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Mortimer R, Lanes A, Ginsburg ES. History of hysteroscopic adhesiolysis and the risk of placental disorders and postpartum hemorrhage. Am J Obstet Gynecol 2024:S0002-9378(24)00725-7. [PMID: 38964634 DOI: 10.1016/j.ajog.2024.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Roisin Mortimer
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115; Harvard Medical School, Boston, MA.
| | - Andrea Lanes
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115; Harvard Medical School, Boston, MA
| | - Elizabeth S Ginsburg
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115; Harvard Medical School, Boston, MA
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Laranjo M, Aniceto L, Domingues C, Gonçalves L, Fonseca J. Managing Placenta Accreta and Massive Hemorrhage: A Case Report on Anesthetic and Surgical Interventions. Cureus 2024; 16:e64071. [PMID: 39114213 PMCID: PMC11304637 DOI: 10.7759/cureus.64071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2024] [Indexed: 08/10/2024] Open
Abstract
Obstetric haemorrhage is a leading cause of maternal morbidity and mortality and is a common reason for intensive care unit (ICU) admission in the postpartum. Primary postpartum obstetric haemorrhage is associated with four main causes: tone, thrombin, trauma, and tissue. Regarding the last one, placenta accreta is an abnormal invasion of the placenta into the myometrium. Early diagnosis of placenta accreta allows for better perioperative management; however, it is sometimes only identified during caesarean delivery when the placenta cannot be removed. We report a case of a 37-year-old woman with a history of caesarean section due to placenta previa, who was admitted at 36 weeks and 1 day for an urgent caesarean section (c-section) due to cord presentation. A subarachnoid block (SAB) was used for anaesthesia. It was chosen over general anaesthesia because it allows the patient to experience the birth of her children, enhances pain control, and avoids complications associated with general anaesthesia. Besides our centre has expertise in neuraxial anaesthesia. During the procedure, placental accretism and massive haemorrhage occurred, and a life-saving abdominal hysterectomy was needed. The patient experienced hypotension, partially responsive to volume replacement and vasopressors, leading to norepinephrine infusion and conversion to general anaesthesia. The surgery lasted 2.5 hours with a blood loss of 3500 ml. The patient was extubated without complications and transferred to the post anaesthesia care unit (PACU). Risk factors for placenta accreta spectrum (PAS) include previous surgery and placenta previa with a prior c-section. Antenatal diagnosis is crucial, and women with risk factors should undergo imaging at experienced centres. Delivery centres must have protocols for unexpected PAS and major obstetric haemorrhage. Both general and neuraxial anaesthesia can be suitable for managing PAS, and caesarean hysterectomy is often required to control haemorrhage. Postoperatively, adequate monitoring and care is essential. PAS management should involve excellent communication between a multidisciplinary team in specialised centres.
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Affiliation(s)
- Marta Laranjo
- Anaesthesiology, Unidade Local de Saúde da Região de Leiria, Leiria, PRT
| | - Leonor Aniceto
- Anaesthesiology, Unidade Local de Saúde da Região de Leiria, Leiria, PRT
| | - Catia Domingues
- Anaesthesiology, Unidade Local de Saúde da Região de Leiria, Leiria, PRT
| | - Luís Gonçalves
- Anaesthesiology, Unidade Local de Saúde da Região de Leiria, Leiria, PRT
| | - João Fonseca
- Anaesthesiology, Unidade Local de Saúde da Região de Leiria, Leiria, PRT
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Mortimer RM, Lanes A, Srouji SS, Waldman I, Ginsburg E. Treatment of intrauterine adhesions and subsequent pregnancy outcomes in an in vitro fertilization population. Am J Obstet Gynecol 2024:S0002-9378(24)00608-2. [PMID: 38777163 DOI: 10.1016/j.ajog.2024.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Asherman syndrome refers to the presence of intrauterine adhesions, which have clinical implications, including infertility. There are few studies assessing the effect of serial hysteroscopies for adhesiolysis on reproductive and pregnancy outcomes among women who subsequently undergo in vitro fertilization, and none have looked at maternal, neonatal, or placental pregnancy complications. OBJECTIVE This study aimed to explore the effect of hysteroscopic adhesiolysis among a cohort of patients who subsequently undergo in vitro fertilization. STUDY DESIGN This was a retrospective cohort study of all patients who underwent hysteroscopic adhesiolysis for intrauterine adhesions at our center between 2005-2020 and subsequently attempted conception by in vitro fertilization. A control group of patients who underwent in vitro fertilization for nonuterine factor infertility and had no history of intrauterine adhesions was chosen for comparison. RESULTS There were 691 patients included in this study, of whom 168 were intrauterine adhesion cases. The implantation rate (41.3% in both groups) and live birth rate (adjusted relative risk, 0.93 [95% confidence interval, 0.76-1.14]) were not statistically different between cases and controls. When grouped by number of previous adhesiolysis surgeries, patients who underwent ≥2 adhesiolysis surgeries had a lower live birth rate than controls (adjusted relative risk, 0.53 [95% confidence interval, 0.28-0.99]). Endometrial thickness before the transfer was significantly reduced in cases vs controls (8.23 vs 10.25 mm; adjusted relative risk, 0.84 [95% confidence interval, 0.78-0.90]). Adverse placental outcomes, including placenta accreta spectrum, placenta previa, or vasa previa, were significantly more likely to occur in cases than controls (adjusted relative risk, 2.08 [95% confidence interval, 1.25-3.46]). When grouped by the number of adhesiolysis surgeries, the risk appeared to increase as the number of prior surgeries increased. This is likely because of the increased severity of these adhesions. CONCLUSION Overall, patients with a history of treated intrauterine adhesions have the same live birth rate as patients undergoing in vitro fertilization for nonuterine factor indications. However, the subgroup of patients who require multiple surgeries for correction of intrauterine adhesions had a lower live birth rate after in vitro fertilization than controls. Patients with a history of treated intrauterine adhesions are at significantly greater risk of placenta accreta syndrome disorder than control patients who underwent in vitro fertilization for nonuterine factor indications.
