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INTRODUCCIÓN: Las alteraciones en la placentación son causa importante de morbilidad materna y neonatal y, en ocasiones, de mortalidad. La literatura científica menciona la posible asociación entre acretismo placentario y alteraciones en los parámetros bioquímicos para aneuploidía, sin descripciones de casos en que coincidan estos dos hallazgos. OBJETIVO: Este es un reporte de caso de una gestante con placenta percreta y producto con trisomía 13 REPORTE DE CASO: Gestante de 34 años, gesta 4 cesáreas 2, abortos 1, vivos 2, con embarazo de 20.4 semanas, sin antecedentes de importancia, con hallazgos en ecografía de iii nivel de alteraciones morfológicas en el sistema nervioso central, onfalocele, malformación cardiaca y deformidades en miembros. Con doppler de placenta que evidencia placenta mórbidamente adherida variedad percreta; hallazgos ecográficos confirmados con el estudio anatomopatológico. CONCLUSIONES: La trisomía 13 es una condición genética que debido a las múltiples malformaciones asociadas se considera incompatible con la vida, la placenta mórbidamente adherida se ha asociado con morbimortalidad neonatal y fetal, la no evidencia en la literatura de estas dos condiciones asociadas puede ser debido a la interrupción temprana de las gestaciones en las que se confirma el primer diagnóstico.
BACKGROUND: Alterations in placentation are an important cause of maternal and neonatal morbidity and, sometimes, deaths. The scientific literature mentions the possible association between placental accreta and alterations in the biochemical parameters for aneuploidy, without descriptions of cases in which these two findings coincide. OBJECTIVE: This is a case report of a pregnant woman with placenta percreta and trisomy 13, in which an ultrasound and pathological analysis were made. The use of keywords, in different databases, did not yield information that directly comply with these associations. CASE REPORT: A 34-year-old pregnant woman, G4C2A1V2 with a 20.4-week pregnancy, without significant medical records, with findings at III level ultrasound of morphological alterations of the central nervous system, omphalocele, cardiac malformation and limb deformities. Also, with placental Doppler that evidences morbidly adhered placenta variety percreta; ultrasound findings confirmed with the pathological study. CONCLUSION: The morbidly adhered placenta has been associated with neonatal and fetal mortality, in which some of the identified causes of fetal death are congenital anomalies. This way this case report allows for the first time to describe the association of placental accreta with aneuploidy, type trisomy 13, demonstrated by the morphological alterations of the pathological and karyotype study.
Subject(s)
Humans , Female , Pregnancy , Adult , Placenta Accreta/diagnostic imaging , Placenta, Retained/diagnostic imaging , Trisomy 13 Syndrome/diagnostic imaging , Placenta Accreta/pathology , Congenital Abnormalities , Ultrasonography, Prenatal , Placenta, Retained/pathology , Trisomy 13 Syndrome/pathologyABSTRACT
Background: Abnormal placentations such as placenta accreta, placenta increta and placenta percreta are important causes of hemorrhage after delivery causing maternal morbidity and mortality. Risk factors for abnormal placentation are prior caesarean section, placenta previa and pre-eclampsia. There is a need for reliable antenatal diagnosis for these serious conditions. If these pregnancies can be identified, antepartum, site and time of delivery as well as the surgical approach can be planned ahead; this decreases the incidence of maternal mortality due to massive hemorrhage. Aim: (1) To study the incidence of abnormal placentation in emergency peripartum hysterectomy specimen. (2) To evaluate various risk factors associated with abnormal placentation. Materials and Method: Retrospective cross-section study done in patients with abnormal placentation leading to emergency peripartum hysterectomy during a course of eight-year period. Result: We received total of 18 emergency hysterectomy specimens during eight-year period of which placenta accreta accounts 55.5 percent (10/18), placenta increta upto 38.8 percent (7/18) and placenta percreta 5.5 percent (1/18). Analysis of result with parity shows uniparous women up to 22.2 percent (4/18), and multiparous women 77.7 percent (14/18). Risk factor analysis shows previous caesarean section in 55.5 percent (10/18), placenta previa in 33.3 percent (6/18) and pre-eclampsia in 11.1 percent (2/18). Conclusion: In our study, among abnormal placentation, incidence of placenta accreta accounts for 55.5 percent and it is more common in multiparous women than uniparous women. Among risk factors in our study, previous caesarean section is commonly associated with abnormal placentation followed by a placenta previa and pre-eclampsia.
