Inserción velamentosa de cordón umbilical y rotura de un vaso previo con evolución neonatal favorable / Velamentous umbilical cord insertion and laceration of a vasa previa with favorable perinatal outcome

La presencia de un vaso previo es una variante anatómica poco frecuente. La rotura de un vaso previo se asocia a una alta tasa de mortalidad fetal que oscila entre el 58 y el 100% de los casos. En nuestro centro se ha producido recientemente un caso de exanguinación fetal debida a la laceración de un vaso previo de una inserción velamentosa de cordón umbilical sin diagnosticar. A pesar de que la evolución del neonato ha sido favorable, se considera la necesidad del diagnóstico precoz y la finalización de la gestación de forma programada, mediante una cesárea, para evitar este dramático suceso (AU)

Vasa previa is an unusual anatomical variant. Rupture of a vasa previa is associated with a high rate of fetal mortality oscillating between 58% and 100% of cases. We report a recent case of fetal exsanguination that occurred in our hospital due to vasa previa laceration of an undiagnosed velamentous umbilical cord insertion. Although neonatal outcome was favorable, we stress the need for early diagnosis and cesarian section to avoid this dramatic event (AU)

Placenta previa y hemorragia posparto incoercible. Empleo de taponamiento de compresión pélvica: ¿una técnica olvidada? / Use of pelvic compression tamponade. A forgotten technique?

Se expone el caso de una mujer de 39 años de edad, embarazada de 31 semanas de gestación, diagnosticada de placenta previa oclusiva total, a quien se realizó una cesárea urgente por hemorragia grave. Después de la cesárea se observó una hemorragia incontrolable, por lo que se realizó una histerectomía de hemostasia y una ligadura de la arteria ilíaca interna derecha, que se complicó con una coagulación intravascular diseminada. Al no conseguir la hemostasia adecuada, se colocó, como único recurso, un taponamiento pélvico compresivo, que resultó extremadamente útil y eficaz

We report the case of a 39-year-old woman at 31 weeks of gestation with a diagnosis of total occlusive placenta previa who underwent emergency cesarean section due to severe hemorrhage. After the cesarean section, intractable hemorrhage occurred and hemostasis hysterectomy and ligature of the right internal iliac artery were performed. However, disseminated intravascular coagulation was observed and, given the lack of adequate hemostasis, a pelvic compression tamponade was placed as a last resort. This measure proved extremely useful and effective

Placenta previa-accreta: risk factors and complications.

OBJECTIVE: The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA). STUDY DESIGN: Patients with placenta previa (n = 347) delivered over 20 years were reviewed, divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared. RESULTS: Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome. CONCLUSION: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa.

Placenta previa totalis complicated with pulmonary embolism during cesarean section: a case report.

Venous thromboembolism is believed to be rare in Japan, whereas increases in occurrence of pulmonary embolism have been drawing attention because it has become the most common cause of maternal death in recent years. A 36-year-old woman at 33 weeks of pregnancy was transferred to our hospital because of placenta previa totalis and treated with emergency cesarean section on the same day. Soon after the delivery of the fetus, the patient developed pulmonary embolism. The condition of pulmonary embolism was suspected when abnormal values were noted in respiratory and circulatory parameters and then confirmed by intraoperative transesophageal echocardiography, which revealed a thrombus in the right atrium. Anticoagulant treatment with unfractionated heparin started during the operation caused a tendency to bleed during and after the operation, and subsequently required a second laparotomy to control bleeding. After insertion of an inferior vena cava filter, a third laparotomy was performed to remove a giant hematoma. Heparin discontinuation intended to decrease the tendency to bleed was followed by two recurrences of pulmonary embolism, resulting in a dangerous condition. Despite these difficult complications, our interventions successfully saved the patient's life and restored her health. We report changes observed in her conditions along with treatment and management we provided, and describe the specificity of pulmonary embolism occurring during the operation.

Fetal/neonatal outcome in abruptio placentae during preterm gestation.

