Anomalías de inserción placentaria: diagnóstico y tratamiento oportuno / Placental insertion anomalies: timely diagnosis and treatment

Paciente de 34 años, gestante de 34 semanas. Doble cesáreada anterior con estudio ecográfico previo con informe de signos indirectos de ascetismo placentario, sin estudio de Resonancia Magnética Nuclear. Se realizó Operación Cesárea abdominal corporal, se dio nacimiento a recién nacido vivo. Se realizó instilación de 2 ampollas de 2 ml. de polidocanol al 3 % con sonda K33 en cordón umbilical para disminución del riesgo de sangrado, ligadura del mismo, introducción de cordón en cavidad uterina y cierre de Histerorrafia + Histerectomía subtotal El diagnóstico oportuno por medio de estudios de imagen, actuación médica criteriosa y el seguimiento de los protocolos establecidos nos llevara a la excelencia en la resolución de dichos casos.

34-year-old patient, 34 weeks pregnant. Previous double caesarean section with a previous ultrasound study with a report of indirect signs of placental asceticism, without a Nuclear Magnetic Resonance study. An abdominal cesarean section was performed, giving birth to a live newborn. Instillation of 2 ampoules of 2 ml was performed. of 3% polidocanol with a K33 probe in the umbilical cord to reduce the risk of bleeding, ligation of the cord, introduction of the cord into the uterine cavity and closure of hysterorrhaphy + subtotal hysterectomy Timely diagnosis through imaging studies, judicious medical action and following established protocols will lead us to excellence in the resolution of these cases.

Ruptura uterina por placenta percreta en el tercer trimestre del embarazo: reporte de un caso / Uterine rupture by placenta percreta in the third quarter of pregnancy: case report

Resumen ANTECEDENTES: La placenta percreta es la forma más rara e invasiva del acretismo placentario: supone el 5% de estos casos y concentra la mayor morbilidad y mortalidad materna y perinatal. Además, es la principal causa de ruptura uterina, por ello su diagnóstico y atención temprana son decisivos. Hoy día, el ultrasonido es la herramienta esencial y de elección para identificar el alto riesgo de acretismo placentario. CASO CLÍNICO: Paciente con 32.5 semanas de embarazo, ingresada a Urgencias con signos sugerentes de choque hipovolémico e inconsciente. Se decidió la cesárea de urgencia, con histerectomía abdominal y salpingooferectomía izquierda, por ruptura uterina en torno del cuerno izquierdo, con exposición parcial de la placenta, de aspecto percreta, con salida de vellosidades, laceraciones en el intestino y sangrado de 3500 mL. Nació una niña y se salvó la vida de la madre. CONCLUSIONES: La disponibilidad de personal capacitado y experimentado permite la actuación rápida ante estas urgencias médicas. Los bancos de sangre y las unidades de cuidados intensivos son indispensables para ofrecer una atención médica completa y de calidad que responda a las necesidades de la población.

Abstract BACKGROUD: Placenta percreta is the rarest and most invasive form of accreta placenta spectrum disorders, accounts for 5% of these cases, and concentrates the highest maternal and perinatal morbidity and mortality, in addition to being the main cause of uterine rupture, due to This diagnosis and early attention are decisive. Ultrasound has become the essential and choice tool to identify women at high risk of placental accreta. CLINICAL CASE: Patient with a pregnancy of 32.5 weeks of gestation is admitted to the emergency department with suggestive signs of hypovolemic shock and unconscious, an emergency body caesarean section was performed with abdominal hysterectomy and left salpingooferectomy due to uterine rupture at the level of the left horn with partial exposure of placental appearance Percreta with exit of villi, lacerations in intestine and a total bleeding of 3500 mL. Thanks to the appropriate and timely action of the staff, a unique live product of the female sex was obtained and safeguard the life of the mother. CONCLUSIONS: The importance of having highly trained staff who act quickly in this kind of medical emergency, in addition to having a blood bank and an intensive care unit makes possible a complete and quality medical care that meets the needs of the population.

