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A pregnant woman with gravida 3, para 2, living 2 and gestational age of 37 weeks and 3 days was referred to a zonal hospital as previous two lower segment caesarean section (LSCS) term pregnancy with placenta previa for safe confinement with complaints of dry cough. She was admitted with a diagnosis of COVID-19 suspect. During her hospitalization, oxygen (O2) saturation was normal. On investigations her counts were normal. Patient was planned for elective LSCS. COVID-19 test i.e. real time-polymerase chain reaction (RTPCR) report was suspect and asked for repeat sampling. During elective LSCS, delivered single live female baby with intra operative findings of placenta previa with adherent placenta and permpartum hysterectomy was done for same. Uterus with placenta was sent for histopathological examination (HPE). During the surgery her oxygen concentration was normal. Her postoperative recovery was uneventful.
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Background: Postpartum haemorrhage (PPH) is a life-threatening condition. The objective of this study was to determine the incidence, demographic characteristics, indications, and feto-maternal outcomes associated with obstetric hysterectomy in a tertiary care centre.Methods: This is a retrospective analytical study conducted over a period of six years, from March 2014 to April 2020. A total of 68 cases of obstetric hysterectomy were studied at tertiary care centre in Ahmedabad, Gujarat, India.Results: Present study reported 68 obstetric hysterectomies per 44663 total deliveries (incidence - 0.15%), out of them 20 following 26446 vaginal deliveries (0.07%) and 48 following 18217 caesarean section (0.26%). Morbidly adherent placenta (29.41%) was the most common indication followed by atonic postpartum haemorrhage (25.00%) and uterine rupture (17.64%). The most frequent sequelae were disseminated intravascular coagulation (26.47%) and febrile morbidity (10.29%), maternal mortality was 16.17% whereas neonatal mortality was 26.47%.Conclusions: The incidence of obstetric hysterectomy has been found to be more following caesarean sections. There is a change in the indications of obstetric hysterectomy in the past two decades with placenta accreta spectrum being the commonest in present study. This is because of rising number of caesarean sections. Patients who underwent emergency obstetric hysterectomy due to atonic PPH had a higher mortality.
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Introduction: Placenta previa occurs when a baby's placentapartially or totally covers the mother's cervix or the outlet forthe uterus. The aim of this descriptive retrospective cohortstudy was to identify maternal complications, placentalposition, mode of delivery, management and fetal outcomes inPlacenta Previa (PP) and Morbidly adherent placentaMaterail and methods: Study was conducted in Departmentof Obstetrics and Gynecology, Pak Red Crescent Medical andDental College (PRCM&DC) Hospital Lahore from June 2017to June 2019. A total of 62 pregnant women were registered.All booked and un-booked mothers with and without historyof previous section with provisional clinical and/or USGdiagnosis of Placenta Previa or MAP.Results: In total, 62 patients with PP were identified 22.58%patients with morbidly adherent placenta were unbooked andother wise are booked. 61.2% patients were the age groupbetween 20-30 years and remaining are more than 30 years. In25.8% type IV placenta previa and same 25.8% are morbidlyadherent placenta and remaining are type I,II &III PP. Placentaprevia, only 6.45% cases were diagnosed in 2nd trimester and93.5% cases were diagnosed in 3rd trimester.Conclusion: Placenta Previa and Morbidly adherent placentaare not a very uncommon condition. Frequency of Incidenceincreases as the rate of cesarean section or abdominal surgerywere increases. Early diagnoses and pre plan mode of deliverywill decrease the risk of low birth weight and low APGARscore infants
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Background: Morbidly adherent placenta is associated with high maternal morbidity and mortality. Its increased prevalence seems to be proportional to the increasing number of caesarean sections. In this study the presentation and management of 32 cases was reviewed with morbidly adherent placenta and maternal and perinatal outcomes from 2014 to 2016, at the hospital.Methods: Study type was retrospective. We reviewed clinical information from patients’ case sheets regarding the risk factors, preparations prior to cesarean section, intraoperative and postoperative complications. Results were interpreted and conclusions were withdrawn.Results: Among the 32 cases, 28 were diagnosed prenatally while 4 were diagnosed intraoperatively. Out of 28 patients, 5 patients were diagnosed early between 14 and 18 weeks of gestational age and other 23 were diagnosed during third trimester by ultrasonography. Caesarean hysterectomy was required in 28 cases.4 were managed conservatively, out of which hysterectomy proved to be necessary in the postpartum period because of severe secondary postpartum hemorrhage in 2 cases. Average no of hospital stay is 10 days ranging from 8-18 days.Conclusions: Prenatal diagnosis of morbidly adherent placenta is essential to plan for the better maternal and perinatal outcome. The decision to perform a cesarean hysterectomy or conservation of uterus (using balloon tamponade or putting haemostatic sutures) is based on the extent of infiltration, the patient’s hemodynamic status, and her desire for future pregnancy. The risk of infection and severe hemorrhage remains high if conservative management is chosen and requires prolonged close monitoring postoperatively. Ideally all the cases should be electively planned and operated by senior surgeon and experienced assistants with senior anesthetist, urosurgeon and physician, with full backup of ICU and blood bank.