The purpose of this study was to evaluate the fetal/neonatal outcome and to determine the important factors in that outcome, including the use of ultrasonography and fetal heart rate monitoring, in abruptio placentae during preterm gestation. A case-control study was performed using a logistic regression model. Adverse outcome was defined as neonatal death before hospital discharge or a diagnosis of cerebral palsy in surviving neonates. Stillbirth (group 1) occurred in eight of 50 cases of abruptio placentae (16%). Adverse outcome was seen in 11 survivors (11 of 42; 26.2%). The obstetrical disseminated intravascular coagulation (DIC) score in group 1 (11.8 +/- 7.1) was higher than that in the adverse (5.7 +/- 1.3) and satisfactory (5.3 +/- 2.4) outcome groups. A low Apgar score (< 7) at 5 minutes (odds ratio, 19.8; 95% confidence interval, 2.0 to 197.8) was associated with increased risk of adverse outcome in the logistic regression model. Although the obstetrical DIC score was high and may reflect the severity of maternal complications in the stillbirth group, there were no typical ultrasonographic findings and fetal heart rate patterns in abruptio placentae during preterm gestation predicting adverse outcome among survivors.

Abnormal placentation: twenty-year analysis.

OBJECTIVE: This study was undertaken to determine whether the rate of abnormal placentation is increasing in conjunction with the cesarean rate and to evaluate incidence, risk factors, and outcomes. STUDY DESIGN: Cases from 1982-2002 were identified by histopathologic or strong clinical criteria. Risk factors were assessed in a matched case-control study, and analyzed using conditional logistic regression models. RESULTS: There were 64,359 deliveries, with cesarean rates increasing from 12.5% (1982) to 23.5% (2002). The overall incidence of placenta accreta was 1 in 533. Significant risk factors for placenta accreta in our final analysis included advancing maternal age (odds ratio [OR] 1.13, 95% CI 1.089-1.194, P < .0001), 2 or more cesarean deliveries (OR 8.6, 95% CI 3.536-21.078, P < .0001), and previa (OR 51.4, 95% CI: 10.646-248.390, P < .0001). CONCLUSION: The rate of placenta accreta increased in conjunction with cesarean deliveries; the most important risk factors were previous cesarean delivery, previa, and advanced maternal age.

Emergency peripartum hysterectomy in a tertiary London hospital.

OBJECTIVE: The objective was to review all emergency peripartum hysterectomies performed at a tertiary hospital in London, UK, and to identify the risk factors for emergency peripartum hysterectomy. METHOD: A retrospective case control study. The cases consisted of all women who had emergency peripartum hysterectomy between 1 January 1993 and 31 December 2003. Controls were women who delivered immediately before and after the indexed case. Demographic data, medical and surgical histories, pregnancy, intrapartum and postpartum data were collected. Differences between cases and controls were compared with chi2, Fisher exact and Student t tests. Multiple logistic regression analysis was performed to identify independent risk factors for emergency peripartum hysterectomy. RESULTS: There were 15 cases of emergency peripartum hysterectomy in 31,079 deliveries, giving a rate of 0.48 per 1,000. Women who had emergency peripartum hysterectomy were significantly older (mean age 37 years vs. 29 years, P<0.001) and multiparous (P=0.02). More of the cases had a history of uterine surgery (67 vs. 30%, P=0.01), placenta praevia (60 vs. 3%, P<0.0001) and were delivered by caesarean section (86.7 vs. 30%, P=0.003). Eighty percent of the hysterectomies were performed in the daytime and all were done by consultants. Haemorrhage due to placenta praevia was the main indication for emergency peripartum hysterectomy (47%). Independent risk factors for emergency peripartum hysterectomy were older age (odds ratios [OR] 1.2, 95% confidence interval [95% CI] 1.2-1.6), multiparity (OR 2.6, 95% CI 1.3-10.2), history of previous caesarean section (OR 13.5, 95% CI 2.7-65.4), caesarean delivery in index pregnancy (OR 11.6, 95% CI 2.1-68.6) and caesarean delivery in index pregnancy for placenta praevia (OR 18, 95% CI 3.6-69). CONCLUSION: Caesarean deliveries, especially repeat caesareans in women with placenta praevia, significantly increase the risk of emergency peripartum hysterectomy.

Autologous blood transfusion in patients with placenta previa.

