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Placenta percreta associated with a second-trimester pregnancy termination
1002 Communications in brief
December 15, 1984
Am J Obstet Gynecol
uction seen among more than 500 complete autopsies done on stillborn fetuses at our hospital during the last 5 years. E. coli produces "gas" from sugar fermentation and has been associated with fatal gas embolism in adults. 2 The amniotic fluid was the likely site of the initiating infection, such amniotic fluid infection being confirmed by the presence of chorioamnionitis, organismcontaining microabscesses in the placental membranes, and placental membrane cultures that were positive for E. coli. Since lung involvement was minimal and intervillitis absent, a likely portal of entry into the fetus would be the umbilical vein, a contention supported by the occurrence of numerous organisms within the lumen and wall of the umbilical vein. That the portal of entry was vascular is strongly supported by the marked intravascular location of the organisms in all organs. The origin of the E. coli in the insulin-dependent diabetic mother was either a documented E. coli urinary tract infection or a consequence of the extensive effort required to induce labor. The correlation of postmortem radiographic, morphologic, microscopic, and bacteriologic studies in this stillborn fetus led us to conclude that E. coli was the source of "gas" production and that E. coli should be
considered as a possible etiologic agent in excessive "gas"production in stillborn fetuses. REFERENCES
l. Holm OF. Occurrence of free gas in the fetus in cases of intrauterine death. Acta Radio! 1957;48:257. 2. Jones B. Massive gas embolism in E. coli septicemia. Gastrointest Radioll981;6:16l.
Placenta percreta associated with a second-trimester pregnancy termination Mark D. Hornstein, M.D., Jonathan M. Niloff, M.D., Philip F. Snyder, M.D., and Fredric D. Frigoletto, M.D. Department of Obstetrics and Gynecology, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
Placenta percreta is a rare and potentially serious complication of pregnancy. Three types of invasive placentation have been described: placenta acreta, in which the chorioric villi invade the decidua but not the myometrium; placenta increta, in which the villi invade the myometrium; and placenta percreta, in which the villi penetrate through the myometrium, reach the serosa, and often rupture into the peritoneal cavity. 1 The reported incidence of invasive placenta varies Reprint requests: Mark D. Hornstein, M.D., Department of Obstetrics and Gynecology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
Fig. I. Photograph of hysterectomy specimen. The probe locates the site of rupture of the cornual pregnancy. from one in 540 to one in 93,000 pregnancies, 2 but only 7 5 instances of placenta percreta have been reported in the literature. Placenta percreta usually becomes apparent in the third trimester, with only rare cases reported earlier in pregnancy. This report describes the first case of a placenta percreta occurring in an asymptomatic woman at the time of an elective secondtrimester pregnancy termination. A 40-year-old, gravida 1, para 0, black woman was admitted at 15 weeks' gestation by ultrasound determination for pregnancy termination. Past medical history was unremarkable. Physical examination revealed a uterus of 16 weeks' gestation with an anterior leiomyoma; otherwise examination was normal. Laminaria were placed in the cervix the evening prior to the procedure. A suction curettage was performed with a 16 mm cannula a~d a Nesacaine paracervical block. Intravenous analgesia and sedation were provided with 0.05 mg of fentanyl and 5 mg of diazepam. The procedure was accomplished uneventfully until, upon removal of the suction cannula, the patient became unresponsive, diaphoretic, tachycardiac with a heart rate of 140 bpm, and hypotensive with a systolic blood pressure of 50 mm Hg. Despite aggressive fluid resuscitation, she remained hypotensive. The abdomen became distended, and the hematocrit was 20 mg/100 mi. At emergency laparotomy, 2 L of fresh blood was evacuated from the peritoneal cavity. The left cornual region of the uterus was enlarged in a bulbous fashion and surrounded by a large hemorrhagic area with a tract leading into the endome-
Communications in brief
Volume 150 Number 8
1003
the majority of such patients, she was primigravid. Given the increasing frequency of cesarean sections, a greater number of women may be at risk for this entity. Clinicians should be aware of this complication and its associated risk factors when evaluating patients for midtrimester pregnancy terminations. Although a rare complication, placenta percreta should be considered in the differential diagnosis of patients with postabortal abdominal pain and shock, as well as in women with atypical abdominal pain during labor. REFERENCES l. Irving FD, Hertig AT. A study of placenta accreta. Surg
Gynecol Obstet 1937;64: 178. 2. Fox H. Placenta accreta. Obstet Gynecol Surv 1972;27:475.
