been rising but rarely in some cases can it present in young primigravida with Rh negative pregnancy.
CONCLUSION
In the cases of morbidly adherent placenta it is necessary for obstetrician to early identify such conditions and timely intervene to save the mother's life. Moreover Rh negative could be a hidden risk factor.
PubMed: 38061086
DOI: 10.1016/j.ijscr.2023.109121 -
Placenta accreta spectrum in early and late pregnancy from an imaging perspective. A scoping review.Radiologia 2023Placenta accreta spectrum (PAS) disorders (with increasing order of the depth of invasion: accreta, increta, percreta) are quite challenging for the purpose of diagnosis... (Review)
Review
Placenta accreta spectrum (PAS) disorders (with increasing order of the depth of invasion: accreta, increta, percreta) are quite challenging for the purpose of diagnosis and treatment. Pathological examination or imaging evaluation are not very dependable when considered as stand-alone diagnostic tools. On the other hand, timely diagnosis is of great importance, as maternal and fetal mortality drastically increases if patient goes through the third phase of delivery in a not well-suited facility. A multidisciplinary approach for diagnosis (incorporating clinical, imaging, and pathological evaluation) is mandatory, particularly in complicated cases. For imaging evaluation, the diagnostic modality of choice in most scenarios is ultrasound (US) exam; patients are referred for MRI when US is equivocal, inconclusive, or not visualizing placenta properly. Herewith, we review the reported US and MRI features of PAS disorders (mainly focusing on MRI), going over the normal placental imaging and imaging pitfalls in each section, and lastly, covering the imaging findings of PAS disorders in the first trimester and cesarean section pregnancy (CSP).
Topics: Pregnancy; Humans; Female; Placenta Accreta; Placenta; Cesarean Section; Magnetic Resonance Imaging
PubMed: 38049252
DOI: 10.1016/j.rxeng.2023.02.001 -
Radiologia 2023Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive...
BACKGROUND AND AIMS
Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation.
MATERIAL AND METHODS
Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete.
RESULTS
Mean blood loss during cesarean section after REBOA (3507.5 mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was <2 days.
CONCLUSION
The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.
Topics: Humans; Female; Pregnancy; Placenta Accreta; Cesarean Section; Placenta; Aorta; Hemorrhage; Balloon Occlusion
PubMed: 38049249
DOI: 10.1016/j.rxeng.2022.05.005