BACKGROUND: Several studies have shown that autologous blood storage during pregnancy is relatively safe for mother and fetus. However, the need for reappraisal of autologous blood transfusion in obstetric patients has been proposed. METHODS: We retrospectively reviewed the cases of placenta previa and low-lying placenta among pregnancies at our hospital during an 18-year period, 1985-2002. The utility of autologous blood transfusion program, which started in 1994 for those with placental positional disorders, was evaluated. RESULTS: Of the pregnancies reviewed, there were 158 cases (1.9%) of placenta previa or low-lying placenta. The number of patients transfused with homologous blood decreased from 27.6% (21/76) in the period before implementation of the autologous blood transfusion program to 8.5% (7/82) after its implementation in 1994. In the latter time period, 39.0% (32/82) of patients with placenta previa and low-lying placenta were phlebotomized and had blood stored. Of those, 71.9% (23/32) were reinfused where one patient (3.1%) needed homologous blood as well. The volume of collected blood per phlebotomy was 367 +/- 65 ml, the total volume of collected blood per patient was 803 +/- 350 ml, and the total of estimated blood loss per patient was 1326 +/- 873 ml. The volume of reinfused blood per patient was 578 +/- 326 ml. CONCLUSIONS: The program of autologous blood collection and transfusion in patients with placenta previa resulted in a decrease in homologous blood transfusion. In our program, we recommend starting blood collection and storage at 32 weeks' gestation and phlebotomize 400 ml per week to reach a volume of stored blood of 1200-1500 ml.

Pregnancy outcome following recurrent spontaneous abortions.

OBJECTIVE: The purpose of the present study was to examine the association between spontaneous consecutive recurrent abortions and pregnancy complications such as hypertensive disorders, abruptio placenta, intrauterine growth restriction and cesarean section (CS) in the subsequent pregnancy. METHODS: A population-based study comparing all singleton pregnancies in women with and without two or more consecutive recurrent abortions was conducted. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 154,294 singleton deliveries occurred, with 4.9% in patients with history of recurrent consecutive abortions. Using a multivariate analysis, with backward elimination, the following complications were significantly associated with recurrent abortions-advanced maternal age, cervical incompetence, previous CS, diabetes mellitus, hypertensive disorders, placenta previa and abruptio placenta, mal-presentations and PROM. A higher rate of CS was found among patients with previous spontaneous consecutive recurrent abortions (15.9% versus 10.9%; OR = 1.6; 95% CI, 1.5-1.7; P < 0.001). Another multivariate analysis was performed, with CS as the outcome variable, controlling for confounders such as placenta previa, abruptio placenta, diabetes mellitus, hypertensive disorders, previous CS, mal-presentations, fertility treatments and PROM. A history of recurrent abortion was found as an independent risk factor for CS (OR = 1.2; 95% CI, 1.1-1.3; P < 0.001). About 58 cases of inherited thrombophilia were found between the years 2000-2002. These cases were significantly more common in the recurrent abortion as compared to the comparison group (1.2% versus 0.1%; OR = 11.1; 95% CI, 6.5-18.9; P < 0.001). CONCLUSION: A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions. Careful surveillance is required in pregnancies following recurrent abortions, for early detection of possible complications.

Recent advances in the management of placenta previa.

PURPOSE OF REVIEW: Despite the widespread and routine use of ultrasound to make the diagnosis of placenta previa, evidence-based classification and management strategies have failed to evolve over the years. The purpose of this review is to present the current evidence supporting the screening, diagnosis and management of placenta previa. RECENT FINDINGS: The prevalence of placenta previa is significantly overestimated due to the practice of routine mid-pregnancy scan, and many women currently undergo a repeat scan in late pregnancy for placental localization. Recent reports support limiting third-trimester scans to only those cases where the placental edge either reaches or overlaps the internal cervical os at 20-23 weeks of pregnancy. In some cases of mid-trimester placenta previa, the placental edge is more likely to "migrate" than others, and it appears that ultrasound may be useful to predict this process. At term, women with placental edge within 2 cm of the internal cervical os require a Caesarean section for delivery, whereas an attempt at vaginal birth is appropriate if this distance is more that 2 cm. Ultrasound also has a role in the diagnosis and management of both vasa previa and placenta accreta. SUMMARY: This review addresses screening for placenta previa. A simple and pragmatic ultrasound classification of placenta previa and low-lying placenta is proposed. Caesarean section is recommended for delivery in cases of placenta previa. Women with a low-lying placenta have at least 60% chance of a vaginal birth, but should be monitored for post-partum haemorrhage. Vasa previa is a rare complication but antenatal diagnosis is possible. It should particularly be suspected in in-vitro fertilization conceptions, and where the placental edge covers the os in mid-pregnancy but recedes later on. Prenatal diagnosis of placenta accreta should be based on the placental lacunae signs rather than the absence of retro-placental clear space.

