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      Unilateral Uterine and Ovarian Arterial Ligations in a Case of Missed Abortion at 12 Weeks of Gestation with Undiagnosed Placenta Accreta

      case-report
      1 , , 1
      ,
      Cureus
      Cureus
      placenta accrete, first trimester, dilatation and evacuation

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          Abstract

          Placenta accreta is abnormal placental attachment to the myometrium, and the incidence rate has risen with the increased use of Cesarean sections. First-trimester placenta accreta is a rare, potentially life-threatening condition due to the severe hemorrhage it may cause, necessitating a hysterectomy. We present a case of a 38-year-old woman with a history of two Cesarean section deliveries who developed severe bleeding during curetting due to undiagnosed placenta accreta. Unilateral uterine and ovarian arterial ligations were performed to reduce expected bleeding along with a local resection of the placental implantation site that was invading the old scar. This procedure was effective with fewer complications than traditional procedures and preserved the patient’s fertility.

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          Most cited references17

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          Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques.

          To assess the role of three-dimensional (3D) power Doppler in the antenatal diagnosis of placenta accreta and compare its diagnostic performance with gray-scale and color Doppler ultrasonography. One hundred and seventy pregnant women with persistent placenta previa totalis (after 28 weeks' gestation) were prospectively enrolled into this study. Gray-scale transabdominal ultrasound examination was performed to detect loss of the subendometrial echolucent zone and other abnormalities suggestive of placenta accreta. Color flow mapping was used to scan the whole placenta to detect any newly formed vessels at the serosa-bladder border or the presence of abnormal lacunae. Finally a targeted examination of angioarchitecture in the basal and lateral views of the placenta was carried out using 3D power Doppler. The ultrasound findings were analyzed with reference to the final diagnosis made during Cesarean delivery. Placenta accreta and its variants (including increta and percreta) were confirmed in 39 patients at the time of Cesarean delivery. Based on receiver-operating characteristics analysis, 'numerous coherent vessels' visualized using 3D power Doppler in the basal view was the best single criterion for the diagnosis of placenta accreta, with a sensitivity of 97% and a specificity of 92%. If we considered the presence of at least one criterion to be diagnostic when using each ultrasound technique, then 3D power Doppler would have the best positive predictive value (76%), followed by gray-scale (51%) and color Doppler (47%). The majority of patients with placenta accreta showed multiple characteristic features on ultrasound imaging. In contrast, those patients with a false-positive diagnosis (i.e. the final diagnosis was placenta previa alone) tended to show isolated ultrasound markers of the condition. 3D power Doppler may be useful as a complementary technique for the antenatal diagnosis or exclusion of placenta accreta.
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            Immediate complications after medical compared with surgical termination of pregnancy.

            To estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data. All women in Finland undergoing induced abortion from 2000-2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyze the risk of the three main complications (hemorrhage, infection, and incomplete abortion) and surgical (re)evacuation. The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death. Both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion. II.
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              Return hospital visits and morbidity within 60 days after day surgery: a retrospective study of 18,736 day surgical procedures.

              As day surgery includes more extensive procedures focus should be put on late outcome. The frequency of day surgery-related return visits and the associated morbidity were examined to identify suitable indicators of quality. From two centres, 16,048 patients underwent 18,736 day surgery operations including 4,829 surgical abortions. Patients were retrospectively analysed for contacts to Danish hospitals within 60 post-operative days and the associated morbidity and mortality. Data were obtained from the Danish National Patient Registry and the National Causes of Death Registry. Patient records were studied to validate contacts as being definite, likely, possible or not related. Altogether 113 patients (not including the surgical abortions) were readmitted to hospitals with 117 complications definitely or likely related to day surgery. The most common complications were haematomas or haemorrhage (0.40%) and infections (0.29%). Morbidity after the two most common procedures, hernia repair and knee arthroscopy, was observed in 1:39 patients and 1:220 patients, respectively. More serious complications included four patients with septic arthritis of the knee and six patients with venous thromboembolism. After surgical abortion, pelvic inflammation and bleeding were observed in 3.1% and 2.2%, respectively, with centre differences. Altogether no myocardial infarctions, central nervous system deficits, pneumonias or deaths were recorded that could definitely or likely be related to day surgery. Day surgery in Denmark is a safe practice. Readmission rates, haematomas and wound infections are likely future indicators of outcome quality after day surgery.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                8 November 2018
                November 2018
                : 10
                : 11
                : e3562
                Affiliations
                [1 ] Obstetrics & Gynecology, King Saud Hospital, Unizah, SAU
                Author notes
                Article
                10.7759/cureus.3562
                6325025
                28626ee9-39eb-4aeb-b52c-37407696d57d
                Copyright © 2018, Alnafisah et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 28 September 2018
                : 7 November 2018
                Categories
                Cardiac/Thoracic/Vascular Surgery
                Obstetrics/Gynecology

                placenta accrete,first trimester,dilatation and evacuation

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