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With the opening of the second child policy,the incidence of pernicious placenta previa increases, which is dangerous and seriously endangers the life of pregnant and parturition. The main way of delivery is cesarean section. Reducing the risk of pernicious placenta previa is the goal of obstetrician. At present,several methods of adju-vant therapy for the pernicious placenta previa are summarized,including drug and non-drug treatment,non-drug therapy including pressurized uterine cavity filling, vascular ligation and interventional therapy. Among them, the development of interventional therapy is particularly rapid and the treatment options are varied.
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Objective To explore the ultrasonographic imaging characteristics of placenta increta and clinical data, and analyze the reasons for failure to make an accurate diagnosis. Methods By means of a retrospective analysis of 27 patients with placenta increta confirmed by operation and pathologic examination from January 2014 to May 2017 in the General Hospital of the People's Liberation Army (also Hospital 301 for short), the reasons for missed diagnosis and misdiagnosis are comprehensively summarized. Results The ultrasound examination in all the 27 cases (5 cases of first pregnancy, 17 cases of scar, 5 cases of maternal) illustrated the poorly-defined boundary between placenta and uterus mesometrium, the loss of retroplacental space, multiple lacunae echo areas, and the incomplete high-echo area of the serous membrane of placenta and bladder (involving the bladder); despite 3 normal placenta, the rest 24 were all diagnosed as placenta previa before operation, of which 20 belonged to central placenta previa and the other 4 belonged to marginal placenta previa. Twenty liveborn infants were delivered in the study, 13 of them went through abdominal hysterectomy after cesarean section surgery, 8 of them only received cesarean section surgery; 2 of them went through vaginal hysterectomy, 1 received cesarean section surgery after interventional embolization, 1 Uterine rupture in utero before got to the hospital, with the rest 2 received interventional embolization clamp scraping as a consequence of deadly induced labor or stillbirth. Postoperative placenta increta types demonstrated adhensive implantation, penetrating implantation, and implantation into muscular but not membrane layer in 3, 2, and 22 cases respectively. In terms of implanting position, only 3 patients (3/17) with cicatricial uterus did't undergo the implantation into the scar area mainly in the left wall, left anterior wall and posterior wall, as for patients with non-scar uterus, posterior wall implantation was the main mode presented in 6 cases (6/10). Fifteen of all the involved 27 cases were identified while 12 cases failed to be distinguished. The deep reasons of misdiagnosis were placental location (placenta adheres to the posterior wall), fetal head shelter, or small placental placement, gestational age, larger range of placenta implantation, emergency ultrasound only pay attention to the emergency situation and ignore the exist at the same time, experience of inspectors with placenta increta and so on. Conclusions Although there are some limitations in prenatal ultrasound diagnosis of placenta, it is still an important method for the diagnosis and prenatal dynamic monitoring of the condition before the placenta implantation.
