misoprostol and Placenta-Accreta

Major obstetric hemorrhage is an extremely challenging obstetric emergency associated with significant morbidity and mortality. Pharmacological treatment of uterine atony has not altered much in recent years apart from the increasing use ofmisoprostol, although controversy surrounds its advantages over other uterotonics. Placenta accreta is becoming more common, a sequel to the rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine compression sutures, intrauterine tamponade balloons and cell salvage have been introduced in the last decade.

Topics: Cesarean Section; Female; Humans; Misoprostol; Obstetric Labor Complications; Oxytocics; Placenta Accreta; Postpartum Hemorrhage; Pregnancy; Uterine Hemorrhage

Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS.. A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS.. ① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and β-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination.. Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.

Topics: Abortifacient Agents, Steroidal; Abortion, Induced; Adult; Cesarean Section; China; Female; Humans; Hysterotomy; Labor, Induced; Mifepristone; Misoprostol; Placenta Accreta; Placenta Previa; Pregnancy; Pregnancy Trimester, Second; Retrospective Studies; Vaginal Birth after Cesarean; Young Adult

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.

Topics: Adult; Cesarean Section; Female; Humans; Hysterectomy; Massage; Middle Aged; Misoprostol; Oxytocics; Oxytocin; Placenta Accreta; Placenta Previa; Postpartum Hemorrhage; Pregnancy; Severity of Illness Index; Suture Techniques; Treatment Failure; Uterine Inertia; Young Adult

To describe the management and outcomes of placenta accreta, increta, and percreta in the UK.. A population-based descriptive study using the UK Obstetric Surveillance System (UKOSS).. All 221 UK hospitals with obstetrician-led maternity units.. All women diagnosed with placenta accreta, increta, and percreta in the UK between May 2010 and April 2011.. Prospective case identification through the monthly mailing of UKOSS.. Median estimated blood loss, transfusion requirements.. A cohort of 134 women were identified with placenta accreta, increta, or percreta: 50% (66/133) were suspected to have this condition antenatally. In women with a final diagnosis of placenta increta or percreta, antenatal diagnosis was associated with reduced levels of haemorrhage (median estimated blood loss 2750 versus 6100 ml, P = 0.008) and a reduced need for blood transfusion (59 versus 94%, P = 0.014), possibly because antenatally diagnosed women were more likely to have preventative therapies for haemorrhage (74 versus 52%, P = 0.007), and were less likely to have an attempt made to remove their placenta (59 versus 93%, P < 0.001). Making no attempt to remove any of the placenta, in an attempt to conserve the uterus or prior to hysterectomy, was associated with reduced levels of haemorrhage (median estimated blood loss 1750 versus 3700 ml, P = 0.001) and a reduced need for blood transfusion (57 versus 86%, P < 0.001).. Women with placenta accreta, increta, or percreta who have no attempt to remove any of their placenta, with the aim of conserving their uterus, or prior to hysterectomy, have reduced levels of haemorrhage and a reduced need for blood transfusion, supporting the recommendation of this practice.

Topics: Blood Transfusion; Cesarean Section; Cohort Studies; Dinoprost; Ergonovine; Female; Humans; Hysterectomy; Misoprostol; Oxytocics; Oxytocin; Placenta Accreta; Postpartum Hemorrhage; Pregnancy; Prospective Studies; Treatment Outcome; United Kingdom; Uterine Artery Embolization

Topics: Administration, Oral; Drug Therapy, Combination; Female; Humans; Mifepristone; Misoprostol; Oxytocics; Placenta Accreta; Pregnancy

Hemostatic square suturing is a useful technique for postpartum hemorrhage, but some complications may occasionally occur.. A 36-year-old pregnant woman with placenta previa and percreta at 35 weeks' gestation complicated with massive vaginal bleeding. An emergency cesarean section was performed, and placenta previa with percreta and uterine atony were noted. A hemostatic square suture was placed to compress the uterus and stopped the hemorrhage successfully. The estimated blood loss was approximately 2,200 mL. Thirty-seven days after operation, massive vaginal bleeding developed and the ultrasonography showed a 6.84 x 5.71-cm complex intrauterine mass. The patient was treated with intravenous oxytocin, rectal misoprostol, and blood transfusion. The beta-human chorionic gonadotropin levels returned to normal level on day 70 postoperatively, and ultrasonography revealed no obvious intrauterine mass.. Late postpartum hemorrhage may result from the use of hemostatic square suture technique.

Topics: Adult; Cesarean Section; Chorionic Gonadotropin, beta Subunit, Human; Female; Hemostatic Techniques; Humans; Misoprostol; Oxytocics; Oxytocin; Placenta Accreta; Placenta Previa; Postpartum Hemorrhage; Pregnancy; Suture Techniques; Ultrasonography; Uterus

Uterine anomalies are often first suspected after bimanual or ultrasonographic examination. Currently there are no specific recommendations for further evaluation of asymptomatic women with suspected uterine anomalies in pregnancy.. A young primigravida with a history of an ultrasound diagnosis of bicornuate uterus presented with mild abdominal pain. An ultrasound examination showed a viable 18-week fetus with anhydramnios in the left uterine horn. Labor induction with misoprostol culminated in uterine rupture. At laparotomy, a ruptured left noncommunicating rudimentary uterine horn of a unicornuate uterus was noted.. Pregnancies within noncommunicating uterine horns significantly increase the risk of potentially catastrophic outcome, therefore, consideration should be given to performing 3-dimensonal ultrasonography and/or magnetic resonance imaging examinations to determine the nature of uterine anomalies. Caution should be exercised if prostaglandins are considered for use in this setting.

Topics: Abdomen, Acute; Abortifacient Agents, Nonsteroidal; Adult; Female; Humans; Labor, Induced; Laparotomy; Misoprostol; Placenta Accreta; Pregnancy; Pregnancy Complications; Pregnancy Trimester, Second; Pregnancy, Ectopic; Ultrasonography, Prenatal; Uterine Rupture; Uterus