Planned conservative management of placenta accreta - experience of a regional general hospital.

OBJECTIVE: There are only a few series treating ≥10 cases of accreta conservatively, all from university teaching hospitals, with reported success rate of 60-85%. We reported the first series of accreta managed by planned uterine conservation in the setting of non-university district general hospital. METHODS: Women with placenta previa overlying previous cesarean scar who desired uterine conservation were included. For cases with accreta confirmed during cesarean delivery, placenta was purposefully left behind, followed immediately by uterine artery embolization. Cases were followed in our special postnatal clinic. Charts were reviewed to retrieve clinical details. RESULTS: Among 15 cases of placenta previa overlying cesarean scar opting for conservative management, 12 (80%) were confirmed to be accreta intra-operatively. They had 20-100% of the adherent placentae retained (median 90%) and their uterus preserved. Postpartum, abnormal vaginal bleeding and/or infection led to unscheduled readmission in 67% (8/12), all managed conservatively. Sonographic resolution of placenta took 2-13 months (median 6.6), and was later than menstrual return in 11 cases. CONCLUSIONS: Successful planned conservative management of placenta accreta is feasible in the setting of district general hospital with facilities for interventional radiology.

Use of second-line therapies for management of massive primary postpartum hemorrhage.

OBJECTIVE: To determine rates of use and success of second-line therapies for massive primary postpartum hemorrhage (PPH). METHODS: A retrospective cohort study was conducted among 91 women who gave birth at Kwong Wah Hospital, Hong Kong, between January 1, 2006, and December 31, 2011. Inclusion criteria were gestational age of at least 24 weeks and massive PPH (defined as blood loss ≥1500 mL within 24 hours after birth). Second-line therapies assessed were uterine compression sutures, uterine artery embolization, and balloon tamponade after failure of uterine massage and uterotonic agents to stop bleeding. RESULTS: The rate of massive PPH was 2.65 per 1000 births. Second-line therapies were used among 42 women with PPH, equivalent to a rate of 1.23 per 1000 births. Only 21.4% of the women who received second-line therapies required rescue hysterectomy. A rising trend was observed for the use of second-line therapies, whereas the incidence of rescue hysterectomy and estimated blood loss were found to concomitantly decrease. CONCLUSION: Increasing use of second-line therapies among women with massive PPH was associated with a decreasing trend for rescue hysterectomy. Obstetricians should, therefore, consider all available interventions to stop PPH, including early use of second-line options.

A clinical comparison of the Flexiblade and Macintosh laryngoscopes for laryngeal exposure in anesthetized adults.

The Flexiblade is a laryngoscope with a flexible blade. To evaluate the efficacy of the Flexiblade compared with the classic Macintosh laryngoscope, we performed a clinical study in 200 paralyzed patients undergoing elective surgery requiring general anesthesia and endotracheal intubation. Direct laryngoscopy was performed with a size 3 Macintosh laryngoscope and the Flexiblade, with and without activation of the lever. The laryngeal views were recorded, without manipulation, according to the Cormack and Lehane classification. No laryngoscopic view obtained by the Macintosh blade was worse than that obtained by the Flexiblade without the lever activated. The Macintosh blade improved 58.5% of non-Grade I views obtained by the Flexiblade with its lever not activated. However, when the Flexiblade lever was activated, 39.6% of non-Grade I views obtained by the Macintosh blade were improved, whereas 84.5% of non-Grade I views obtained by the inactivated Flexiblade were improved. Activating the Flexiblade lever never caused a deterioration of view. In only one case was the view better with the Macintosh blade than that with the activated Flexiblade. We conclude that the Flexiblade, after lever activation, is significantly better than the Macintosh laryngoscope for laryngeal visualization in paralyzed adults (P < 0.0001).