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Background: Placenta accreta is a severe pregnancy complication and is currently the most common indication for peri partum hysterectomy. It is becoming an increasingly common complication mainly due to the increasing rate of cesarean delivery. Placenta accreta is considered a severe pregnancy complication that may be associated with massive and potentially life-threatening intrapartum and postpartum hemorrhage. It has become the leading cause of emergency hysterectomy. Maternal morbidity had been reported to occur in up to 60% and mortality in up to 7% of women with placenta accreta. In addition, the incidence of perinatal complications is also increased mainly due to preterm birth and small for gestational age fetuses. Placenta cretas are defined as abnormal adherences and/or ingrowths of the placenta to the uterine wall. Placenta creta is currently classified according to the depth of abnormal adhesion and invasion of the chorionic villi to the myometrium in the absence/deficiency of decidualization. The incidence of placenta accreta, defined as the abnormal adherence of the placenta to the uterine wall, has been increasing alarmingly in the developed as well as the developing world.. The exact pathogenesis of placenta accreta is unknown. Generally, placenta B. Bheeshma, B.S. Nithyananda, Sumaiyya Fatima, Fatima Anjum. A Retrospective Study of Placenta cretas: A 4 year experience at Modern Government Maternity Hospital, Hyderabad. IAIM, 2017; 4(5): 31-36. Page 32 accreta has been diagnosed on hysterectomy specimens when an area of accretion showed chorionic villi in direct contact with the myometrium and an absence of decidua or in placental basal plate. Aim: The aim of this study was to determine the incidence of placentas cretas in our hospital and to profile the associated risk factors. Materials and Methods: The patients who underwent gravid hysterectomies for placenta creta at Modern Government Maternity Hospital from 2013 to 2016 were included in study. A total of 25 cases during 4 year period were included out of 33063 deliveries. The indications for hysterectomy in majority of cases were heavy bleeding after removal of placenta or inability to remove the placenta manually either partially or totally. The specimens received in pathology department were thoroughly examined grossly and the representative sections were taken from all the specimens after proper fixation which was submitted for tissue processing and H&E stained sections were studied for final diagnosis. Results: Amongst 33093 deliveries which occurred at our institute from January 2013 to December 2016, there were a total of 25 patients with placenta accreta diagnosed by histopathology, which was a rate of 0.7% cases per 1,000 . This total included 2 cases of focal placenta accreta (8%), 10 cases of placenta accreta vera (40%), 9 cases of placenta increta (36%), and 4 cases of placenta percreta (16%). Conclusion: The incidence is considerably higher in women with both a previous caesarean delivery and placenta praevia. Therefore it is important to have a high index of suspicion in such cases. Women with a placenta previa overlying a uterine scar should be evaluated for the potential diagnosis of placenta accreta and arrangements should be made for delivery accordingly to reduce maternal and fetal morbidity and mortality
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The incidence of morbidly adherent placentation has increased in the current era of obstetrics paralleling the cesarean rate. The problem of abnormal placental adherence is a significant contributor to maternal morbidity and requires multi-disciplinary care for management. The epidemiology, antenatal diagnosis, and a multidisciplinary care model are presented in this review. Multiple methods of imaging are reviewed in detail. In addition, both surgical and non-surgical interventions for management of the abnormally adherent placenta are evaluated.
La incidencia de placentación adherida mórbidamente ha aumentado en la era actual de la obstetricia, en paralelo con la tasa de cesárea. La adherencia placentaria anormal contribuye significativamente a la morbilidad materna y requiere un manejo multidisciplinario. En esta revisión se presenta la epidemiología, diagnóstico prenatal y un modelo de atención multidisciplinario. Se revisa en detalle los varios métodos de imágenes utilizados en el diagnóstico. Y se evalúa las intervenciones quirúrgicas y no quirúrgicas para el manejo de la placenta adherida anormalmente.
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Objective To study the clinical characteristicsand perioperative managementof complicated placenta increta, effectively reduce the maternal adverse perinatal outcomes. Methods Retrospective analysis 25 cases of complicated placenta increta between January 2013 and December 2015 in the Third Affiliated Hospital Of Guangzhou Medical University. Grouped into preoperative line 9 cases of ureteral catheter group and without catheter group 16 cases; Conventional hysterectomy group of 17 cases and the posterior hysterectomy group of 8 cases , compare the operation time , postpartum hemorrhage , blood transfusion amount , bladder injury or ureteral injury rate , rate of transferred to the ICU and hospital stay. Results 76% appear repeatedly painless vaginal bleeding during pregnancy , 56% appear bleeding before delivery. Prenatal diagnosis of 17 cases (68%). The preoperative line cystoscopy + bilateral retrograde ureteral catheter or after the posterior hysterectomy , shorter operation time , less postpartum hemorrhage , reduce blood transfusion volume , no urinary tract injury rate, transferred to the ICU rate is low, the difference was statistically significant (P < 0.05). Conclusions We should attach importance to repeated painless vaginal bleeding , improve prenatal diagnostic rate of complicated placenta increta. The perioperative managementis more comprehensive , effective and standard participation , preoperative ureteral catheter and the posterior hysterectomy can effectively reduce the maternal adverse perinatal outcomes.