Reporte de caso: placenta percreta con previa embolización de vasos anómalos / Case Report: Placenta Percreta With Previous Embolization of Anomalous Vessels / Relato de caso: placenta percrete com embolização prévia de vasos anómalos

Resumen: el acretismo placentario es una de las complicaciones obstétricas más temidas. Se entiende como el proceso de inserción placentaria anormal, secundario a un procedimiento quirúrgico, lo que ocasiona un error de decidualización en el área cicatricial que lleva a la profundización anormal del trofoblasto. La frecuencia de esta patología ha ido en aumento debido al incremento en la tasa de cesáreas en los últimos años. El caso se presenta en el hospital Universitario Clínica San Rafael en Bogotá, se trata de una paciente de 36 años, gestación de 37,1 semanas, con antecedente de cesárea previa, en quien se evidenció percretismo placentario; luego del nacimiento, se dejó placenta in situ y así el servicio de cirugía endovascular realizó embolización de vasos anómalos, lo que disminuyó el sangrado en la histerectomía diferida. Se comprobó evolución favorable y seguimiento de la paciente hasta ser dada de alta de la institución sin complicaciones. Actualmente existen diversos abordajes terapéuticos, entre ellos la histerectomía posterior de la cesárea y el manejo médico hasta involución de la placenta e histerectomía diferida, todos encaminados a disminuir complicaciones asociadas, entre las cuales las más frecuentes son la hemorragia, los requerimientos de transfusión y los días de hospitalización e infección, con el fin de disminuir la morbimortalidad materna extrema.

Abstract: placental accretism is one of the most feared obstetric complications. It is understood as the process of abnormal placental insertion, secondary to a surgical procedure, which causes a decidualization error in the scar area leading to abnormal deepening of the trophoblast. The freguency of this pathology has been increasing due to the increase in the rate of cesarean sections in recent years. The case is presented in the hospital Universitario Clínica San Rafael in Bogotá, it is a 36-year-old patient, 37,1 weeks gestation, with a history of previous cesarean section, with an evident case of placenta percreta; after birth, placenta was left in place and thus the endovascular surgery service performed embolization of anomalous vessels, which reduced bleeding in the deferred hysterectomy. A favorable evolution was verified, and the patient was followed up until she was discharged from the institution without complications. Currently, there are several therapeutic approaches, including hysterectomy after cesarean section and medical management up to placental involution and delayed hysterectomy, all aimed at reducing associated complications, among which the most frequent are hemorrhage, transfusion requirements and days of hospitalization and infection, in order to reduce extreme maternal morbimortality.

Resumo: o acretismo placentário é urna das complicações obstétricas mais temidas. Entende-se como o processo de inserção placentária anormal, secundário a um procedimento cirúrgico, que causa um erro de decidualização na área cicatricial levando ao aprofundamento anormal do trofoblasto. A frequência dessa patologia vem aumentando devido ao aumento da taxa de cesarianas nos últimos anos. O caso é apresentado no Hospital Universitário Clínica San Rafael, em Bogotá, é uma paciente de 36 anos, 37,1 semanas de gestação, com história de cesariana anterior, na qual foi evidenciado percretismo placentário; após o nascimento, a placenta foi deixada in situ e, portanto, uma cirurgia endovascular foi feita para que fosse possível embolizar os vasos anómalos, o que diminuiu o sangramento na histerectomia tardia. Evolução favorável e acompanhamento da paciente até receber alta da instituição sem complicações. Atualmente, existem várias abordagens terapêuticas, incluindo histerectomia pós-cesariana e manejo médico até involução placentária e histerectomia tardia, todas com o objetivo de reduzir as complicações associadas, dentre as quais as mais comuns são sangramento, necessidade de transfusão e dias de internação e infecção, a fim de reduzir a mortalidade materna extrema.

