Rotura uterina por placenta percreta. Un caso clínico en útero bicorne unicollis / Uterine rupture due to placenta percreta. A case in uterus bicornis unicollis

Se expone el caso de una gestante de 27 semanasde amenorrea, diagnosticada de útero bicorneunicollisy portadora de cerclaje cervical, queacude a urgencias por dolor abdominal. No seobserva dinámica. Tras empeoramiento general yprogresivo en 4 h, se retiró el cerclaje y se indicócesárea urgente por shock hipovolémico ysospecha de desprendimiento prematuro deplacenta normalmente inserta. En la laparotomíase observó hemoperitoneo 2 l, útero bicorne,acretismo placentario con perforación de 3 cmen fondo del hemiútero gestante. Nació un fetomujer vivo de 1.030 g, que evolucionósatisfactoriamente

A woman in the 27th week of gestation, with aprior diagnosis of uterus bicornis unicollis and acervical cerclage in situ, presented to theemergency department with severe abdominal pain.No uterine dynamics were observed. The patientrapidly deteriorated shortly after admission,warranting removal of the cervical cerclage andemergency cesarean section delivery with theworking diagnoses of hypovolemic shock andabruptio placentae. Laparotomy showed free bloodin the peritoneum (2 liters) as well as a placentaaccreta with a 3-cm perforation in the uterinefundus. A female infant, weighing 1030 g, wasdelivered and progressed satisfactorilyshockwav

Inversión uterina puerperal / Puerperal uterine inversion

Introducción: La inversión uterina es una emergencia obstétrica y una rara complicación del tercer estadio del trabajo del parto. Objetivo: Describir las características clínicas, diagnósticas, terapéuticas y evolutivas de las pacientes con inversiones uterinas. Material y métodos: Estudio retrospectivo basado en 6 parturientas diagnosticadas de inversión uterina en el posparto en el Hospital de León durante el año 2005. Resultados: Las inversiones se produjeron en primíparas a término, con analgesia epidural y con partos instrumentales. En el 83% se utilizó oxitocina durante la dilatación, cuya duración media fue de 6,5 h. El diagnóstico fue mayoritariamente clínico, excepto en un caso grado II, que precisó una ecografía y cuya resolución fue quirúrgica. En el resto de los casos la resolución fue mediante reposición manual (83%). La disminución media de la hemoglobina preparto tras el episodio fue de 2,7 g/dl y sólo 2 pacientes precisaron transfusión. Conclusiones: Los factores predisponentes son la hipotonía uterina, la implantación fúndica y las placentas accretas. El 60% se debe a maniobras precipitadas, como la tracción de cordón o una presión fúndica inapropiada. El diagnóstico es esencialmente clínico. Aunque poco común, si no es diagnosticada, la inversión uterina pueda causar una hemorragia importante y shock, y provocar la muerte materna. Una vez diagnosticada, se deben tomar medidas para estabilizar a la paciente, realizándose inmediatamente la reducción manual. Los tocolíticos, como la ritrodina, la terbutalina y el sulfato de magnesio, o los anestésicos halogenados, pueden administrarse para facilitar la reversión. La nitroglicerina por vía intravenosa puede ser una alternativa. El fracaso requeriría tratamiento quirúrgico

Introduction: Uterine inversion is a rare obstetric emergency that occurs during the third stage of labor. Objective: To describe the clinical, diagnostic and therapeutic characteristics and outcomes in patients with uterine inversion. Material and methods: We performed a retrospective study of six patients with uterine inversion during the puerperium in the Hospital de Leon (Spain) in 2005. Results: All inversions occurred in primiparous women with epidural anesthesia and instrumental delivery at term. Oxytocin was used in 83% during dilatation, the average duration of which was 6.5 hours. Diagnosis was mainly clinical except in one grade II inversion, which required ultrasonography and was resolved surgically. The remaining cases were resolved through manual reduction (83%). After the episode, hemoglobin levels were reduced by an average of 2.7 g/dl from prepartum levels, and only two patients required blood transfusion. Conclusions: Factors predisposing to uterine inversion were hypotonic uterus, fundal implantation of the placenta, and placenta accreta. Sixty percent of all cases were caused by precipitous maneuvers including traction on the cord or improper fundal pressure. Diagnosis is essentially clinical. Although uncommon, uterine inversion will result in severe hemorrhage and shock if left unrecognized, leading to maternal death. Once a diagnosis is made, immediate measures must be taken to stabilize the mother. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as ritrodine, magnesium sulphate and terbutaline, or halogenated anesthetics may be administered to relax the uterus and aid its reversal. Intravenous nitroglycerin is an alternative to tocolytics. Failure of reversion or recurrence requires surgical treatment (AU)