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Objective To evaluate the predictive value of MRI features in the diagnosis of placenta increta/percreta preoperative-ly.Methods We retrospectively reviewed MRI of 39 pregnant women who were suspected to have placenta increta/percreta by the ultrasound previously.1 7 patients were defined as placenta increta/percreta according to the surgical-pathological results,while 22 patients were defined without abnormal placentation.We assessed the presence or absence of the specialized MRI features of placenta increta/percreta.The binary logistic regression analysis was used to determine the valuable MRI findings for predictive of placenta increta/percreta.Results The tenting of the superior wall of bladder or the infiltration of adjacent organs were the most useful signs to predict placenta percreta,with the highest odds ratio (OR)value of 70,P =0.008.The low signal intensity bands on T2 WI and focally interrupted interface of placenta/myometrial were valuable signs to the predictive of placenta increta,with the OR value of 6.4 and 5.6 respectively according to the univariate analysis.On multivariate regression analysis,the low signal intensity bands on T2WI was independent predictive factor for placenta increta(OR 6.6,P =0.02),while the focally interrupted interface of placen-ta/myometrial was not independent factor (OR 3.1 6,P =0.1 75).Conclusion The most useful predictive MRI features for placenta increta/percreta are tenting of the superior wall of bladder and the infiltration of adjacent organs,followed by the low signal intensity on T2 WI.The focally interrupted interface of placenta/myometrial is useful factor.
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Objective:To analyze the ultrasonography and MRI characteristics of placenta increta and to compare and analyze the value of ultrasonography and MRI for the diagnosis of placenta increta.Methods: From November, 2012 to October 2014, 56 patients with suspected placenta increta were selected as the objects of experiment. All patients were examined by ultrasound and MRI before the surgery. The ultrasound and MRI image features were retrospectively analyzed and summarized its detection. The reliability and accuracy of detection were compared and analyzed.Results: The visible vortex in the placenta, disappearance of placenta back clearance, local thinning of muscularis and placental pathologic thickening were the main characters of ultrasound images. The boundary wavy, placental thickness heterogeneity, signal heterogeneity, the interface and serosal signal loss or interruption and vascular rich were the main characters of MRI. For ultrasonography, there were 17 cases accurate detection, the sensitivity was 89.47%, the specificity was 92.60%, the precision ratio was 92.86%, the diagnostic index was 85.18%. For MRI, there were 18 cases accurate detection, the sensitivity was 94.74%, specificity was 96.30%, the precision ratio was 96.43%, the diagnostic index was 92.60% and Kappa value was 0.86, after the data comparison of two groups, (Kappa=0.86, P>0.05), there was no significant difference.Conclusion: The ultrasound and MRI were the important means of clinical diagnosis of placenta increta, and their diagnostic value cannot be replaced by each other. To take advantages of both was suggested and a more accurate and reliable diagnosis can be made.
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Uterine rupture is a rare life-threatening complication. It mainly occurs in the third trimester of pregnancy and is rarely seen during the first or second trimesters. Our centre experienced three important cases of uterine rupture. First case: spontaneous uterine rupture at 14 weeks of pregnancy, which was diagnosed at autopsy. It was misled by the ultrasound finding of an intrauterine pregnancy, and searching for other non-gynaecological causes delayed the urgent obstetric surgical management. Second case: ruptured uterus at 24 weeks following medical termination due to foetal anomaly. It was diagnosed only at laparotomy indicated for failed medical termination and chorioamnionitis. Third case: uterine rupture at 21 weeks of pregnancy in a patient with gastroenterology symptoms. In these reports, we have discussed the various risk factors, presentations, course of events and difficulties in diagnosing uterine rupture. The study concludes that the clinical presentation of uterine ruptures varies. It occurs regardless of gestational age. Ultrasound findings of intrauterine pregnancy with free fluid do not exclude uterine rupture or ectopic pregnancy. Searching for non-gynaecological causes in such clinical presentations might delay crucial surgical intervention, which leads to unnecessary morbidity, mortality or loss of obstetrics function.