Placenta Percreta And Its Successful Outcome: A Rare And Difficult Case Report And With Review Of Literature

Placenta Percreta is one of the most serious complications of placenta previa, the incidence of which has been on a rising trend and is frequently associated with severe obstetric hemorrhage usually necessitating hysterectomy. lacenta Previa complicates 0.3–0.5% of all pregnancies and is a major cause of third-trimester hemorrhage which is on the rise due to rise in incidence of cesarean sections. Significant maternal morbidity in form of increased incidence of fetal malpresentation, cesarean delivery, increased blood loss, and peripartum hysterectomy have been noted in cases of placenta previa and can lead to prolonged hospitalization in these women. Premature deliveries can occur which lead to higher admission to neonatal intensive care unit and stillbirths. (1).We present a case of placenta previapercreta in a case of previous cesarean section , managed excellently with a surgical expertise.

Placenta percreta: a rare presentation of obstetric emergency in second trimester

Incidence of adherent placenta is on the rise nowadays due to various reasons. Placenta percreta is seen in 5-7% of cases with adherent placenta, patients with morbidly adherent placenta are at increased risk for major obstetric hemorrhage, usually in the third trimester. Here we present an unusual case of placenta percreta presenting with obstetric emergency after trauma to abdomen in the second trimester. Emergency exploratory laparotomy was done for abruptio placentae with scar dehiscence at 20 weeks period of gestation. Consent for obstetric hysterectomy, if needed, was also taken. Intraoperatively, the placenta was found to be adherent to posterior wall of bladder. Emergency obstetric hysterectomy with bilateral internal iliac ligation with cystoscopy with detrusorrhaphy was done. Patient had an uneventful recovery. Multidisciplinary management with obstetricians, urologists and intensivist is presented hereed.

Placenta mórbidamente adherente asociada a malformaciones congénitas: reporte de caso / Morbidly adherent placenta associated with congenital malformations: a case report

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.

Placenta praevia: percreta and accreta, our experience

Background: morbidly adherent placenta has an increasing incidence over decades. The purpose of this study is to identify risk factors and etiology of placenta previa- accreta and percreta.Methods: A cross sectional observational study of patients with morbidly adherent placenta previa including placenta accreta and placenta percreta were studied over a period of three years from June 2017 to June 2019 in a tertiary care centre, Mumbai.Results: Cases showed a higher incidence in patients with previous cesarean delivery (CS), grandmultiparity, abortions without the history of check curettage and anterior/central placentae.Conclusions: History of uterine surgeries and previous cesarean are some important risk factors for accreta in placenta previa patients.

Retrospective study of placenta accreta, placenta increta and placenta percreta in Peripartum hysterectomy specimens

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.

Tratamiento de pacientes con placenta anormalmente adherida, con hemorragia. Revisión sistemática / Treatment of patients with abnormally attached placenta, with hemorrhage. Systematic review

Resumen OBJETIVO: Reportar la evidencia quirúrgica, disponible en la bibliografía actual, acerca de la conducta médica que debe seguirse en pacientes con placenta anormalmente adherida en embarazos mayores de 20 semanas, según la pérdida hemática que se correlaciona con la morbilidad y mortalidad materna. METODOLOGÍA: Revisión sistemática de la bibliografía asentada en PubMed, Google Scholar, Uptodate y SciELO de artículos publicados en inglés y español, entre 2002 y 2019, con las palabras clave Mesh (Medical Subject Headings): placenta acreta; placenta previa; uterine repair; caesarean hysterectomy; placenta percreta; uterine conservation; uterine compression suture; hemorragia obstétrica; placentación anómala; placenta anormalmente adherida. Criterios de inclusión: artículos de casos y controles, y series de casos que incluyeron pacientes con diagnóstico de placenta anormalmente adherida, con apartados de la técnica quirúrgica utilizada y descripción de su desenlace. RESULTADOS: Se encontraron 40 artículos y se seleccionaron 34 que describían casos con diagnóstico de placenta anormalmente adherida y descripción de la técnica quirúrgica aplicada para disminuir la morbilidad y mortalidad materna. Se compararon las distintas técnicas quirúrgicas; se encontraron 9 artículos con técnicas quirúrgicas distintas para el control de la hemorragia obstétrica, en 2 de ellos no hubo reporte de la pérdida hemática, útil para esta revisión. CONCLUSIONES: Se demuestra que la técnica vascular integral avanzada (VIVA) y de Bautista son las que mejor se relacionan con disminución de la morbilidad y mortalidad materna. La búsqueda de técnicas quirúrgicas y estrategias para abatir la muerte materna, por placenta anormalmente adherida y la aplicación y comprensión de lo aquí expuesto, puede contribuir a disminuir la incidencia de desenlaces fatales.

