Urologic considerations of placenta accreta: a contemporary tertiary care institutional experience.

BACKGROUND: As the incidence of cesarean delivery has increased, we are experiencing a higher incidence of subsequent placenta accreta and the associated complications, including urologic complications. METHODS: This is a retrospective review of all patients delivered from 2000 to 2011 with a histologically proven diagnosis of placenta accreta. Data were analyzed for baseline maternal characteristics, intraoperative and postoperative outcomes and complications. RESULTS: 83 patients were included in the analysis. The depth of placenta accreta invasion varied in the cohort, with 48, 25 and 27% being classified as placenta accreta, placenta increta and placenta percreta, respectively. 88% of patients had had a previous cesarean delivery, and 58% had more than one prior operative delivery. Cystotomy was encountered in 27% of patients and ureteral injury occurred in 4%. Degree of placenta accreta invasion, number of prior cesarean deliveries and intraoperative blood loss were associated with a higher likelihood of urologic injury. CONCLUSIONS: Urologic injuries are among the most frequently encountered intraoperative complications of placenta accreta. Surgeons involved in these cases need to be aware of this risk and maintain a high level of surveillance intraoperatively.

Comparison between emergent and elective delivery in women with placenta accreta.

OBJECTIVE: To identify possible predictive factors associated with emergent delivery of antenatally diagnosed placenta accreta and to estimate association between emergent delivery and adverse maternal outcomes in comparison to elective delivery. METHODS: A retrospective study of all patients with placenta accreta diagnosed antenatally and confirmed pathologically, who were delivered between 2000 and 2010. Baseline characteristics and outcomes of emergent deliveries were compared with elective deliveries. RESULTS: A total of 48 women met inclusion criteria, of which 24 (50%) were delivered emergently. 79.2% of emergent deliveries were preceded by antenatal bleeding (p = 0.0005), and 62.5% were preceded by recurrent bleeding (p = 0.001). Comparison of elective and emergent deliveries revealed no clinical significant difference in maternal outcome. CONCLUSIONS: Antenatal bleeding is associated with an increased risk of emergent delivery. Emergent delivery in a tertiary care facility with immediate access to blood bank and ICU capabilities does not appear to be associated with an increased risk of adverse maternal outcomes. Consequently, some patients may be candidates for delivery later than 34 weeks of gestation.

Acceptance and compliance with postpartum human papillomavirus vaccination.

OBJECTIVE: Despite the efficacy of vaccines against human papillomavirus (HPV), vaccination rates remain low in many countries. We estimated the acceptability and satisfaction of HPV vaccination in postpartum women. METHODS: Postpartum women aged 18-26 years were offered the quadrivalent HPV vaccine. Women were vaccinated during hospitalization after delivery, at the 6-week postpartum visit, and at a third dedicated vaccination visit. The primary outcome was completion of all three vaccinations. Secondary outcomes included the influence of knowledge and attitudes of HPV, decisional conflict, and satisfaction. RESULTS: A total of 150 women were enrolled. Overall, seven (4.7%) women did not receive any doses of the vaccine, 62 (41.3%) received one dose, 35 (23.3%) received two doses, and 46 (30.7%) completed the series and received all three doses of the vaccine. Knowledge of HPV and HPV-related disease, attitudes about HPV, and decisional conflict were not associated with completion of the vaccine series (P>.05). The vaccine was well tolerated with few side effects. The majority of women reported a high degree of satisfaction with postpartum vaccination; 97.2% thought vaccination was worthwhile, 98.6% thought postpartum vaccination was convenient, and 99.3% were happy they participated. Furthermore, 50.4% of women reported that they would not have otherwise asked about vaccination. After vaccination, only 17.5% said they would have rather made a separate trip for vaccination. CONCLUSION: A strategy of postpartum HPV vaccination is convenient and associated with a high degree of patient satisfaction. LEVEL OF EVIDENCE: II.

Cesarean hysterectomy requiring emergent thoracotomy: a case report of a complication of placenta percreta requiring a multidisciplinary effort.

BACKGROUND: Currently a leading indication for cesarean hysterectomy among multiparous women, placenta accreta is associated with significant maternal morbidity and mortality. CASE: A 34-year-old woman with a pregnancy complicated by placenta previa and previous cesarean deliveries was transferred to our institution following late diagnosis of placenta percreta. She underwent cesarean hysterectomy complicated by substantial hemorrhage. Massive blood product replacement precipitated severe hyperkaIemia and hypocalcemia with resultant asystole. Cardiac bypass with concomitant obligate anticoagulation was temporarily required while normalizing the patient's electrolytes. Numerous surgical and medical interventions were required to achieve hemostasis, and the patient survived to hospital discharge with moderate residual morbidity. CONCLUSION: Optimal management of placenta accreta requires a multidisciplinary approach within a tertiary center possessing extensive resources necessary for managing the most severe complications.

Trauma in pregnancy: a systematic approach.

Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. Potential complications include maternal injury or death, shock, internal hemorrhage, intrauterine fetal demise, direct fetal injury, abruptio placentae, and uterine rupture. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma. Many of the assessment and management aspects of obstetric trauma are unique to pregnancy, although initial evaluation and resuscitation should always be maternally directed. Once maternal stability is established, vigilant evaluation of fetal well-being becomes warranted. Continuous fetal heart monitoring, ultrasonography, computed tomography, open peritoneal lavage, and/or exploratory laparotomy may be indicated in a case of obstetric trauma. In view of the significant impact of trauma on the pregnant woman and her fetus, preventive strategies are paramount.