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ObjectiveTo investigate the MRI features of placenta accreta.MethodsFrom Apr 2009 to Jun 2011,15 patients with placenta accrete received MRI examination.In them,placenta accrcta was diagnosed based on clinical manifestations or postoperative histopathologv.The MR features of placenta accreta in thcm( study group) were retrospectively analyzed and compared with those in 15 pregnant women without placenta accreta (control group)with Fisher exact test.ResultsIn the 15 patients with placenta accreta,uterine bulging and(or) a focal outward contour bulge was detected in 14 patients; heterogeneous signal intensity in the placenta was detected in 15 patients; dark intraplacental bands on T2-weighted images was detected in 15 patients; and increased subplacental vascularity was detected in 11 patients on T1- weighted images.In the study group,14 patients showed at least three of the above four features,and in all of them uterine bulging and(or) a focal outward contour bulge,heterogeneous signal intensity in the placenta and dark intraplacental bands on T2-weighted images were detected; one patient showed heterogeneous signal intensity in the placenta,dark intraplacental bands on T2-weighted images and increased subplacental vascularity.In the control group,none patient had three of the above features.Uterine bulging and(or) a focal outward contour bulge,heterogeneous signal intensity in the placenta,dark intraplacental bands on T2-weighted images and increased subplacental vascularity were detected in 3,6,3 and 4 patients (P=0.000,0.001,0.000 and 0.027 ),respectively.ConclusionsThe main MRI features of placenta accreta are uterine bulging and(or) a focal outward contour bulge,heterogeneous signal intensity in the placenta and dark intraplacental bands on T2-weighted images Besides,increased subplacental vascularity also could provide useful information for the diagnosis of placenta accreta.
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Abnormal attachment of the placenta (Placenta accreta, increta, and percreta) is an uncommon but potentially lethal cause of maternal mortality from massive postpartum hemorrhage. A 33-yr-old woman, who had been diagnosed with a placenta previa, was referred at 30 weeks gestation. On ultrasound, a complete type of placenta previa and multiple intraplacental lacunae, suggestive of placenta accreta, were noted. For further evaluation of the placenta, pelvis MRI was performed and revealed findings suspicious of a placenta increta. An elective cesarean delivery and subsequent hysterectomy were planned for the patient at 38 weeks gestation. On the day of delivery, endovascular catheters for balloon occlusion were placed within the hypogastric arteries, prior to the cesarean section. In the operating room, immediately after the delivery of the baby, bilateral hypogastric arteries were occluded by inflation of the balloons in the catheters previously placed within. With the placenta retained within the uterus, a total hysterectomy was performed in the usual fashion. The occluding balloons were deflated after closure of the vaginal cuff with hemostasis. The patient had stable vital signs and normal laboratory findings during the recovery period; she was discharged six days after delivery without complications. The final pathology confirmed a placenta increta.
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Adult , Female , Humans , Pregnancy , Arteries/surgery , Catheterization , Cesarean Section , Gestational Age , Hysterectomy/methods , Placenta/blood supply , Placenta Accreta/surgery , Placenta Previa/surgery , Postpartum Hemorrhage/prevention & control , Treatment OutcomeABSTRACT
Placenta accreta is a rare complication of pregnancy with high rates of maternal morbidity and mortality. Although the incidence of placenta accreta was rare in the past, it is sharply rising as a result of the dramatic increases in the cesarean section rate. Hysterectomy is the most effective way to manage the placenta accreta in the majority of cases. While in many situations hysterectomy will remain appropriate, there are other management options available involving conservative approaches. In this article, we report our experience of a successful conservative treatment using methotrexate and misoprostol to a patient in whom the whole placenta was not detachable from the uterus due to placenta increta.
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Female , Humans , Pregnancy , Cesarean Section , Hysterectomy , Incidence , Methotrexate , Misoprostol , Placenta , Placenta Accreta , UterusABSTRACT
Placenta increta is a kind of placental adhesion which can cause severe postpartum hemorrhage and life-threatening condition. It might necessitate a hysterectomy, but conservative management can be considerable for preserving reproductive potential when possible. A 34-years-old woman in her 41st week of pregnancy had normal full term spontaneous delivery. Retained placenta after removal by placenta forceps resulted in mild bleeding. Placenta increta was clinically diagnosed on computerized tomography. Remnant placenta in situ was nearly disappeared 2 months later after five-time intramuscular injection of 50 mg methotrexate and three-times curettage was done for conservative management.
