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1.
J Matern Fetal Neonatal Med ; 35(26): 10660-10666, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36543387

RESUMO

OBJECTIVE: To analyze how precise the surgical staging is after prenatal diagnosis of patients with placenta accreta spectrum (PAS). MATERIAL AND METHODS: This was a retrospective cohort study that included 622 women diagnosed with placenta accreta spectrum who underwent surgery between 1 January 2000, and 1 January 2020, in public, private, and university hospitals in Buenos Aires, Argentina. Prenatal diagnosis included abdominal and transvaginal ultrasounds and T2-weighted MRI scans. Comprehensive surgical staging (CSS) was performed by dissecting the coalescence spaces of the pelvic fasciae, including the broad ligament and the colpouterine and retrouterine spaces. Once the compromised uterine wall (lateral, anterior or posterior) was identified, the characteristics of the lesion were evaluated. The lateral invasion was classified as type A when there was no placental tissue in the parametrial zone; type B when the placental tissue protruded laterally and was covered by serosa, and type C when the placental tissue included neoformed vessels. Involvement of the retrovesical space (anterior uterine wall) was classified as type A when no neoformed vessels and no firm adherence between nearby organs were present, type B when the retrovesical area partially adhered but the planes could be dissected, and type C when the lower dissection of the vesicouterine space was extremely adhered or impossible.The posterior uterine aspect was classified after exteriorizing the organ, with the placenta still inside. It was determined as type A when there was no evidence of placental invasion, type B when there was organ adherence or it showed a heterogeneous appearance of the posterior uterine wall above the peritoneal reflection, and type C when there was adherence to other organs or when the invasion or neovascularization was below the peritoneal reflection. RESULTS: CSS increases the efficacy of prenatal studies, including ultrasound and MRI, by up to 50%. The diagnosis of type 2 (parametrial) PAS or low retrovesical invasion implied an immediate modification of the surgical tactics, vascular control, or a specific type of surgery. Additionally, deep interfacial dissection allowed the identification of healthy uterine tissue, modifying the initial indication of hysterectomy for a conservative reconstructive procedure. CONCLUSIONS: Comprehensive surgical staging of PAS proved to be an excellent tool for determining the extent and specific topography of placental invasion.


Assuntos
Placenta Acreta , Placenta Prévia , Gravidez , Humanos , Feminino , Placenta Acreta/diagnóstico por imagem , Placenta Acreta/cirurgia , Estudos Retrospectivos , Ultrassonografia Pré-Natal , Diagnóstico Pré-Natal/métodos , Útero/diagnóstico por imagem , Útero/cirurgia , Útero/patologia
2.
Am J Obstet Gynecol MFM ; 5(2): 100802, 2022 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-36372188

RESUMO

BACKGROUND: There are 3 treatment options for placenta accreta spectrum: cesarean delivery with hysterectomy, expectant management, and uterine-sparing surgical techniques. One-step conservative surgery is the most extensively described conservative surgical technique, and it has extensive evidence supporting its usefulness; however, few groups apply it, most likely because of the misconception that it is a complex procedure that requires extensive training and is applicable to only a few patients. OBJECTIVE: This study aimed to evaluate the clinical outcomes of patients undergoing one-step conservative surgery in 4 placenta accreta spectrum reference hospitals and provided detailed steps for successfully applying this type of surgery. STUDY DESIGN: This was a multicenter, descriptive, prospective study that described the outcomes of patients with placenta accreta spectrum treated in 4 reference hospitals for this condition. The patients were divided into those managed with one-step conservative surgery and those managed with cesarean delivery and hysterectomy. RESULTS: Overall, 75 patients were included. One-step conservative surgery was possible in 85.3% of placenta accreta spectrum cases (64 patients). Intraoperative staging and placenta accreta spectrum topographic classification allowed for the selection of one-step conservative surgery candidates. The clinical outcomes of the 2 groups were similar, except for the frequency of transfusions (81.8% in the cesarean delivery and hysterectomy group vs 67.2% in the one-step conservative surgery group) and vascular interventions (27.3% in the cesarean delivery and hysterectomy group vs 4.7% in the one-step conservative surgery group), which were both higher in patients who underwent hysterectomy. In addition, the operation time was shorter in the one-step conservative surgery group (164.4 minutes vs 216.5 minutes). CONCLUSION: One-step conservative surgery is a valid procedure in most patients with placenta accreta spectrum. It is an applicable technique even in scenarios with limited resources. However, its safe application requires knowledge of the topographic classification and the application of intraoperative staging.

5.
Am J Obstet Gynecol ; 227(1): 96-97, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35248574

RESUMO

Obstetrical hemorrhage is the leading cause of maternal death, and its treatment frequently involves surgical procedures. In the most serious cases, regardless of the etiology, the priority is to stop the bleeding and obtain the conditions to definitively repair the injury that generates the bleeding. Multiple options for achieving hemostasis have been described, but most of them require extensive training or technological resources that are not available in all hospitals. Internal manual aortic compression is a procedure that is widely used in the management of massive pelvic bleeding; it was first described more than 50 years ago in obstetrics but is rarely used by obstetricians today. We describe in detail the technique for internal manual aortic compression and highlight the simplicity and effectiveness of the procedure, especially as an initial measure, to avoid the metabolic consequences of massive blood loss. We hope that internal manual aortic compression is taken into account by each obstetrician when caring for a pregnant woman with massive bleeding.