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.

Placenta previa-accreta: risk factors and complications.

OBJECTIVE: The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA). STUDY DESIGN: Patients with placenta previa (n = 347) delivered over 20 years were reviewed, divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared. RESULTS: Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome. CONCLUSION: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa.

Spontaneous uterine rupture at an unusual site due to placenta percreta in a 21-week twin pregnancy with previous cesarean section.

Spontaneous uterine rupture is a rare, but serious complication of placenta percreta. This case report is about a spontaneous uterine rupture at an unusual site due to placenta percreta in a 21-week twin pregnancy with previous cesarean section. A 30-year-old, G3, P2 woman was referred to our unit in the 21st week of a twin pregnancy with acute abdomen. An emergency laparotomy was performed with the diagnosis of uterine rupture and intra-abdominal hemorrhage. A significant hemoperitoneum was found, with both fetuses freely floating in the peritoneal cavity. A large transverse rupture at the posterior isthmus wall was detected. Subtotal hysterectomy with preservation of both ovaries was performed. Pathological investigation of the uterus revealed placenta percreta.

Placenta percreta causing rupture of an unscarred uterus at the end of the first trimester of pregnancy: case report.

Reports on placenta percreta in early pregnancy leading to a spontaneous rupture of the uterus are rare. We report a case of this potentially life-threatening complication in the 14th week of pregnancy in an otherwise healthy woman who underwent a manual extraction of the placenta during a previous delivery but who had no history of severe pathology that could have potentially resulted in uterine damage. The occurrence of severe abdominal pain and the presence of a large quantity of free fluid in the abdomen necessitated an emergency laparotomy, revealing a haemoperitoneum due to rupture of the uterus, which was followed by a hysterectomy. This case demonstrates that in patients with a history of placenta accreta and subsequent manual extraction of the placenta, a close investigation of the uterine wall and placentation should be performed in the first trimester in order to anticipate a placenta percreta.

Spontaneous uterine rupture as an unusual cause of abdominal pain in the early second trimester of pregnancy.

A case of placenta percreta causing spontaneous uterine rupture is presented. This is a rare condition, which may present in the antepartum period as abdominal pain, with or without signs of hemorrhagic shock. This entity can lead to significant morbidity and mortality if not aggressively managed. A discussion follows on the pathophysiology, incidence, risk factors, presentation and management of this condition.

Placenta accreta and intrauterine fetal death in a woman with prior endometrial ablation: a case report.

BACKGROUND: Few cases of pregnancy following endometrial ablation have been reported. Placenta accreta and poor perinatal outcome are potential risks due to underlying endometrial destruction and uterine scarring. CASE: A 41-year-old, white woman presented for initial prenatal care at 12 weeks, 3 years after endometrial ablation with resection of a leiomyoma. The patient's prenatal care was unremarkable until 20 weeks, when she presented with intrauterine fetal death. Labor was induced with misoprostol, and a stillborn fetus resulted. The placenta failed to deliver spontaneously after 6 hours and continuing doses of misoprostol. An attempt at manual extraction failed to demonstrate a clear cleavage plane between the placenta and endometrium. The patient underwent a hysterectomy for placenta accreta, which was confirmed on pathology. CONCLUSION: Endometrial ablation may predispose the patient to abnormal placentation and intrauterine fetal death. Physicians should counsel their patients appropriately about the likelihood of this outcome.

Is placenta accreta catching up with us?