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Female , Humans , Pregnancy , Curettage , Hemorrhage , Hysterectomy , Injections, Intramuscular , Methotrexate , Placenta , Placenta Accreta , Placenta, Retained , Postpartum Hemorrhage , Surgical InstrumentsABSTRACT
Objective To investigate the effect of combination of methotrexate and Chinese herbs in treating placenta increta.Methods 42 cases with stable vital signs were divided randomly into observe group and control group.On the basis of intravenous injection of methotrexate,the observe group were treated with Shenghua decoction while the control group were not.Results 5 cases of the observe group were given hysterectomy because of massive hemorrhage,10 cases were given uterine curettage,the successful rate of conservative treatment was 76.2%.12 cases of the control group were given hysterectomy because of massive hemorrhage,8 cases were given uterine curettage,the successful rate of conservative treatment was 42.9%.After statistics comparison,there was significant difference(P＜0.05)between observe group and control group.Conclusion Combination of methotrexate and Chinese herbs iS a better therapy for placenta increta.
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Objective To investigate the clinical characteristics, diagnosis and treatment of placenta increta.Methods A retrospective analysis was carried out on 13 admitted cases of placenta increta from 1989～2006. Results Among the 13 cases analysed, 5 cases with a history of Caesarian section had a 0% success rate of treatment with conservative care (0/5), 100% less than that of cases with no history of Caesarian section (8/8), P＜0.05; the success rate of treatment of partial placenta increta with methotrexate with Jia Wei Sheng Hua Tang was 100%. Conclusion Caesarian section is a risk factor of placenta increta, and its prognosis is poor; however, Jia Wei Sheng Hua Tang has proven satisfactory as a supplementary treatment for placenta inereta.
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Placenta increta is one of lethal complications of pregnancy characterized by invasion of placenta villi into the underlying myometrium and usually presented in early postpartum period with difficult placental removal and massive bleeding. Placenta increta may complicate first and early second-trimester pregnancy loss causing profuse post-curettage hemorrhage but the lesion is rarely found and hard to diagnose. We experienced a case of hemoperitoneum caused by implanted chorionic villi on the uterine serosa regurged from uterine cavity, 6weeks after artificial abortion at gestational age of 5 weeks and 5 days.
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Animals , Female , Humans , Mice , Pregnancy , Chorionic Villi , Dilatation and Curettage , Gestational Age , Hemoperitoneum , Hemorrhage , Myometrium , Placenta , Placenta Accreta , Postpartum Period , Pregnancy Trimester, First , Serous MembraneABSTRACT
Uterine sacculation is a very rare complication associated with pregnancy in which a part of the uterine wall balloons, and it is difficult to diagnose because it is usually asymptomatic. It frequently contains the placenta and sometimes may be involved with the trapped placenta after delivery due to its structural characteristic. It is impossible to remove the retained placenta in the sac by using usual methods such as manual delivery or curettage so most of patients with it end up with having a laparotomy. Especially, if the placenta in it is accompanied by abnormal adherence of the placenta or serious hemorrhage, hysterectomy should be considered. Currently several conservative methods for the retained placenta including selective uterine artery embolization and administration of methotrexate have been introduced and these may be tried to treat the retained placenta in the uterine sacculation for avoiding operation and preserving future reproductive potential in selective cases. We experienced a case of placenta increta in the uterine sacculation that was diagnosed first during cesarian section and was treated with selective uterine artery embolization followed by methotrexate administration. This case is reported with a brief review of the literatures.
Subject(s)
Humans , Pregnancy , Curettage , Hemorrhage , Hysterectomy , Laparotomy , Methotrexate , Placenta Accreta , Placenta , Placenta, Retained , Uterine Artery EmbolizationABSTRACT
Uterine sacculation is a very rare complication associated with pregnancy in which a part of the uterine wall balloons, and it is difficult to diagnose because it is usually asymptomatic. It frequently contains the placenta and sometimes may be involved with the trapped placenta after delivery due to its structural characteristic. It is impossible to remove the retained placenta in the sac by using usual methods such as manual delivery or curettage so most of patients with it end up with having a laparotomy. Especially, if the placenta in it is accompanied by abnormal adherence of the placenta or serious hemorrhage, hysterectomy should be considered. Currently several conservative methods for the retained placenta including selective uterine artery embolization and administration of methotrexate have been introduced and these may be tried to treat the retained placenta in the uterine sacculation for avoiding operation and preserving future reproductive potential in selective cases. We experienced a case of placenta increta in the uterine sacculation that was diagnosed first during cesarian section and was treated with selective uterine artery embolization followed by methotrexate administration. This case is reported with a brief review of the literatures.