Abstract OBJECTIVE: Report the surgical evidence available in the current literature about the medical behavior to be followed in patients with abnormally attached placenta in pregnancies older than 20 weeks, according to blood loss that correlates with maternal morbidity and mortality. METHODOLOGY: Systematic review of the literature available on PubMed, Scholar.google.com, Uptodate, SciELO, of articles published in English and Spanish, from 2002 to the present (August 2019), with the following keywords Mesh (Medical Subject Headings ): placenta acreta; previous placenta; uterine repair; Caesarean Hysterectomy; placenta percreta; uterine conservation; uterine compression suture; obstetric hemorrhage; anomalous placentation; abnormally attached placenta. Inclusion criteria: articles of control cases and case series that included pregnant patients with abnormally adhered placental diagnosis and sections of the surgical technique used, the outcome of which is described in the manuscript. RESULTS: 40 articles were found but only 34 studies were described that described cases with abnormally adhered placental diagnosis and description of the surgical technique used to achieve a decrease in maternal morbidity and mortality, so the different surgical techniques were compared, 9 articles were found with techniques different surgical procedures for the control of obstetric hemorrhage, in 2 of them there was no report of blood loss, useful for this review. CONCLUSIONS: It is shown that the advanced integral vascular technique (VIVA) and that of Bautista are the ones that are best related to a decrease in maternal morbidity and mortality. The search for surgical techniques and strategies to reduce maternal death, due to an abnormally attached placenta and the application and understanding of what is stated here, can contribute to reducing the incidence of fatal outcomes.

Broad ligament term pregnancy in an unscarred uterus: misdiagnosis and the challenges

A broad ligament pregnancy is a rare condition, but full term broad ligamnet pregnancy especially in an unscarred uterus is extremely rare. It is often misdiagnosed and usually finally diagnosed during surgery. Here is case of full term broad ligament pregnancy, which remained undiagnosed throughout her pregnancy, unfortunately had IUFD. Patient was referred to our hospital in view of failure of induction with increased BP records. No ultrasound was available on admission. On clinical assessment it appeared as transverse lie with IUFD. So cesarean was decided as a mode of delivery. Emergency ultrasound could just confirm IUFD with pelvic mass? Fibroid (actually deviated uterus). On laparotomy the broad ligament pseudosac had occupied entire abdomen. After delivery of baby, anatomy was found completely distorted. Highly vascular omental adhesions on fundus with difficulty in placental removal. Placenta could be traced reaching abdomen posteriorly. The first clinical impression was suspicion of placenta percreta. Uterus appeared non salvageable and hysterectomy was decided. Placenta was found lying in abdomen, adhered to bowel, omentum and fundus of uterus. The final diagnosis of broad ligament pregnancy could be made after the cut section of the uterus and anatomic evaluation. Patient required blood transfusions preoperatively .She remained stable and discharged on postoperative day nine. This case holds importance because may be outcome was different if it was a booked and investigated pregnancy. May be baby and uterus were salvageable with better outcome.

Placental adherence to small bowel: An uncommon appearance of placenta percreta; Managed without intestinal resection

Placenta percreta is an uncommon and potentially fatal condition in pregnancy. It can invade the adjacent structures of uterus including the urinary bladder, rectum, and small bowel. The invasion of bladder is common but that of small bowel is extremely rare. This report presents a case of placenta percreta with small bowel invasion which was managed without intestinal resection.

