Placenta percreta invading left broad ligament in a woman with twin pregnancy: A case report

Introduction

and importance: Placenta percreta is an abnormal of placentation disorder that causes firm and deep attachment of placenta into myometrium due to absent decidua basalis and leads to significant morbidity and mortality due to severe hemorrhage.

Presentation of case

A 28-year, old women gravida 2 para 1 + 0 with previous one Lower segment caesarean section (LSCS), presented to emergency department of HFH with complaint of per vaginal bleeding. It was a twin pregnancy and was a rare case of complex placenta percreta with invasion into left broad ligament and urinary bladder in a woman having twin pregnancy. Placental invasion into bladder was diagnosed pre-operatively on USG scan, however; the broad ligament involvement was diagnosed intraoperatively. Patient underwent hysterectomy and internal iliac artery ligation to control hemorrhage soon after delivery of twins with T2 being IUD and patient shifted to ventilatory support but unfortunately due to massive hemorrhage and hemodynamic instability patient did not survive.

Discussion

Placenta percreta is a subtype of placenta accreta spectrum disorder that is associated with significant morbidity and mortality depending upon nature and extent of placental invasion. Preoperative diagnosis and management can be of significant value in preventing obstetrics related morbidity. A multidisciplinary approach is required in management of such cases and due to involvement of surrounding structures including urinary bladder.

Conclusion

Placenta percreta is a rare disorder of placentation that poses significant life-threatening risk of bleeding and maternal mortality and multidisciplinary approach can be of benefit in such cases.

Labor outcome of primigravidae in Mymensingh Medical College Hospital

This cross sectional study was done in the department of Obstetrics and Gynae, Mymensingh Medical College Hospital, during the period 1st January to 30th June 2000 to evaluate the labor outcome in primigrvidae women. Total 1250 cases were delivered in this period. Among all 500(40%) were primigravidae. All the primigravidae were included and labor was monitored and managed by close observation. Condition of the baby was determined by applying APGAR (Appearance, Pulse, Grimace, Activity and Respiration) score. Maximum (66.6%) of patients were belonged to 21-29 years age group. Only few 28.2% had regular antenatal check-up. Risk factors were present in 32% cases. Common risk factors were PET (Pre-eclamptic toxemia) and eclampsia. Mode of deliveries were normal vaginal delivery (NVD) in (51.6%) cases, Lower Uterine Caesarean section (LUCS) in 43.8% cases, Ventouse in 2.8% cases, Forceps in 9(1.8%) cases and craniotomy was required in 2(0.4%) cases. Complications during labor were prolonged labor, postpartum hemorrhage, obstructed labor and perineal tear. PET was common (29.62%) in age group 30-36 years and eclampsia was more common (15%) in age group 16-20 years. NVD were more (55.85%) in 21-29 years group than other age group. The duration of labor pain was short in the age group of 21-29 years and was prolonged in the age group 30-36 years. Maternal mortality was 1.6% (8) cases. Causes of death were septic shock, renal failure and Cerebrovascullar accident. Morbidities after delivery were hypertension, wound infection, puerperal psychosis, acute renal failure, vesicovaginal fistula, hypertensive retinopathy, chronic ill health and retention of urine. Among 500 cases 92.6% were live born and 7.4% were still born. Among total cases 81.6% babies were healthy, 6.8% were asphyxiated, 71.2% had normal birth weight 21.4% had low birth weight, 18% were premature and 7.4% were IUGR. This study shows the safest and easiest delivery age group of primigravidae is between 21-29 years. Maternal mortality and early neonatal death are still holding high rate.

Expression, purification, and evaluation of recombinant LecA as a candidate for an amebic colitis vaccine

Entamoeba histolytica, which causes amebic colitis and liver abscess, is considered a major enteric pathogen in residents and travelers to developing countries where the disease is endemic. Interaction of this protozoan parasite with the intestine is mediated through the binding of the trophozoite stage to intestinal mucin and epithelium via a galactose and N-acetyl-d-galactosamine (Gal/GalNAc) lectin comprised of a disulfide linked heavy (ca. 180 kDa) and light chain (ca. 35 kDa) and a noncovalently bound intermediate subunit (ca. 150 kDa). Our efforts to develop a vaccine against this pathogen have focused on an internal 578 amino acid fragment, designated LecA, located within the cysteine-rich region of the heavy chain subunit because: (i) it is a major target of adherence-blocking antibodies of seropositive individuals and (ii) vaccination with his-tagged LecA provides protection in animal models. We developed a purification process for preparing highly purified non-tagged LecA using a codon-optimized gene expressed in Escherichia coli. The process consisted of: (i) cell lysis, collection and washing of inclusion bodies; (ii) solubilization and refolding of denatured LecA; and (iii) a polishing gel filtration step. The purified fragment existed primarily as a random coil with β-sheet structure, contained low endotoxin and nucleic acid, was highly immunoreactive, and elicited antibodies that recognized native lectin and that inhibited in vitro adherence of trophozoites to CHO cells. Immunization of CBA mice with LecA resulted in significant protection against cecal colitis. Our procedure yields sufficient amounts of highly purified LecA for future studies on stability, immunogenicity, and protection with protein-adjuvant formulations.

Histopathological analysis of hysterectomy specimens

The objective of this study was to explore the histopathological findings and the rate of removal of ovaries in hysterectomy specimens. This study took into account 328 hysterectomy specimens examined in the Department of Pathology, Mymensingh Medical College and in one private Pathology Laboratory in Mymensingh town from March to August, 2005. Formalin fixed paraffin embedded tissue sections stained with haematoxylin and eosin were examined under light microscope. Patients' age, parts of uterus examined and their histopathological findings were retrieved from laboratory records. The common histopathological findings were: chronic cervicitis (87.80%), leiomyoma (17.07%), uterine prolapse (16.72%), adenomyosis (3.96), non-specific endometritis (3.35%), squamous cell carcinoma of cervix (2.44%), endometrial polyp (2.44%), serous cystadenoma of ovary (2.44%) and endometrial hyperplasia (1.83%). Some of the specimens show more than one lesions in the body of uterus, of which coexistence of adenomyosis and leiomyoma was the most common. Neoplastic lesions in cervix were 4.27%, in body 16.92% and in ovaries 5.06%. Malignant neoplasms were found in cervix 71.43%, in uterine corpus 3.03% and in ovaries 25%. Ovaries of both sides were removed in 48.17% of total cases. Their median age was 45 years, lowest age 23 years and maximum age was 82. The rate of removal of both ovaries was found to be increasing with the increase of age. Only one case was found to be subtotal hysterectomy and others were total hysterectomy. The present study revealed that the most common histopathological cause of hysterectomy is chronic cervicitis. Most common neoplastic cause of hysterectomy is leiomyoma. The rationalities and the possible after effect of hysterectomy in sexual functions and other physiological impairment should be followed up.