Morbidly Adherent Placenta: Ultrasound Assessment and Supplemental Role of Magnetic Resonance Imaging.

Morbidly adherent placenta or placenta accreta is being increasingly encountered in obstetrical practice mainly owing to the increasing rates of cesarean delivery. This condition is associated with increased maternal morbidity and mortality resulting from postpartum hemorrhage. When unsuspected, outcomes can be catastrophic to the pregnant woman. Timely diagnosis during the antenatal period, on the contrary, allows for optimal planning of a multidisciplinary management approach and delivery at a tertiary care institution. A higher index of suspicion in those at greatest risk such as in women with placenta previa and with history of some prior cesarean deliveries should lead to diligent antenatal evaluation for possible placenta accreta. Management of invasive placenta implantation often involves cesarean delivery hysterectomies; uterus-sparing alternatives to manage this condition can be an option in selected cases. Ultrasound imaging remains the modality of choice for the diagnosis. This review article discusses the ultrasound image findings in placenta accreta, its limitations and pitfalls, and the supplemental role of magnetic resonance imaging in the imaging evaluation of placenta accreta.

Predictors of clinical outcomes in the laparoscopic management of adnexal masses.

OBJECTIVE: Laparoscopy has become an accepted approach in the management of adnexal masses. We evaluated clinical outcomes of laparoscopic management of adnexal masses thought to be benign preoperatively. METHODS: We performed a retrospective study of patients undergoing laparoscopic evaluation of adnexal masses over a 7-year period. Regression models evaluated predictors of blood loss, length of stay, complications, mass rupture, conversion to laparotomy, and operating time. Preoperative predictors of malignant and borderline disease were evaluated using a separate model. RESULTS: Complications occurred in 8% of 396 patients undergoing laparoscopic evaluation of adnexal masses and were associated with concurrent hysterectomy (P =.01) and smaller mass (P =.01). Conversion to laparotomy occurred in 25% and was associated with larger mass (P =.001), prior hysterectomy (P =.002), and younger age (P =.002). Mass rupture occurred in 25% and was associated with prior (P <.001) or concurrent (P =.003) hysterectomy and younger age (P =.001). Blood loss greater than 500 mL was associated with concurrent hysterectomy (P <.001). Length of stay was associated with concurrent (P <.001) and prior (P <.001) hysterectomy, larger mass (P =.01), prior abdominal surgery (P =.009), and medical comorbidities (P =.007). Malignancy occurred in 2%, and laparoscopic management was not associated with adverse outcomes. CONCLUSION: Adnexal masses thought to be benign preoperatively were successfully managed laparoscopically in three fourths of cases and clinical outcomes were acceptable. To a great extent, adverse events were attributable to concurrent hysterectomy rather than removal of the adnexal mass.