Cell Saver en Obstetricia. Primer caso reportado en Chile / Cell Saver in Obstetrics. First case reported in Chile

La hemorragia obstétrica representa un desafío para el equipo médico, aportando con importante morbilidad y mortalidad a las pacientes embarazadas.El manejo adecuado, precoz y expedito beneficia el logro de resultados favorables para la madre e hijo; es por esto que debemos reconocer activamente aquellas pacientes en riesgo de presentar un sangrado obstétrico significativo.Presentamos el primer caso reportado en Chile de una paciente embarazada con mala inserción placentaria, sometida a cesárea y decómo se realizó el manejo del sangrado intraoperatorio, con énfasis en el uso de Cell Saver como técnica ahorradora de sangre.(AU)

Obstetric hemorrhage is a challenge for the medical team, contributing with significant morbidity and mortality to the pregnant patient.An appropriate, early, and expeditious management eases the achievement of favourable results for mother and son. We must recognizeactively those patients at risk of a significant obstetric bleeding.We present the first case report in Chile of a pregnant patient with abnormal placentation, undergoing a caesarean section and howbleeding was handled during the surgery, with emphasis on the use of a Cell Saver device as a blood-saving technique.(AU)

A Retrospective Study of Placenta cretas: A 4 year experience at Modern Government Maternity Hospital, Hyderabad

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

Spontaneous uterine rupture due to placenta percreta in the second trimester of pregnancy: a case report / 고신대학교의과대학학술지

A 32-year-old multiparous woman (gravida 2, para 2) with a history of previous cesarean section had acute abdominal pain and collapsed at 21 weeks of gestation. Exploratory laparotomy was performed because of the patient's worsening condition; ultrasound examination results were suggestive of massive hemoperitoneum, and fetus in vertex presentation with bradycardia. Uterine rupture between the left lower segment and borderline of the cervix in the anterior wall with active bleeding was confirmed. An uncomplicated classical cesarean section was performed, but the fetus was stillborn due to preterm birth. Hysterectomy was performed after the cesarean section. The patient was admitted to intensive care units for 3 days and was discharged in 12 days following delivery. Placenta percreta at the anterior lower segment of the uterus was confirmed in the pathology report.

The morbidly adherent placenta / La placenta mórbidamente adherida

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.

MRI features for the placenta increta/percreta / 实用放射学杂志

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.

Efficiency of ring butterfly sewing in lower uterine segment aided with tourniquet in treating pernicious ;placenta previa combined with placenta percreta / 中华围产医学杂志

Objective To investigate the efficiency of ring butterfly sewing in lower uterine segment aided with tourniquet in treating pernicious placenta previa combined with placenta percreta. Methods Twelve pregnant women diagnosed with pernicious placenta previa combined with placenta percreta by prenatal ultrasound in Peking University First Hospital from April 1, 2012 to November 30, 2014, were enrolled. All of them received elective cesarean delivery using ring butterfly sewing in lower uterine segment aided with tourniquet. The efficiency of this novel technique, in term of blood loss and vital signs during operation, blood transfusion, and postoperative recovery, was analyzed. Results Twelve cases were diagnosed with placenta percreta during operation, with placenta invading the perimetrium in seven cases and urinary bladder being involved in one case. Ring butterfly sewing in lower uterine segment aided with tourniquet during elective cesarean delivery was all successful in the 12 cases. The median amount of blood loss was 1 000(400-2 000) ml during operation and the amount of blood loss was lower than 1 000 ml in three cases. Two cases received no blood transfusion, and the median blood transfusion in the other 10 cases were 400(400-1 200) ml. The mean operation time was (75±22) min (43-131) min. Eleven cases had normal lochia and temperature after operation and the other one had placenta invading urinary bladder and partial placenta in situ, and developed fever at day 3 after operation, but recovered after antibiotic treatment, and no placenta tissue was seen by ultrasound at day 59 after operation. Conclusions The ring butterfly sewing in lower uterine segment aided with tourniquet is highly effective for the pernicious placenta previa combined with placenta percreta, and it is a simple, fast and fertility sparing technique with low blood loss and without usage of special equipment.