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Background: Obstetric hysterectomy is done as a lifesaving procedure in very trying circumstances of life threatening severe hemorrhage. The study was undertaken with the aim to evaluate the relative frequency of hysterectomy done for obstetric indication among the hysterectomy specimens and also to assess the histopathological findings in the hysterectomy specimens.Methods: The study was conducted at a tertiary care center over a period of two and half years. Consecutive specimens of hysterectomy done for obstetrical indication were included. Gross and microscopic findings noted and data analysed. The study was approved by the Institute Ethical Committee.Results: Of the total hysterectomy specimens received obstetrical hysterectomy comprised only 1.3%(12/915) of all the hysterectomies. Patient’s age ranged from 20-36 years; mean 28.6 years. Parity ranged from 1 to 5; mean 2. More multiparous women 91.7%(11/12) had hysterectomies as compared to primiparous 8.3%(1/12) cases (p value <0.0001). All patients had single pregnancy. All (100%) patients underwent surgery through abdominal route with subtotal hysterectomy with preservation of the bilateral adnexae undertaken in most (11/12; 91.7% cases). About 5(41.6%) cases hysterectomies were performed after previous caesarean section and had abnormal placentation. Histopathological examination revealed adherent placenta in 33.4%(4/12), endometritis in 25%(3/12), rupture in 25%(3/12) and histologically unremarkable in 16.6%(2/12) cases.Conclusions: Obstetric hysterectomy is an emergency lifesaving procedure done in situations of uncontrolled post-partum hemorrhage. In recent years with more number of caesarean sections the incidence of abnormal placentation has drastically increased, thus making adherent placenta as the most common histopathological finding.
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Background: The adherent placenta is a range of pathologic adherence of the placenta, including placentaincreta, placenta percreta, and placenta accreta. Villous invasion depth determines the severity of thecomplications, and the villi sometimes invade the surrounding pelvic organs. Therefore, any surgical procedurebecomes technically difficult, especially with excessive neovascularity. Objective: The prenatal diagnosis of theadherent placenta has become essential to its management and outcome. In this article, we aimed to review thepublished literature that discussed adherent placenta diagnosis and management. Method: A comprehensivesearch was done using biomedical databases including Medline, and PubMed to study the role of AdherentPlacenta. Keywords used in our search through the databases were “Adherent Placenta”, “Placenta Increta,Placenta Percreta, and Placenta Accreta”, and “Pathophysiology and Management”. Conclusion: The mainstayimaging technique in cases of placenta accreta is ultrasound. Pelvic ultrasound is highly reliable to diagnose orexclude the presence of placental adhesive disorders. However, when the ultrasound results are not conclusive,MRI is recommended, because it has a higher potential benefit. In general, the recommended management of anadherent placenta is planned cesarean hysterectomy with a hysterotomy that avoids the placenta. Appropriatecounseling can be conducted to consider alternative management strategies. A center with a multidisciplinaryteam experienced in the care of the condition should conduct the delivery in order to optimize the response toevery peri and intraoperative complication.
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Background: The objective of the present study was to describe management of morbidly adherent placenta with placenta previa and feto-maternal outcome.Methods: All antenatal USG diagnosed cases of morbidly adherent placenta were analyzed. The cases were managed by elective caesarean hysterectomy and non-separation of placenta at delivery. Amount of blood loss, blood transfused, ICU admission, postnatal complications and hospital stay was recorded.Results: From January 2010 to October 2018, 22 cases of morbidly adherent placenta were diagnosed on gray scale and color Doppler during antenatal ultrasound scan. Scheduled caesarean hysterectomy without attempting placental removal was done. Subtotal hysterectomy was performed in 17(77.2%) cases and total hysterectomy in remaining 5(22.8%) cases. All the patients required blood transfusion. Seven (31.8%) patients had urinary bladder injury. One case developed DIC and One needed ventilatory support. No patient died in this series.Conclusions: Antenatal diagnosed cases of morbidly adherent placenta, avoidance of placental separation and caesarean hysterectomy results in better maternal outcome.
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Over 500,000 women die each year due to complications of pregnancy and childbirth, a number that has remained relatively unchanged since 1990, when the first global estimates of the burden of maternal mortality were developed. Hemorrhage due to uterine atony, adherent placenta and PPH are still the causes of maternal death in developing countries. Although advances have been made in the development of conservative medical and surgical treatment of obstetric haemorrhage like brace sutures, internal iliac artery ligation, selective arterial embolization etc emergency obstetric hysterectomy remains a lifesaving procedure in the management of intractable haemorrhage unresponsive to conservative management.
