| A case of third trimester bleeding from placenta previa is presented in which serial ultrasonograms were obtained from the 30th to the 36th gestational week and confirmed by isotopic scanning. Evidence is presented showing a migration of a placenta previa marginalis away from the cervical os followed by vaginal delivery at term. The concept and mechanism of placental migration are reviewed. ( info) |
2/100. Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. OBJECTIVE: Obstetric hemorrhage is a significant cause of maternal morbidity and death. postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years. STUDY DESIGN: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included cervical pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2). RESULTS: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days. CONCLUSIONS: uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary. ( info) |
| This is the first report of placenta previa increta in which the placenta villi penetrated the entire thickness of the uterine myometrium, but did not invade the pubocervical fascia. Ultrasonographic and magnetic resonance imaging findings are described. ( info) |
4/100. Conservative management of a case of placenta praevia percreta. Pregnancies complicated by placenta praevia and a history of caesarean section are associated with increased risk of placenta percreta (1). Placenta praevia percreta sometimes involves the bladder or other pelvic organ, invasion leading to genital bleeding or haematuria (2, 3). Bladder injury or uncontrollable profuse haemorrhage occasionally occurs in such patients during surgery. Examination of placental invasion is necessary as this clinical condition is severe. Treatment of placental myometrium invasion is required to prevent uncontrollable profuse haemorrhage during surgery. We present a multiparous patient who was diagnosed prenatally with placenta praevia percreta using magnetic resonance imaging (MRI) and who was treated conservatively with a good prognosis. ( info) |
5/100. A hypothesis to explain the occurence of inner myometrial laceration causing massive postpartum hemorrhage. BACKGROUND: Inner myometrial lacerations were found in three patients who developed uncontrollable postpartum massive bleeding despite the usual treatment for uterine atony. Because all the patients suffered from hemorrhage shock and their medical status deteriorated, their uteri were surgically removed to stop bleeding. After removal, one of them died. postpartum hemorrhage was caused by inner myometrial laceration. We hypothesized a cause of inner myometrial laceration, using the three resected uteri, an assumed model of the uterine body, and 34 women. methods: The subjects were 37 women, of whom three were patients with inner myometrial laceration, 23 were women without inner myometrial laceration who underwent cesarean section, and 11 were women in the first stage of labor. The three resected uteri were examined both macroscopically and microscopically. We measured the thickness of the wall of the uterine muscle at the widest point of the uterine corpus and the thickness of the myometrial wall at a transverse section of the uterine cervix, as well as the radius of the inner lumen at the widest point of the uterus in 23 women during cesarean section. We also measured the thickness of the myometrial wall at the widest point of the uterine corpus in 11 women at the end of the first stage of labor during ultrasonic examination. The data were then used to estimate the stress on the uterine muscle. RESULTS: The stress on the uterine cervix was stronger than that on the uterine corpus during labor. When the stress on the uterine muscle is stronger than a specific value, inner myometrial lacerations develop on the right and/or left side of the uterine cervix. These lacerations may involve large vessels. CONCLUSIONS: We have discovered another cause of postpartum hemorrhage which we have named inner myometrial laceration. These lacerations appeared to result from a strong stress on the uterine cervix caused by an abnormal rise in intrauterine pressure during labor. ( info) |
6/100. Placenta percreta: report of a case. placenta accreta, increta, or percreta are rare but potentially lethal obstetric emergencies. Removal of abnormal growth of the placenta into the uterine wall is difficult or impossible and results in massive blood loss. hysterectomy may be necessary to save the mother's life. The common predisposing factors in development of placenta percreta are repeat cesarean and placenta previa. The diagnosis of placenta percreta may remain undiagnosed until delivery. The case presented describes a scenario involving placenta percreta with bladder involvement in which the diagnosis was known in advance. The article describes the preoperative preparation, intraoperative events, and postoperative status of this particular case. ( info) |
7/100. Extrauterine abdominal pregnancy: report of a case. A healthy, 34-year-old, gravida 3, para 1,011, patient presented for cesarean delivery in her 35th week of gestation with a diagnosis of complete placenta previa. During her 26th week of gestation, the patient was admitted to a high-risk obstetric unit with the diagnosis of premature rupture of membranes. Numerous ultrasonographic studies were conducted throughout her 10-week hospital stay, confirming the admitting diagnosis. A routine cesarean section was planned, and preparations were made for a potential increase in blood loss related to the placenta previa. The procedure began under spinal anesthesia and, upon incision of the abdomen, an extrauterine pregnancy was identified. The patient was immediately anesthetized and intubated at the request of the surgeon. During the 3-hour surgical procedure, the patient sustained massive blood loss, transfusions, central line placement, and aggressive pharmacological therapy. The patient was extubated the day after surgery, and was discharged approximately 1 week later. The only major complication was compartment syndrome of the left upper extremity related to the infiltration of vasopressors requiring fasciotomy and closure 2 days later. The incidence, morbidity/mortality, and anesthetic implications of abdominal pregnancy are reviewed. ( info) |
8/100. placenta accreta/increta. review of 10 cases and a case report. A review of the patients seen at the Department of obstetrics at Dokkyo University Hospital who had suffered placenta accreta/increta in the past 18 years, was performed. There were 10 such cases out of 9,716 deliveries during this period. This incidence is higher than that which has been reported in other Western countries. Forty percent of the patients in our study had placenta accreta/increta accompanied by placenta previa or low lying; 30% had had a prior cesarean section (C/S); 70% had previously experienced dilatation and curettage (D & C); 80% had previously undergone a C/S and/or D & C: and 40% had a history of miscarriage. Three of the ten patients with placenta accreta/increta required a hysterectomy; 2 patients were successfully treated with hemostatic stitches on the endometrium; and the remaining 5 mild cases were treated with removal of the placenta, either manually or with the use of forceps. There was no case of maternal death. In 2 cases, neonatal asphyxia was noted, but the neonate immediately recovered. ( info) |
9/100. A case report and review of pregnancies in rudimentary noncommunicating uterine horns. A liveborn and subsequently thriving child was delivered abdominally from a pregnancy in a rudimentary noncommunicating uterine horn. This is the 13th English language report of neonatal survival from such an unusual and life-threatening situation. The case presents some 'clues' in the history and a review of the literature suggests that the previously reported bleak outlook for these pregnancies can now be tempered with cautious optimism. Ultrasound diagnosis of Mullerian abnormalities during pregnancy remains difficult but has been reported in several other cases in the literature and may become more common in the future. ( info) |
10/100. Second-trimester presentation of placenta percreta. Placenta percreta is diagnosed usually in the third trimester as massive postpartum hemorrhage when an attempt to remove the placenta reveals lack of a cleavage plane. However, placenta percreta may present in the second trimester with signs and symptoms of uterine rupture. The diagnosis of this event may be difficult because of mild abdominal discomfort often associated with normal pregnancy. We describe two cases that occurred in the second trimester with an unusual presentation. Both patients suffered considerable surgical morbidity. Other cases reported in the literature are mentioned as well. When a patient with risk factors for abnormal placentation presents with abdominal pain and/or vaginal bleeding in the second trimester of pregnancy, the diagnosis of placenta percreta should be considered. A laparotomy is indicated immediately when hemoperitoneum is suspected because uterine rupture has most likely occurred. Placenta percreta in the second trimester is a potentially life-threatening condition that warrants expeditious diagnosis to limit maternal postoperative morbidity. ( info) |