BACKGROUND: Concomitant with the increase in Caesarean birth over the past three decades there has been an apparent rise in the incidence of placenta accreta and its variants. The sequelae of an increase in the occurrence of abnormal placentation is the enhanced potential for severe maternal morbidity. AIM: To determine the contempory demographics of placenta accreta over a 5-year period in a tertiary level teaching hospital. METHODS: A retrospective review of all cases of placenta accreta and variants during the period of 1998-2002. Individual charts review followed case ascertainment via the hospital obstetric database. RESULTS: Thirty-two women with placenta accreta (or variant) were identified. Median maternal age was 34 years, with a median parity of 2.5. Seventy-eight percent of cases had had at least one prior Caesarean birth, and 88% of cases were associated with placenta praevia. Pre-delivery ultrasonography was performed in all cases, providing diagnostic sensitivity of 63% and specificity of 43% with a predictive value of 76%. Hysterectomy was performed in 91% of cases with median intraoperative blood loss of 3000 mL. There were no maternal deaths in the current series. CONCLUSION: A strong association between placenta accreta, placenta praevia and prior Caesarean birth has been demonstrated. As there is the potential for significant maternal morbidity the risk of placenta accreta needs to be recognised and women at risk should be considered for delivery at an institution with appropriate expertise and resources in managing this condition.

Placenta percreta with urinary bladder involvement.

A 37-year-old Pakistani lady, who had previously undergone one cesarean delivery and one uterine curettage, was admitted to the labor ward at 29 weeks of gestation with history of a sudden severe painless vaginal bleeding from a sonographically diagnosed placenta previa. An immediate cesarean section was performed and a live male infant was delivered. The placenta was morbidly adherent to the lower uterine segment and attempts at removal caused torrential bleeding, necessitating cesarean hysterectomy. In addition, attempts to dissect the bladder from the lower uterine segment were unsuccessful and, hence, the diagnosis of placenta percreta with involvement of the urinary bladder was made. A modified posterior approach to the hysterectomy was carried out, with subsequent good recovery.

Conservative management of spontaneous uterine perforation associated with placenta accreta: a case report.

BACKGROUND: Placenta accreta occurring in an unscarred uterus is exceedingly rare. Previous cases of spontaneous uterine perforation associated with placenta accreta were treated with hysterectomy. CASE: A nulliparous woman was clinically diagnosed with placenta accreta when spontaneous vaginal delivery was complicated by postpartum hemorrhage and a retained placenta. Magnetic resonance imaging subsequently revealed focal areas of placenta accreta. Acute-onset abdominal pain and cul-de-sac fluid prompted diagnostic laparoscopy, which revealed a spontaneous uterine perforation in the right posterior-lateral aspect of the uterus. This area was oversewn, and the patient received 2 weeks of postoperative antibiotics because of Enterococcus faecalis bacteremia. CONCLUSION: Spontaneous uterine perforation associated with placenta accreta can be managed conservatively.

Uterine artery embolization: an effective treatment for intractable obstetric haemorrhage.

AIM: To present the findings of uterine artery embolization (UAE) in the management of obstetric haemorrhage. MATERIALS AND METHODS: From October 1999 to February 2003, 10 women with postpartum haemorrhage (n=7) and post-abortion haemorrhage with placenta accreta (n=3), were referred to our department for pelvic angiography and possible arterial embolization. RESULTS: Angiography revealed engorged and tortuous uterine arteries in all patients; and contrast medium extravasation in three patients. Eight patients (three with and five without detectable active bleeding) then underwent bilateral UAE. Medium-sized (250-355 microm) polyvinyl alcohol particles were injected via a coaxial catheter into the uterine arteries, followed by gelatin sponge pieces via a 4F Cobra catheter. Microcoil devascularization was also performed in the two patients with visible, active bleeding. The vaginal bleeding resolved in all patients, without any ischaemic complications. At follow-up, all patients who underwent UAE had normal menstruation; three of them subsequently gave birth to full-term healthy babies. CONCLUSION: Selective UAE by the coaxial method is safe and effective to control obstetric haemorrhage, with the potential to preserve fertility.