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Background@#Morbidly adherent placenta (MAP) refers to a spectrum of conditions characterized by abnormal adherence of the placenta to the implantation site. It is usually associated with peripartum hysterectomies, excessive blood loss, and bladder and bowel injuries. Reliable antenatal diagnosis of MAP is needed as unexpected encounter with such condition can lead to catastrophic outcomes. It allows the pre-operative assembly of a multidisciplinary team in the surgical management of such cases, an approach which has been shown to improve maternal and fetal outcomes.@*Case summary@#A case of a morbidly adherent placenta diagnosed antenatally using gray-scale, Color Doppler, 3-Dimensional power Doppler ultrasound and Magnetic Resonance Imaging is reported. A multidisciplinary team consisting of OB - GYN ultrasonologist, radiologist, maternal fetal medicine specialist, gynecologic oncologist, anesthesiologist, neonatologist, internist, urologic-oncologist, vascular and general surgeons, was used to manage the case. Favorable maternal and fetal outcomes resulted from the use of this team.@*Conclusion@#Prenatal diagnosis of MAP with gray-scale, Color Doppler, 3-Dimensional power Doppler ultrasound and Magnetic Resonance Imaging and the use of standardized imaging descriptors for AIP allowed the development of a multidisciplinary care team approach during delivery which provided a safe outcome for both mother and baby.
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Imageamento por Ressonância MagnéticaRESUMO
Background: Morbidly adherent placenta is a life threatening condition that requires multidisciplinary approach for management. Women presenting with placenta praevia have become the highest risk for abnormal placental adherence. Aim: Aim of the present study is to evaluate the efficacy of ultrasound and colour Doppler in the antenatal diagnosis of morbidly adherent placenta in women presenting with placenta praevia. Materials and methods: This was a prospective study conducted on patients with persistent placenta praevia who underwent transabdominal B mode and colour Doppler ultrasound evaluation in the third trimester during the period of May, 2015 to May, 2017. The imaging findings were compared with the final diagnosis at the time of delivery and at pathological examination. Results: In the present study, there were a total of 24 patients of morbidly adherent placenta with an incidence of 1.17 per 1000 pregnancies. Previous caesarean section with placenta praevia was the main risk factor for placental adherence. Conclusion: Ultrasound and colour Doppler have a fairly good sensitivity for prenatal diagnosis of placenta accrete.
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Background: The contemporary obstetrician is increasingly put to the test by rising numbers of pregnancies with morbidly adherent placenta. This study illustrates our experience with prophylactic bilateral internal iliac artery occlusion as part of its management. Methods: Between January 2011 to January 2014, 13 consecutive patients received the intervention prior to scheduled caesarean delivery for placenta accreta. All cases were diagnosed by ultrasonography, color Doppler imaging and supplemented with MRI where necessary. The Wanda balloonTM catheter (Boston Scientific, Natick, MA, U.S.A) were placed in the proximal segment of the internal iliac arteries preceding surgery. This was followed by a midline laparotomy and classical caesarean section, avoiding the placenta. Both internal iliac balloons were inflated just before the delivery of fetus and deflated once haemostasis was secured. Primary outcomes measured were perioperative blood loss, blood transfusion requirement and the need for ICU admission. Results: The mean and median intraoperative blood loss were 1076mls±707 and 800mls (300-2500) respectively while mean perioperative blood loss was 1261mls±946. Just over half of the patients in our series required blood and/or blood products transfusion. Two patients (15.4%) required ICU admission. Conclusion: Our study suggests that preoperative prophylactic balloon occlusion of bilateral internal iliac arteries reduces both blood loss and transfusion requirement in patients with placenta accreta, scheduled to undergo elective caesarean hysterectomy. It is an adjunct to be considered in the management of a modern day obstetric problem, although the authors are cautious about generalizing its benefit without larger, randomized trials.
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Placenta AcretaRESUMO
Morbidly adherent placenta with spontaneous rupture of membrane at extreme prematurity poses poor pregnancy outcome. Various issues on different management modalities still remain perplexed and individual consideration is vital. Two cases of morbidly adherent placenta with symptomatic per vaginal bleeding and spontaneous rupture of membrane at severe prematurity were reviewed and discussed. We found that, active intervention by termination of pregnancy and methotrexate therapy at early gestation can prevent the need of hysterectomy following major obstetrics haemorrhage.
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OBJECTIVE: To evaluate the clinical indications and incidence of emergency peripartum hysterectomy by dermographic characteristics by a retrospective review based on hospital data of 98 patients over 8 years. METHODS: We reviewed their medical records of the 98 cases of peripartum hysterectomy among 50,338 deliveries, from January. 1992 to December. 1999, at St Mary, Kang Nam St Mary, and Holy Family hospital of Catholic University. RESULTS: The total incidence of peripartum hysterectomy was 98/50,338 (0.19%), Cesarean hysterectomy was performed in 96 of 22,561 Cesarean sections (0.43%) and in 2 of 27,777 vaginal deliveries (0.01%). The higher the age, the higher incidence of peripartum hysterectomy was noted and the most common indication for hysterectomy was abnormal adherent placentation (45.48%) followed by uterine atony (39.80%). During peripartum hysterectomy, patients were transfused with mean 10.04 pints. Although one maternal death occurred, maternal morbidity remained high (51.02%), including postoperative febrile condition in 15 (15.3%), intraoperative urologic injury in 11 patients (11.2%). CONCLUSION: There is a strong association between advancing age and incidence of peripartum hysterectomy. The data identify abnormal adherent placentation as the primary cause for peripartum hysterectomy and then considering the mean volume of blood loss more than 10 pints of blood should be prepared before emergency hysterectomy.