'Nausicaa' compression suture: a simple and effective alternative to hysterectomy in placenta accreta spectrum and other causes of severe postpartum haemorrhage.
ABSTRACT: Postpartum haemorrhage (PPH), especially resulting from placenta accreta spectrum (PAS), has become a worldwide concern in maternity care. We describe a novel method of uterine compression sutures (the 'Nausicaa' technique) as an alternative to hysterectomy for patients who have suffered from major PPH. We applied this technique in 68 patients with major PPH during caesarean section (including 43 patients with PAS, 20 patients with placenta praevia totalis, and five patients with uterine atony), and none of these patients required further hysterectomy. We conclude that our Nausicaa suture is a simple and feasible alternative to hysterectomy in patients suffering from major PPH.
Project description:Placenta praevia/accreta is associated with significant maternal morbidity and mortality and is a common cause of obstetric hysterectomy. This paper describes posterior retrograde abdominal hysterectomy, a new surgical technique for caesarean hysterectomy, in 11 women with placenta percreta, increta or accreta There were no intraoperative or postoperative maternal complications, and only one fetus required admission to the neonatal unit, for prematurity. Our technique in placenta praevia/accreta allows easy identification of the vagina and early uterine devascularisation, as well as safe resection of the involved urinary bladder in women with placenta percreta showing bladder penetration. Analytical studies are needed to confirm our findings.Posterior retrograde abdominal hysterectomy in women with placenta praevia/accreta may enable safer surgery.
Project description:BACKGROUND:Placenta accreta spectrum (PAS) disorders have become a significant life-threatening issue due to its increased incidence, morbidity and mortality. Several studies have tried to identify the risk factors for PAS disorders. The ideal management for PAS disorders is a matter of debate. The study objectives were to evaluate the incidence and risk factors of PAS disorders and to compare different management strategies at a tertiary referral hospital, Minia, Egypt. METHODS:This prospective study included 102 women diagnosed with PAS disorders admitted to Minia Maternity university hospital, Egypt between January 2017 to August 2018. These cases were categorized into three groups according to the used approach for management: Group (A), (n = 38) underwent cesarean hysterectomy, group (B), (n = 48) underwent cesarean section (CS) with cervical inversion and ligation of both uterine arteries and group (C), (n = 16): the placenta was left in place. RESULTS:The incidence of PAS disorders during the study period was 9 / 1000 maternities (0.91%). The mean age of cases was 32.4 ± 4.2 years, 60% of them had a parity ≥3 and 82% of them had ≥2 previous CSs. Also, 1/3 of them had previous history of placenta previa. Estimated blood loss (EBL) and blood transfusion in group A were significantly higher than other groups. Group (C) had higher mean hospital stay duration. Group A was associated with significantly higher complication rate. CONCLUSIONS:The incidence of PAS disorders was 0.91%. Maternal age > 32 years, previous C.S. (≥ 2), multiparity (≥ 3) and previous history of placenta previa were risk factors. The management of PAS disorders should be individualized. Women with PAS disorders who completed their family should be offered cesarean hysterectomy. Using the cervix as a tamponade combined with bilateral uterine artery ligation appears to be a safe alternative to hysterectomy in patients with focal placenta accreta and low parity desiring future fertility. Patients with diffuse placenta accreta keen to preserve the uterus could be offered the option of leaving the placenta aiming at conservative management after proper counseling. TRIAL REGISTRATION:Registered 28th October 2015, ClinicalTrials.gov NCT02590484 .
Project description:Placenta previa and placenta accreta carry significant maternal and fetal morbidity and mortality. Several techniques have been described in the literature for controlling massive bleeding associated with placenta previa cesarean sections. The objective of this study was to evaluate the efficacy and safety of the use of the cervix as a natural tamponade in controlling postpartum hemorrhage caused by placenta previa and placenta previa accreta.This prospective study was conducted on 40 pregnant women admitted to our hospital between June 2012 and November 2014. All participating women had one or more previous cesarean deliveries and were diagnosed with placenta previa and/or placenta previa accreta. Significant bleeding from the placental bed during cesarean section was managed by inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment.The technique of cervical inversion described above was successful in stopping the bleeding in 38 out of 40 patients; yielding a success rate of 95%. We resorted to hysterectomy in only two cases (5%). The mean intra-operative blood loss was 1572.5 mL, and the mean number of blood units transfused was 3.1. The mean time needed to perform the technique was 5.4?±?0.6 min. The complications encountered were as follows: bladder injury in the two patients who underwent hysterectomy and wound infection in one patient. Postoperative fever that responded to antibiotics occurred in 1 patient. The mean duration of the postoperative hospital stay was 3.5 daysThis technique of using the cervix as a natural tamponade appears to be safe, simple, time-saving and potentially effective method for controlling the severe postpartum hemorrhage (PPH) caused by placenta previa/placenta previa accreta. This technique deserves to be one of the tools in the hands of obstetricians who face the life-threatening hemorrhage of placenta accreta.ClinicalTrials.gov NCT02590484 . Registered 28 October 2015.