Major placenta praevia should not preclude out-patient management.

OBJECTIVE: To review current management of women with major and minor placenta praevia in view of the recommendations made in the RCOG guideline 2001. To assess whether out-patient care was detrimental to pregnancy outcome. STUDY DESIGN: Retrospective observational study at the Simpson Memorial Maternity Pavilion, Edinburgh (a tertiary referral centre). One hundred and sixty-one women with major and minor placenta praevia between 1994 and 2000 were separated into those who experienced bleeding (antepartum haemorrhage (APH)) and those who had no bleeding during pregnancy (non-APH). Statistical analysis was carried out using SPSS. RESULTS: There were 129 women (80%) in the APH group. Forty-three were out-patients at the time of delivery and 63% had a major degree of praevia. Thirty-two women were in the non-APH group. Sixty-eight were managed as out-patients and 50% had a major degree of praevia. Women with a major degree of praevia were not significantly more likely to experience bleeding. Women with APH were significantly more likely to be delivered early, by emergency caesarean section (C/S), of lower birthweight babies who required neonatal admission than the non-APH group. CONCLUSION: There is a place for out-patient management of women with placenta praevia. Caution is required with increasing number of bleeds but not degree of praevia.

Cervical varix accompanied by placenta previa in twin pregnancy.

BACKGROUND: Uterine cervical varix is a rare complication in pregnant women and can be the cause of obstetric hemorrhage in the vagina resulting in adverse events for both the mother and fetus. CASE: A 34-year-old Japanese woman was hospitalized at 18 weeks gestation because of cervical varix and placenta previa. Prophylactic tocolysis successfully controlled the obstetric hemorrhage. At 27 weeks gestation, emergent cesarean section was performed because of intractable hemorrhage from the marginal placenta previa. Intraabdominal findings revealed no vascular malformation of the uterus, and the operation was performed uneventfully. A speculum examination of the vagina and cervix at 1 month postpartum were unremarkable. CONCLUSION: It is important to recognize the clinical features and available treatments for cervical varix.

Is placenta accreta catching up with us?

BACKGROUND: Concomitant with the increase in Caesarean birth over the past three decades there has been an apparent rise in the incidence of placenta accreta and its variants. The sequelae of an increase in the occurrence of abnormal placentation is the enhanced potential for severe maternal morbidity. AIM: To determine the contempory demographics of placenta accreta over a 5-year period in a tertiary level teaching hospital. METHODS: A retrospective review of all cases of placenta accreta and variants during the period of 1998-2002. Individual charts review followed case ascertainment via the hospital obstetric database. RESULTS: Thirty-two women with placenta accreta (or variant) were identified. Median maternal age was 34 years, with a median parity of 2.5. Seventy-eight percent of cases had had at least one prior Caesarean birth, and 88% of cases were associated with placenta praevia. Pre-delivery ultrasonography was performed in all cases, providing diagnostic sensitivity of 63% and specificity of 43% with a predictive value of 76%. Hysterectomy was performed in 91% of cases with median intraoperative blood loss of 3000 mL. There were no maternal deaths in the current series. CONCLUSION: A strong association between placenta accreta, placenta praevia and prior Caesarean birth has been demonstrated. As there is the potential for significant maternal morbidity the risk of placenta accreta needs to be recognised and women at risk should be considered for delivery at an institution with appropriate expertise and resources in managing this condition.

Maternal mortality in Italy, 1980-1996.

OBJECTIVE: To establish the extent of maternal mortality in Italy in between 1980 and 1996 in order to compare it with the international data. STUDY DESIGN: We conducted a retrospective study on maternal deaths in Italy from 1980 to 1996. Data have been collected by Italian Statistic Institute (ISTAT). We calculated both the maternal mortality rates and the percentages of causes of death in the whole period, according to WHO definitions. RESULTS: The data confirmed the trends of the previous decade: maternal mortality rates have decreased from 13.25 (1980) to 3.78 (1996) for 100000 live births. Haemorrhage and hypertension have been the main causes of maternal death, while pulmonary embolism has had a minor affect on maternal mortality rates compared to other countries, particularly in Europe. CONCLUSION: Italian data appear reassuring and encourage further investigations on detailed welfare problems.