Obstetric hemorrhage.

Despite advances is medical and surgical therapy, obstetric hemorrhage remains a significant medical problem for both the developing and developed world. Depending on the definition that is used, postpartum hemorrhage complicates up to 18% of all deliveries. It is the single most important cause of maternal mortality worldwide, accounting for 25% to 30% of all maternal deaths, and it is the most common maternal morbidity in the developed world. Most cases of hemorrhage are related to uterine atony and abnormal placentation; however, many patients have no identifiable risk factors. Implementation of the active management of labor has resulted in a significant reduction in the incidence postpartum hemorrhage. However, a large number of cases still involve suboptimal care, with delays in diagnosis and treatment identified as common deficiencies.

Transcervical Foley catheter with and without oxytocin for cervical ripening: a randomized controlled trial.

OBJECTIVE: To estimate whether adding oxytocin to transcervical Foley catheter preinduction cervical ripening improves induction success. METHODS: This trial enrolled 200 women with singleton pregnancies presenting for preinduction ripening. Patients were randomly assigned to receive either Foley catheter alone (control) or Foley catheter plus low-dose oxytocin (treatment). Providers were not blinded to use of oxytocin, and labor was managed according to routine obstetric protocols. This study was powered to detect a 20% difference in the proportion of patients delivered within 24 hours. Secondary outcomes were related to vaginal delivery rate, duration of induction, complications, and pain management. RESULTS: Results were available for 183 (92 treatment, 91 control) of 200 patients randomly assigned. There were no differences in proportions of deliveries-overall (65% compared with 60%; relative risk [RR] 1.08, 95% confidence interval [CI] 0.86-1.35, number needed to treat 21) or vaginal (48% compared with 46%; RR 1.04, 95% CI 0.76-1.41, number needed to treat 60)-in 24 hours, or cesarean deliveries or times to deliveries between treatment or control groups. Rates of complications were comparable; however, the treatment group had a higher proportion of regional analgesia requirement during induction than controls (23% compared with 9%, P=.01; RR 2.60, 95% CI 1.21-5.56). CONCLUSION: Addition of oxytocin to transcervical Foley catheter does not shorten the time to delivery and has no effect on the likelihood of delivery within 24 hours or vaginal delivery rate, although there is an increased use of analgesia by these patients during ripening. The use of oxytocin in addition to Foley catheter ripening is not justified. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00468520. LEVEL OF EVIDENCE: I.

Sonographic fetal asymmetry predicts shoulder dystocia.

OBJECTIVE: The purpose of this study was to evaluate the performance of a sonographic measurement of fetal asymmetry, abdominal diameter minus biparietal diameter (AD - BPD), in the prediction of shoulder dystocia (SD) in a patient population that was unselected for diabetes mellitus (DM) status. METHODS: Patients who underwent sonographic estimations of fetal biometric measurements within 14 days of vaginally delivered live-born singleton neonates weighing 3400 g or greater at a tertiary care institution were included in this retrospective cohort. The mean AD - BPD was retrospectively compared in deliveries complicated by SD with those without SD by the Student t test. A receiver operating characteristic curve was generated to determine the optimal cutoff for SD prediction. Test performance characteristics of AD - BPD were determined. RESULTS: Of 5204 deliveries, 332 met inclusion criteria. Shoulder dystocia complicated 23 deliveries (6.9%). The mean AD - BPD was significantly higher in the dystocia group (2.39 versus 1.97; P = .0002). With an AD - BPD of 2.6 cm or greater, the risk rates of SD were 25% for unselected patients and 38.5% with DM. CONCLUSIONS: An AD - BPD of 2.6 cm or greater identifies a subset of patients with and without DM at risk for SD.

Extracorporeal membrane oxygenation in pregnancy.

BACKGROUND: Safety and efficacy of extracorporeal membrane oxygenation (ECMO) in pregnancy is unknown. CASE: A 33-year-old pregnant woman at 23 weeks of gestation presented with acute respiratory distress syndrome unresponsive to conventional mechanical ventilation. Early initiation of ECMO therapy along with protective mechanical ventilation strategy resulted in an excellent maternal and fetal outcome. CONCLUSION: Extracorporeal membrane oxygenation can be life saving when initiated early in pregnant patients with severe acute respiratory insufficiency unresponsive to conventional mechanical ventilation.

Markers of periodontal infection and preterm birth.

OBJECTIVE: This study was undertaken to explore the relationship between clinical, microbiologic, and serologic markers of periodontitis and preterm birth (PTB). STUDY DESIGN: We compared women with a singleton gestation giving birth before the 37th week (cases, n = 83) with term delivery controls (n = 120). Periodontal examination and collection of dental plaque and blood samples were performed within 48 hours after delivery. Microbial levels and maternal immunoglobulin G titers to oral bacteria were analyzed. Multivariate regression models were fitted controlling for common covariates. RESULTS: Cases showed greater mean attachment loss (1.7 vs 1.5 mm, P = .003) and higher prevalence of periodontitis (30.1% vs 17.5%, P = .027). No differences in microbial or serum antibody levels were detected between the groups. Logistic regression revealed that PTB was associated with attachment loss (adjusted odds ratio: 2.75, 95% CI: 1.01-7.54). Linear regression indicated a significant ( P = .04) association between attachment loss and low birth weight (LBW). CONCLUSION: The data support the notion that periodontitis is independently associated with PTB and LBW.