Project description:OBJECTIVE:Estimate the incidence of placenta accreta and describe risk factors, clinical practice and perinatal outcomes. DESIGN:Case-control study. SETTING:Sites in Australia and New Zealand with at least 50 births per year. PARTICIPANTS:Cases were women giving birth (?20 weeks or fetus ?400?g) who were diagnosed with placenta accreta by antenatal imaging, at operation or by pathology specimens between 2010 and 2012. Controls were two births immediately prior to a case. A total of 295 cases were included and 570 controls. METHODS:Data were collected using the Australasian Maternity Outcomes Surveillance System. PRIMARY AND SECONDARY OUTCOME MEASURES:Incidence, risk factors (eg, prior caesarean section (CS), maternal age) and clinical outcomes of placenta accreta (eg CS, hysterectomy and death). RESULTS:The incidence of placenta accreta was 44.2/100 000 women giving birth (95%?CI 39.4 to 49.5); however, this may overestimated due to the case definition used. In primiparous women, an increased odds of placenta accreta was observed in older women (adjusted OR (AOR) women?40?vs <30: 19.1, 95%?CI 4.6 to 80.3) and current multiple birth (AOR: 6.1, 95%?CI 1.1 to 34.1). In multiparous women, independent risk factors were prior CS (AOR ?2?prior sections vs 0: 13.8, 95%?CI 7.4 to 26.1) and current placenta praevia (AOR: 36.3, 95%?CI 14.0 to 93.7). There were two maternal deaths (case fatality rate 0.7%).Women with placenta accreta were more likely to have a caesarean section (AOR: 4.6, 95%?CI 2.7 to 7.6) to be admitted to the intensive care unit (ICU)/high dependency unit (AOR: 46.1, 95%?CI 22.3 to 95.4) and to have a hysterectomy (AOR: 209.0, 95%?CI 19.9 to 875.0). Babies born to women with placenta accreta were more likely to be preterm, be admitted to neonatal ICU and require resuscitation.
Project description:Placentation disorders are the result of impaired embedding of the placenta in the endometrium. The prevalence of these disorders is estimated to be around 0.3?%. A history of previous prior uterine surgery (especially cesarean section and curettage) is the most common risk factor. Impaired placentation is differentiated into deep placental attachment; marginal, partial and total placenta previa; and placenta accreta, increta and percreta. Treatment depends on the severity of presentation and ranges from expectant management to emergency hysterectomy. In most cases, preterm termination of pregnancy is necessary. We report here on the case of a 39-year-old woman with placenta accreta and total placenta previa who underwent hysterectomy in the 19th week of pregnancy.
Project description:BACKGROUND:A scheduled pre-viable hysterectomy is a treatment option for women with early diagnosed placenta accreta spectrum who do not wish future fertility. A minimally invasive hysterectomy with pregnancy in situ for placenta accreta spectrum has not been previously reported. CASE:A patient with evidence of placenta accreta spectrum on prenatal imaging underwent an elective robot-assisted laparoscopic hysterectomy at 16 weeks of gestation. The procedure was uncomplicated and she was discharged on postoperative day 1. Pathology was consistent with placenta percreta. CONCLUSION:Robot-assisted laparoscopic hysterectomy with pregnancy in situ is feasible in a patient with placenta accreta spectrum in the second trimester. TEACHING POINTS:1. Early diagnosis of placenta accreta spectrum is important for surgical planning and management. 2. We present a technique for minimally invasive hysterectomy in a patient with placenta accreta spectrum diagnosed before viability.
