Management of placenta accreta in an Australian tertiary referral centre: a ten-year experience.

PURPOSE OF INVESTIGATION: To report a ten-year experience in management of a highly morbid obstetrical condition in placenta accreta (PA) at a tertiary referral centre, uniquely equipped with an integrated Interventional Radiology theatre, with a primary aim to guide best practice. MATERIALS AND METHODS: Retrospective analysis of all histologically proven PA cases at a tertiary centre in Australia between January 2004 and December 2013. Medical records were reviewed for obstetrics history, operative details, post-operative management and neonatal outcome. RESULTS: Sixteen cases of PA were identified during the tinie period; 75% had identifiable risk factors for PA and 87.5% of patients were diagnosed antenatally. Mean gestational age at time of delivery was 34 ±3.4 weeks. Ten cases were performed electively, while the remaining underwent emergency caesarean section. One patient was managed conservatively with placenta left insitu; time to complete resolution of placenta was 71 days. Among patients who underwent hysterectomy (15/16), the proportion of total (n=8) vs. subtotal (n=7) hysterectomy was similar. Average operating time was 123 ± 45.9 minutes. Compared to emergency cases, patients who underwent elective surgery had significantly lower blood loss (2.2 vs. 3.1 L, p < 0.05). Common iliac artery balloons were deployed in eight cases, with a non-statistically significant reduction in intraoperative blood loss (2 vs. 3.2 L, p < 0.05). Fifty percent of patients required ICU admission. Neonatal survival at six months was 93.75% (15/16). CONCLUSION: The present report demonstrates the importance of timely diagnosis and comprehensive preparation in the surgical management of patients with placenta accreta. The availability of relevant services in the peri-operative phase, including: obstetricians, interventional radiology facility and personnel, intensive care, and neonatology teams, are crucial in achieving optimal outcome for the patient and neonate. In line with reports in the literature, the authors advocate a team-based multidisciplinary approach in a tertiary-level centre for management of this high-risk condition.

Electrocardiographical case. An elderly lady with chest pain. Diagnosis: isolated posterior myocardial infarct (MI).

A 72-year-old woman with diabetes mellitus, hypertension and dyslipidaemia presented with severe chest pain of four hours duration. Her electrocardiogram (ECG) showed tall R waves in leads V1-2, and ST segment depression in leads V1- 4, consistent with an isolated posterior myocardial infarction (MI). Emergency coronary angiogram showed an occluded left circumflex coronary artery, and primary angioplasty and stenting was performed. The ECG criteria for isolated posterior MI and pitfalls in using the conventional 12-lead ECG are discussed.

Clinical outcomes of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty or fibrinolysis.

OBJECTIVE: To compare the early and late outcomes of primary percutaneous transluminal coronary angioplasty (PTCA) with fibrinolytic treatment among diabetic patients with acute myocardial infarction (AMI). DESIGN: Retrospective observational study with data obtained from prospective registries. SETTING: Tertiary cardiovascular institution with 24 hour acute interventional facilities. PATIENTS: 202 consecutive diabetic patients with AMI receiving reperfusion treatment within six hours of symptom onset. INTERVENTIONS: Fibrinolytic treatment was administered to 99 patients, and 103 patients underwent primary PTCA. Most patients undergoing PTCA received adjunctive stenting (94.2%) and glycoprotein IIb/IIIa inhibition (63.1%). MAIN OUTCOME MEASURES: Death, non-fatal reinfarction, and target vessel revascularisation at 30 days and one year were assessed. RESULTS: Baseline characteristics were similar in these two treatment groups except that the proportion of patients with Killip class III or IV was considerably higher in those treated with PTCA (15.5% v 6.1%, p = 0.03) and time to treatment was significantly longer (103.7 v 68.0 minutes, p < 0.001). Among those treated with PTCA, the rates for in-hospital recurrent ischaemia (5.8% v 17.2%, p = 0.011) and target vessel revascularisation at one year (19.4% v 36.4%, p = 0.007) were lower. Death or reinfarction at one year was also reduced among those treated with PTCA (17.5% v 31.3%, p = 0.02), with an adjusted relative risk of 0.29 (95% confidence interval 0.15 to 0.57) compared with fibrinolysis. CONCLUSION: Among diabetic patients with AMI, primary PTCA was associated with reduced early and late adverse events compared with fibrinolytic treatment.

Role of dobutamine stress echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease.

BACKGROUND: Increasingly, dobutamine stress echocardiography has been used for detection of coronary artery disease. Less information exists regarding the incremental prognostic value of the test, including semiquantitative wall scoring, compared with clinical and rest echocardiographic variables. METHODS AND RESULTS: Follow-up information was obtained from 860 patients who underwent dobutamine stress echocardiography over a 2-year period. To determine the value of dobutamine stress echocardiography in predicting cardiac events, including cardiac death and myocardial infarction, clinical and rest and stress echocardiographic data were considered in a stepwise Cox multivariate regression model. During follow-up of up to 52 months, 72 patients underwent coronary revascularization before any cardiac event and were censored. Eighty-six patients had cardiac events, including nonfatal myocardial infarction in 36 and cardiac death in 50. In a multivariate model, a history of congestive heart failure, the percentage of abnormal segments at peak stress, and an abnormal left ventricular end-systolic volume response to stress were independent predictors of cardiac events. The model that best predicted subsequent cardiac events included clinical and stress echocardiographic data. CONCLUSIONS: Dobutamine stress echocardiography with semiquantitative segmental wall scoring provides important incremental information in predicting subsequent cardiac events.

Left ventricular myxoma, adrenal tumour and cutaneous vasculitis--a case report.

Cardiac myxoma has myriad presentations including cutaneous vasculitis. It has also been associated with endocrine neoplasm in Carney's Complex. We report a Chinese patient with cutaneous vasculitis and Raynaud's phenomenon suggesting a collagen vascular disease. In the course of investigation, echocardiogram showed a possible left ventricular myxoma and computed tomography of the abdomen demonstrated a left adrenal tumour. Cardiac myxoma should be considered in the differential diagnosis of vasculitis.

Pasteurella multocida septicaemia following a dog bite.

Bite wounds are often mistakenly considered innocuous. However, they are frequently complicated by infection which may be serious. We describe a case of Pasteurella multocida septicaemia with myopericarditis following a dog bite. Treatment of the infection as well as active support of myocardial function led to a successful outcome.