Maternal and neonatal outcomes following a proactive peripartum multidisciplinary management protocol for placenta creta spectrum as compared to the urgent delivery.

BACKGROUND: Adherent and invasive placenta, termed Placenta Creta Spectrum (PCS), is associated with increased maternal morbidity and mortality. Incidence and risk factors for Placenta Creta are on the rise and call to optimize the obstetric care for this condition. OBJECTIVES: We sought to compare maternal and neonatal outcomes between a ProActive Peripartum Multidisciplinary Approach (PAMA) as compared to the urgent management of the Placenta Creta Spectrum patients. STUDY DESIGN: We conducted a single-center prospective observational study between 2005-2016. PCS patients registered with the implementation of a PAMA protocol 2014-2016 epoch(E2) were compared with the pre-PAMA 2005-2013 epoch(E1), managed by urgent team recruitment. The PAMA protocol is grounded on a continuum of care; A. Antenatal: PCS risk assessment based on clinical history and imaging, surgical, anesthesia, urological consults and designation of a dedicated team to be present at planned surgery; B. Delivery: planned at 34-35 weeks, massive transfusion protocol activation, insertion of ureteral catheters, vertical uterine incision, placement of vessel loops on the iliac vessels, avoidance of active placenta delivery, followed by the decision of hysterectomy or uterine repair; C. Post-operative care: intensive care admission. We evaluated maternal and neonatal outcomes. RESULTS: During the study period 158,438 deliveries were registered in our institution; we identified a total of 72 PCS cases (0.05%): 50(69.4%) in E1 and 22 (30.6%) in E2. Patient characteristics were comparable among epochs. Significantly, patients in E2 vs. E1 had fewer events of massive blood transfusion 36.0% vs. 13.6%, p = 0.05; were transfused less RBC units: median 4 vs. 1.5, p = 0.012, had no transfusion-related respiratory complications and hemorrhage control re-laparotomies. Hysterectomy and hollow visceral injury rates were comparable (72% vs. 63.7%, 26% vs. 22%; respectively). The hysterectomy pathology assessment was available for the majority of the cases in both epochs; percreta diagnosis rate significantly increased in E2. The neonatal outcome was similar among the epochs. CONCLUSIONS: Institution of a PAMA protocol for PCS resulted in eliminating the urgent deliveries and in reducing the associated significant hemorrhagic related maternal morbidity, with no increase in the rate of hysterectomy or adverse neonatal outcome.

The risk of malignancy in post-menopausal women presenting with adnexal torsion.

OBJECTIVES: Adnexal torsion is usually diagnosed in pre-menopausal women and is less common in post-menopausal patients. The risk of malignancy in cases of torsion in menopausal patients is not known. We set out to describe our experience with adnexal torsion in post-menopausal women and to discuss issues related to management in this situation. METHODS: A retrospective chart review was conducted of all post-menopausal patients diagnosed with torsion of the adnexa from January 1990 through December 2005. Patient charts were reviewed for information regarding pre-operative signs and symptoms, pathology, demographics, surgical findings, procedure and outcome. As a control group, we chose a consecutive cohort of 29 pre-menopausal patients diagnosed with adnexal torsion during 2002. RESULTS: Twenty-seven patients were found to be menopausal at the time of diagnosis of adnexal torsion. Median age at presentation was 63 years (range 43-93). A median delay of 40 h was found between the time of hospital admittance to surgery for post-menopausal patients in comparison to the pre-menopausal ones. The cause of torsion was benign in pre-menopausal patients whereas 22% of post-menopausal patients were diagnosed with malignant disease. More adnexas were found to be necrotic in menopausal patients and this resulted in under-diagnosis of malignancy on frozen section analysis. CONCLUSION: The diagnosis of adnexal torsion is less evident in post-menopausal patients leading to delayed treatment. The high risk of malignancy is of major importance and should be taken into account when counseling patients and when using frozen section during surgery.

Massive edema of the ovary: a case report and review of the pertinent literature.

BACKGROUND: Massive edema of the ovary is a rare entity affecting mainly young women. It is often misdiagnosed for a malignancy, posing the young patient at risk for over-treatment with resultant loss of hormonal function and fertility. CASE: A 13-year-old premenarchal girl presented with a large solid pelvic mass after recurrent episodes of self-limited abdominal pain. With a working diagnosis of malignant ovarian tumor, an exploratory laparotomy was done in which a twisted ovarian mass was found and excised completely. Pathological examination of the mass revealed massive edema of the ovary with hemorrhagic necrosis. CONCLUSION: After extensive review of the literature, it seems most cases were over-treated, as was ours. This entity should be suspected in women at the fertile age range with solid enlargement of the ovary and definite treatment should be undertaken only after confirmed pathological diagnosis. Conservative treatment is feasible and should be the rule in these cases, where fertility preservation is mandatory.