Project description:Placenta previa accreta is an obstetrical complication that severely affects the heath of the fetus and the mother due to massive hemorrhage during pregnancy. This study reported a new suture technique called "cervical internal os plasty" to control obstetrical hemorrhage in cesarean delivery for patients with placenta previa accreta and retrospectively evaluated the safety and effectiveness of the new technique.From January 2012 to May 2018, we collected 56 patients with this new suture technique, which repaired the damaged weak area with bleeding from the placental attachment site in the lower uterine segment, and restored the damaged anatomic internal os of the cervix. Meanwhile, we compared it with 60 cases with other conservative methods described by other obstetricians with the same qualifications. The perioperative outcomes (blood loss, blood transfusion, operative time, other applied medical technology, and so on) between the 2 groups were recorded in this report.There were no significant differences between 2 groups among age, gravidity, parity, gestational age, and previous dilatation and curettage techniques (P?>?.05). Of the patients with placenta previa accrete, 77.6% (90/116) had previous dilatation and curettage. The comparison between study group and control group on the rate of postpartum hemorrhage, blood transfusion, and mean operative time, average hospitalization days after cesarean delivery, expenses was not statistically significant (P?>?.05). Compared with the control group, other applied supplementary techniques (including uterine tamponade, pelvic arterial embolization, or emergency hysterectomy) for the bleeding from the the placental attachment site is fewer significantly in the study group. No operative accident and hemorrhea-related complication occurred in the 2 groups.Cervical internal os plasty is useful in patients with placenta previa accreta due to its simplicity, utility, and effectivity as well as its capacity for preserving fertility.
Project description:Placenta percreta is an obstetric condition in which the placenta invades through the myometrium. This is the most severe form of placenta accreta and may result in spontaneous uterine rupture, a rare complication that threatens the life of both mother and fetus. In this case report, we describe a 32-year-old woman in her fourth pregnancy, diagnosed with repeated placenta accreta, which was eventually complicated by spontaneous uterine rupture at 24 weeks' gestation. This patient had a history of abnormal placentation in prior pregnancies and previous uterine injuries. This case demonstrates a pattern of escalating placental invasiveness, and raises questions regarding the process of abnormal placentation and the manifestation of uterine rupture in scarred uteri.
Project description:Placenta accreta spectrum (PAS) is a pathological condition of the placenta with abnormal adhesion or invasion of the placental villi to the uterine wall, which is associated with a variety of adverse maternal and fetal outcomes. Although some PAS-related molecules have been reported, the underlying regulatory mechanism is still unclear. Compared with the study of single gene or pathway, omics study, using advanced sequencing technology and bioinformatics methods, can increase our systematic understanding of diseases. In this study, placenta tissues from 5 patients with PAS and 5 healthy pregnant women were collected for transcriptomic and proteomic sequencing and integrated analysis. A total of 728 messenger RNAs and 439 proteins were found to be significantly different between PAS group and non-PAS group, in which 23 hub genes were differentially expressed in both transcriptome and proteome. Functional enrichment analysis showed that the differentially expressed genes were mainly related to cell proliferation, migration and vascular development. Totally 18 long non-coding RNA were found that might regulate the expression of hub genes. Many kinds of single nucleotide polymorphism, alternative splicing and gene fusion of hub genes were detected. This is the first time to systematically explore the hub genes and gene structure variations of PAS through integrated omics analysis, which provided a genetic basis for further in-depth study on the underlying regulatory mechanism of PAS.
Project description:<b>Aim:</b> Aim of the study was to show that conservative management with preservation of the uterus and of fertility is possible in patients with placenta accreta/increta after vaginal delivery. <b>Method:</b> A retrospective analysis of patients with placental attachment disorders after vaginal delivery was done in a perinatal centre between November 2009 and April 2011. The patient collective was identified using the ICD-10 codes for placenta accreta/increta/percreta, and patient records were analysed for risk factors, maternal morbidity, preservation of the uterus and of fertility, and neonatal outcome. <b>Results:</b> Three cases of placenta increta were identified in the last 1.5 years out of a total of 1457 vaginal deliveries, and all 3 cases were treated conservatively. Mean maternal age was 35.3 years; gestational age ranged from 39 to 41 weeks, and mean duration between delivery of the child and delivery of the placenta was 44.67 days (range: 14-100 days). Two patients developed symptoms of endomyometritis, including fever, leukocytosis and increased CRP levels. All 3 women were successfully managed with preservation of the uterus. <b>Conclusion:</b> In selected cases with placenta accreta/increta after vaginal delivery, it is possible to avoid surgical procedures, particularly hysterectomy procedures, and successfully manage these patients conservatively with preservation of the uterus.