La ecografía Doppler en la detección de invasión vesical en la placenta percreta: nuestra experiencia / Doppler ultrasound in the detection of bladder invasion in the percrete placenta: our experience

Objetivo: Demostrar la utilidad de la ecografía Doppler en la detección de la invasión vesical en el percretismo placentario. Materiales y métodos: Se evaluó por ecografía, desde noviembre de 2011 hasta mayo de 2013, a 21 pacientes de entre 20 y 44 anos que tenían diagnóstico quirúrgico e histopatológico de acretismo placentario (AP). Se consideró invasión vesical a la presencia de estructuras vasculares parietales en la evaluación Doppler color, mientras que se estableció como probable invasión a la presencia de otros hallazgos ecográficos sin senal Doppler. Resultados: De las 21 pacientes con acretismo placentario, 7 presentaron afectación vesical en el examen histopatológico: 5 tuvieron diagnóstico e informe ecográfico de invasión vesical (por la detección de estructuras vasculares en la evaluación Doppler color) y en las 2 restantes se planteó una probable afectación. De las 14 pacientes sin afectación vesical en el resultado histopatológico, hubo 7 con informes normales en la ecografía y 7 con resultados probables. Conclusión: La ecografía Doppler es un método muy útil para la detección de la invasión vesical en el percretismo placentario. Esta se observa con una vascularización parietal positiva en el Doppler color.

Purpose: To demonstrate the usefulness of Doppler ultrasound in the detection of bladder invasion in cases of placenta percreta. Materials and methods: Twenty-one patients, aged 20-44 years old, with surgery and histopathological diagnosis of placenta accreta were tested with ultrasound between November 2011 and May 2013. We considered bladder invasion the presence of hypervascularity detected with Doppler ultrasound, and probable invasion the presence of signs in gray-scale ultrasound, without Doppler color. Results: From the 21 patients included in the study with placenta accreta, 7 had bladder invasion in the histopathological study. Out of these seven, five had been reported to have bladder invasion because of the presence of hypervascularity detected with Doppler ultrasound, and the 2 remaining were reported as probably affected. Regarding the other 14, 7 were reported as normal in the ultrasound, and 7 as probable. Conclusion: Doppler ultrasound is a very reliable method to detect bladder invasion in placenta percreta, seen as hipervascularity of the uterine-bladder interface in the Doppler color exam.

Rotura uterina en la semana 19 de gestación por placenta percreta / Uterine rupture at week 19 of gestation placenta percreta

La rotura uterina durante el embarazo es una complicación obstétrica con graves consecuencias para la madre y el feto. La rotura uterina por placenta percreta es inusual. Comunicamos el caso de una paciente de 30 años, con embarazo de 19 semanas, quien ingresó por dolor abdominal de 24 horas de evolución, a predominio en la región hipogástrica, que durante su evolución padeció afectación hemodinámica y aumento del dolor abdominal. Por ultrasonido se observó líquido libre en la cavidad abdominal y mediante la laparotomía se encontró rotura uterina, se extrajo la placenta y el feto dentro de la bolsa amniótica y se realizó histerectomía. El diagnostico se confirmó mediante estudio histopatológico. (AU)

Uterine rupture during pregnancy is an obstetric complication with serious consequences for the mother and fetus. Uterine rupture is unusual placenta percreta. We report the case of a patient of 30 years, with 19 weeks pregnant, was admitted with abdominal pain 24 hours after onset, predominantly in the hypogastric region, during its evolution suffered hemodynamic compromise and increased abdominal pain. By ultrasound revealed free fluid in the abdominal cavity by laparotomy and uterine rupture was found, the placenta and the fetus within the amniotic sac was removed and hysterectomy was performed. The diagnosis was confirmed by histopathology. (AU)