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Affiliation(s)
- Roisin M Mortimer
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Boston, MA; Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA.
| | - Andrea Lanes
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Boston, MA; Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA
| | - Serene S Srouji
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Boston, MA; Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA
| | | | - Elizabeth Ginsburg
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Boston, MA; Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA
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Bartels HC, Walsh D, Nieto-Calvache AJ, Lalor J, Terlezzi K, Cooney N, Palacios-Jaraquemada JM, O'Flaherty D, MacColgain S, Ffrench-O'Carroll R, Brennan DJ. Anesthesia and postpartum pain management for placenta accreta spectrum: The healthcare provider perspective. Int J Gynaecol Obstet 2024; 164:964-970. [PMID: 37724823 DOI: 10.1002/ijgo.15096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/08/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE To explore the management and experiences of healthcare providers around anesthetic care in placenta accreta spectrum (PAS). METHODS This descriptive survey study was carried out over a 6-week period between January and March 2023. Healthcare providers, both anesthesiologists and those involved in operative care for women with PAS, were invited to participate. Questions invited both quantitative and qualitative responses. Qualitative responses were analyzed using content analysis. RESULTS In all, 171 healthcare providers responded to the survey, the majority of whom were working in tertiary PAS referral centers (153; 89%) and 116 (70%) had more than 10 years of clinical experience. There was variation in the preferred primary mode of anesthesia for PAS cases; 69 (42%) used neuraxial only, but 58 (35%) used a combined approach of neuraxial and general anesthesia, with only 12 (8%) preferring general anesthesia. Ninety-nine (61%) were offering a routine antenatal anesthesia consultation. Content analysis of qualitative data identified three main themes, which were "variation in approach to primary mode of anesthesia", "perspectives of patient preferences", and "importance of multidisciplinary team care". These findings led to the development of a decision aid provided as part of this paper, which may assist clinicians in counseling women on their options for care to come to an informed decision. CONCLUSIONS Approach to anesthesia for PAS varied between healthcare providers. The final decision for anesthesia should take into consideration the clinical care needs as well as the preferences of the patient.
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Affiliation(s)
- Helena C Bartels
- Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Don Walsh
- Department of Anaesthesiology, National Maternity Hospital, Dublin, Ireland
| | | | - Joan Lalor
- School of Nursing and Midwifery, Trinity College, Dublin, Ireland
| | | | | | | | - Doireann O'Flaherty
- Department of Obstetric Anaesthesiology, Coombe Women's Hospital, Dublin, Ireland
| | - Siaghal MacColgain
- Department of Anaesthesiology, National Maternity Hospital, Dublin, Ireland
| | | | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group, Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
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Mohammad Jafari R, Najafian M, Barati M, Saadati N, Jalili Z, Poolad A. Comparison of uterine preservation versus hysterectomy in women with placenta accreta: A cross-sectional study. Int J Reprod Biomed 2022; 20:739-744. [PMID: 36340668 PMCID: PMC9619124 DOI: 10.18502/ijrm.v20i9.12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/27/2021] [Accepted: 05/14/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) is a major cause of obstetric bleeding in third trimester of pregnancy. OBJECTIVE This study aimed to compare the outcomes of uterine preservation surgery vs. hysterectomy in women with PAS. MATERIALS AND METHODS In this retrospective cross-sectional study, the records of 68 women with PAS referred to the Imam Khomeini hospital in Ahvaz, Iran, between March 2015 and February 2020 were included. The women were divided into 2 groups according to surgical approach: hysterectomy vs. uterine preservation (including just removing the lower segment, removing the lower segment with uterine artery ligation, or removing the lower segment with hypogastric artery ligation during cesarean section). The need for blood components transfusion (whole blood, packed cells, and fresh frozen plasma), maternal mortality, duration of surgery, and length of hospitalization were compared between groups. RESULTS In total, we investigated 68 women between the ages of 24-45 yr (mean age of 32.88 ± 5.08 yr). All participants were multiparous and underwent cesarean section. Furthermore, 28 women (41.2%) had a history of curettage. In total, 24 women (35.3%) underwent a hysterectomy, and 44 (64.7%) underwent uterine preservative surgeries. There were no significant differences between groups of hysterectomy and uterine preservative surgeries in terms of the need for blood components transfusion, maternal mortality, duration of surgery, and length of hospitalization. CONCLUSION The results of this study showed no significant difference between groups regarding the studied outcomes. Therefore, conservative surgeries could be used to preserve the uterus instead of hysterectomy in women with PAS.
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Affiliation(s)
- Razieh Mohammad Jafari
- Department of Obstetrics and Gynecology, School of Medicine, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mahin Najafian
- Department of Obstetrics and Gynecology, School of Medicine, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mojgan Barati
- Department of Obstetrics and Gynecology, School of Medicine, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Najmieh Saadati
- Department of Obstetrics and Gynecology, School of Medicine, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Zorvan Jalili
- Department of Obstetrics and Gynecology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Atefeh Poolad
- Department of Obstetrics and Gynecology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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