Assuntos
Hemorragia , Obstetrícia , Aorta/cirurgia , Feminino , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Pelve , Gravidez
6.
J Matern Fetal Neonatal Med ; 35(25): 4994-4996, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33441040

RESUMO

AIM: To report the neonatal outcome after conservative-reconstructive surgery for placenta accreta spectrum (PAS) disorders. MATERIALS AND METHODS: Inclusion criteria were women undergoing conservative-reconstructive surgery for PAS. The outcomes explored were: 5 min Apgar score, birth weight, and need for ventilatory support (RS1 supplementary oxygen, RS2 nasal positive pressure ventilation, or RS3 mechanical ventilatory assistance). Descriptive statistics (means and standard deviations for quantitative and percentage and interquartile range for quantitative variables) were sued to report the data. RESULTS: 84% of women with PAS type 1 were delivered between 35 and 37 weeks of gestation. There was only one case of small for gestational age (SGA) newborn 81% of the newborns required admission to the NICU and 11% respiratory support of those pregnancies complicated by PAS type 2, 59% were delivered between 35 and 36.6 weeks. Neonatal birth weight was consistent with gestational age at birth for all the included cases, and there was no SGA newborn in this group. 84% of the newborns required admission to the NICU, while 21% respiratory support. All women with PAS type 3 were delivered between 30 and 33 weeks of gestation. Although all newborns were admitted to NICU and 73% required ventilatory support, there was no SGA case. Pregnancies complicated by PAS type 4 completed their pregnancy between weeks 35 and 37. There was no case affected by SGA; although all newborns were admitted to NICU, none required ventilatory support. CONCLUSIONS: Conservative surgery in pregnancies complicated by PAS does not seem to increase the risk of adverse neonatal outcomes. Early gestational age at birth and invasion in the inferior third of the lower uterine segment is associated with an increased incidence of neonatal complications, likely due to the earlier gestational age at delivery for these pregnancies.


Assuntos
Placenta Acreta , Gravidez , Recém-Nascido , Feminino , Humanos , Masculino , Placenta Acreta/cirurgia , Placenta Acreta/epidemiologia , Peso ao Nascer , Idade Gestacional , Recém-Nascido Pequeno para a Idade Gestacional , Retardo do Crescimento Fetal
7.
J Matern Fetal Neonatal Med ; 35(25): 6104-6111, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33843408

RESUMO

INTRODUCTION: Placenta accreta spectrum (PAS) causes severe morbidity and can result in maternal death. It must be managed in specialized centers with interdisciplinary groups, but few publications have described the usual management within a specific geographic region. We intend to describe the usual approach for PAS in reference centers in Latin America. METHODOLOGY: This was an observational, multicenter, cross-sectional study conducted in Latin American PAS reference centers. A standardized survey was implemented and applied to obstetric service coordinators and leaders of interdisciplinary groups with experience in PAS between September and November 2020. RESULTS: One hundred fifty-four hospitals were included. Most of them (64.3%) handle approximately one case of PAS every two months, and almost all centers (89.6%) believe that their performance could be improved. CONCLUSIONS: Most of the reference centers for PAS in Latin America attend to a small number of cases each year, and almost all of these hospitals identify opportunities to improve the management or approach for PAS in women.


Assuntos
Placenta Acreta , Gravidez , Humanos , Feminino , Placenta Acreta/epidemiologia , Placenta Acreta/terapia , América Latina/epidemiologia , Estudos Transversais , Estudos Retrospectivos , Hospitais , Placenta
8.
J Matern Fetal Neonatal Med ; 35(25): 6297-6301, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33843411

RESUMO

AIM: To report the outcome of pregnant women with a prior pregnancy complicated by placenta accreta spectrum (PAS) disorders treated with resective-conservative surgery at the time of cesarean section. MATERIALS AND METHODS: Retrospective analysis of pregnant women treated with conservative surgery in the prior pregnancy complicated by PAS disorders. The primary outcome was spontaneous preterm birth with intact membranes or following a preterm labor rupture of the membranes before 37 weeks of gestation. Secondary outcomes were uterine rupture, need for hysterectomy due to severe ante or intrapartum maternal hemorrhage, myometrial thinning at the time of cesarean section, 5 min Apgar score, birth weight centile, and the occurrence of small for gestational age newborns. All these outcomes were observed in women with prior PAS treated with conservative resective surgery divided according to the topographical surgical classification. RESULT: Pregnancies included: 89.6% (181/202) related to PAS type 1; 7.9% (16/202) related to PAS type 2, and 2.5% (5/202) related to PAS type 3. 90% of cases (162/179) (95 CI: 90.3-90.6) completed the pregnancy at term (greater than 37 weeks). The average intergenesic period was 15 months for PAS type 1 and 2 (SD 4,76) (Q1:12; Q3:19), and 18 months for PAS 3 (SD 6,56) (Q1:14; Q3:19). A few mothers presented some complications PPROM 1; premature labor 4; hypertension 2; atony 1; overweight 1; and gestational diabetes 2. The mean age was 30 years (T1), 31 years (T2), and 36 years (T3·). The uterine segment was thicker than usual except for one case of partial uterine dehiscence (twins). There were no placenta previa or PAS, a uterine atony case, and there was one case of hysterectomy by patient request. CONCLUSIONS: Subsequent pregnancies after use of resective-reconstructive for PAS has demonstrated to have similar maternal and neonatal outcomes to typical gestation and cesarean delivery.


Assuntos
Placenta Acreta , Complicações na Gravidez , Nascimento Prematuro , Recém-Nascido , Feminino , Gravidez , Humanos , Adulto , Placenta Acreta/terapia , Resultado da Gravidez/epidemiologia , Cesárea , Estudos Retrospectivos , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/cirurgia , Histerectomia , Complicações na Gravidez/cirurgia
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