Placenta previa: the role of ultrasound in assessment during third trimester.

OBJECTIVE: To assess the role of ultrasound in detecting the migration of placenta previa during the third trimester at Lady Willingdon Hospital and Jinnah Hospital, Lahore during the period July 2000 to September 2002. METHODS: Eighty pregnant women with the diagnosis of placenta previa at 28 to 32 weeks of gestation were included in the study. After base line ultrasound, scan was repeated every two weeks until delivery or placental migration for more than 3 cm from internal cervical os. Detailed information for placental position, distance from cervical os and relation to presenting part was recorded. Women with major degree placenta previa were admitted in the hospital at 32 -34 weeks of gestation. Delivery plan was made according to degree of placenta previa by completed 37 weeks of gestation. Cesarean section was done for the women with major degree placenta previa and minor degree placenta previa with antepartum hemorrhage and obstetric indication RESULTS: Out of 80 women placental migration to a distance of more than 3-5 cm from the internal cervical os occurred in 20 cases (12 anterior/anterolateral, 8 posterior/posterolateral) by 36 weeks of gestation and 20 had complete placenta previa. Out of remaining 40 cases, 12 patients had vaginal delivery and 28 had cesarean section. Placental migration was not observed in women with total placenta previa or posterior placenta previa when the distance of lower edge of placenta was less than 1 cm from the internal os. CONCLUSION: Ultrasound is important for the diagnosis of placental localization and placental migration during third trimester. Placental migration takes place more often in anterior than in complete or posterior placenta previa.

[The therapeutic role of tocolysis]. / Tocolyse dans les situations pathologiques particulières.

In twin pregnancies, the use of beta-adrenergics is associated with a significantly higher incidence of cardiovascular complications, and calcium channel blockers as well as oxytocin antagonists currently appear as first line agents. After extreme preterm delivery of the first twin and in selected patients, the birth of second twin may be delayed with a mean gain of 10-50 days. In cases of symptomatic placenta previa with mild-to-moderate bleeding, tocolytic agents may be associated with a prolongation of pregnancy and increased birth weight without significant impact on frequency or severity of bleeding. Calcium channel blockers are the drugs of choice in the event of diabetes. Indomethacin is a potent tocolytic, in particular in patients with polyhydramnios. However, it may cause oligohydramnios, premature closure of the ductus arteriosus and intrauterine fetal death when high doses are administered for a duration exceeding 48 to 72 hours, particularly beyond 32 weeks' gestation. The neonatal complications of indomethacin occur frequently. Tocolysis appears to reduce the failure rate of external cephalic version at term.

Ectopic pregnancies in Caesarean section scars: the 8 year experience of one medical centre.

BACKGROUND: Our aim was to supplement the mostly individual case reports on the rarely occurring and life-threatening condition of ectopic pregnancy developing in a Caesarean section scar. METHODS AND RESULTS: Eight of all the patients treated in our department between 1995 and 2002 had been diagnosed for ectopic pregnancy that developed in a Caesarean section scar. They comprised this case series group. Four of them underwent methotrexate treatment; one had expectant management, one transcervical aspiration of the gestational sac and two by open surgery. All the non-surgically treated women had an uneventful outcome. One underwent a term Caesarean hysterectomy and the other first trimester hysterotomy and excision of the pregnancy located in the scarred uterus. Analysis of all these women's obstetric history revealed that five of them (63%) had been previously operated because of breech presentation, one had a cervical pregnancy and one had placenta previa. Four of them (50%) had multiple (> or = 2) Caesarean sections. CONCLUSIONS: The women at risk for pregnancy in a Caesarean section scar appear to be those with a history of placental pathology, ectopic pregnancy, multiple Caesarean sections and Caesarean breech delivery. Heightened awareness of this possibility and early diagnosis by means of transvaginal sonography can improve outcome and minimize the need for emergency extended surgery.