Anesthetic management of placenta accreta in a low-resource setting: a case series

BACKGROUND

Current recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting.

METHODS

A retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted.

RESULTS

Thirty-nine cases were identified. Mean (± SD) maternal age was 33 ± 5.4 years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100-2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0-6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred.

CONCLUSION

A multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.

Histopathological Classification of Lesions associated with Natural Paratuberculosis Infection in Cattle

Paratuberculosis-associated lesions in 116 naturally infected adult cows, with or without clinical signs, were classified histopathologically. Tissue samples obtained focused on gut-associated lymphoid tissue. Lesions were divided into five categories. Focal lesions (n=68 cases), consisted of small granulomas in the ileal and jejunal lymph nodes or the ileocaecal lymphoid tissue. In the multifocal type (n=13 cases), small granulomas or scattered giant cells appeared in some intestinal villi, as well as in the lymph nodes. Diffuse multibacillary lesions (n=15 cases), associated with severe granulomatous enteritis affecting different intestinal locations and lymph nodes, were formed by macrophages containing large numbers of acid-fast bacilli. In diffuse lymphocytic lesions (n=3 cases), lymphocytes were the main inflammatory cells, with some macrophages or giant cells containing few if any mycobacteria. In diffuse intermediate forms (n=17 cases), the infiltrate was formed by abundant lymphocytes and macrophages, and mycobacteria were present to varying degrees related to the number of macrophages. Clinical signs and gross lesions were mainly associated with diffuse forms. Thickening of the intestinal wall, which was the most common macroscopical finding, was related to the degree of submucosal change. Mycobacterium avium subsp. paratuberculosis was identified by culture or PCR in all cows with diffuse lesions, and in 55.5 and 37% of those with multifocal or focal forms, respectively. The importance of sampling the ileal and caudal jejunal lymph nodes to find histological lesions of paratuberculosis in cattle is emphasized.

Giant Cell Tumour of Bone in a Cat with Extraskeletal Metastases: Pathological and Immunohistochemical Study

A case of giant cell tumour of bone (GCTb) in the lung and in a subcutaneous mass located in the right flank, with a probable primary origin in the mid-diaphysis of the right tibia, was described in a 8-year-old female cat. Numerous multinucleated giant cells were homogeneously distributed among a population of ovoid or spindle-shaped mononuclear cells. All of them were positive for vimentin suggesting a mesenchymal origin. Spindle-shaped tumour cells resemble fibroblastic cells, showing collagen fibres in their vicinity. Ovoid mononuclear cells are similar to macrophages, with a cytoplasm rich in electron-dense lysosomes. Multinucleated giant cells appear morphologically similar to osteoclasts. These findings are supported for the positive reaction to tartrate-resistant acid phosphatase (TRAP) and lysozyme, encountered only in ovoid and multinucleated giant cells. No immunoreactivity against human oestrogen receptors was observed in the nuclei of any neoplastic cells.

Distribution of lymphocyte subsets in the small intestine lymphoid tissue of 1-month-old lambs

Distribution of lymphocyte subpopulations along the small intestine lymphoid tissue has been examined in 1-month-old lambs using flow cytometric and immunohistochemical techniques. Monoclonal antibodies against CD4, CD8, gamma delta, CD45R and B receptors have been employed in samples from continuous ileal Peyer's patch (IPP), discrete jejunal Peyer's patches (JPP), ileocaecal valve lymphoid tissue (ICVPP), mesenteric lymph node (MLN) and intra-epithelial (IEL) and lamina propria (LPL) lymphocytes. Histological studies were also done. Differences in the lymphocyte distribution have been observed between some of the regions examined, especially between IPP and JPP for most of the markers. A remarkable feature was the existence of morphological and lymphocyte distribution differences between ICVPP and IPP, locations that had been traditionally considered as similar. The antibody against CD45R receptor used in this study, that was supposed to mark B cells and some T cells, detected cell populations located in the dome of the follicles in all the samples, whereas the centre was negative. Lymphocytes positive to the B marker employed were located mainly in the centre, suggesting that both antibodies would mark B cells in different maturation status.

Proximal aortic dissection (dissecting aortic aneurysm) in a mature ostrich

The gross and histopathologic lesions observed in a case of spontaneous proximal aortic dissection (dissecting aortic aneurysm) in a mature ostrich are reported. At necropsy, a dissecting intramural hematoma was seen in the proximal aorta, extended about 12 cm distally from the aortic valves. Histopathologic changes in aortic dissection included fragmentation and disruption of elastic laminae, presence of cystic extracellular spaces, and pooling of ground substance in the tunica media. Hepatic copper levels were measured, and the low concentration found suggested that a copper deficiency together with other risk factors such as the elevation of blood pressure may have been implicated in the development of the aortic dissection seen in this ostrich.