Investigation of obstructive jaundice by an ultra-thin-caliber endoscope: A new technique for potential use in pregnancy Simon Bar-Meir, M.D., and Siegfried Rotmensch, M.D. Department of Gastroenterology, The Edith Wolfson Hospital, Holon, Israel
Fig. 2. Photomicrograph of uterine cornu demonstrating trophoblastic invasion into the serosa.
trial cavity (Fig. 1). A total abdominal hysterectomy was performed. The patient's subsequent course was uneventful and she was discharged home on the sixth postoperative day. She was transfused with a total of five units of packed red blood cells. Pathologic evaluation revealed a 5 by 5 by 3 em purplish red bulge in the uterine cornu with a central perforation. Histologic examination demonstrated a ruptured cornual pregnancy with placenta percreta (Fig. 2). An invasive placenta has been associated with poorly developed or absent decidua. Previously described antecedent risk factors include a uterine scar, usually from a cesarean section, uterine curettage, manual removal of the placenta, and placenta previa. 2 These factors may partially account for the advanced maternal age and high parity also commonly observed in patients with an invasive placenta. However, increasing age alone may lead to a progressive inadequacy of the decidua and account for the increased risk among these patients. Placenta percreta usually presents with severe abdominal pain during labor, the diagnosis being made at laparotomy. Occasionally, patients may have pain for a number of days prior to frank rupture. This diagnosis is rarely made until late in pregnancy. This is the first report of placenta percreta associated with a second-trimester pregnancy termination. This patient had only one of the usual risk factors associated with invasive placenta, advanced maternal age. Unlike
Common bile duct obstruction accounts for 6% of all cases of jaundice in pregnancy.' Since surgical intervention is mandatory, a definitive diagnosis should be obtained before mother and fetus are exposed to the potential risks of operation. In nonpregnant patients the evaluation includes ultrasonography and either endoscopic retrograde cholangiopancreatography or percutanous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography are the most informative and reliable methods, but involve massive xray exposure, which is undesirable in pregnancy. Unnecessary operations can be avoided in 10% to 15% of jaundiced patients by preoperative endoscopic retrograde cholangiopancreatography. A recently developed ultrathin fiberoptic endoscope (2.3 mm in diameter) can be used as an alternative diagnostic tool prior to operation without the necessity for x-ray exposure. The so-called "baby scope" (Fig. l) is introduced through the biopsy channel of a sideviewing duodenoscope into the duodenum. After the papilla of Vater is identified, insertion of the baby scope into the common bile duct is attempted. Examination of the duct system, sometimes including the intrahepatic branches, under direct endoscopic vision follows (Fig. 2). Presented at the Eighth Congress of the Israel Association of Obstetrics and Gynecology, Haifa, Israel, May 2-4, 1984. Reprint requests: Simon Bar-Meir, M.D., Department of Gastroenterology, The Edith Wolfson Hospital, Holon 58100, Israel.
December 15, 1984
Am J Obstet Gynecol
uction seen among more than 500 complete autopsies done on stillborn fetuses at our hospital during the last 5 years. E. coli produces "gas" from sugar fermentation and has been associated with fatal gas embolism in adults. 2 The amniotic fluid was the likely site of the initiating infection, such amniotic fluid infection being confirmed by the presence of chorioamnionitis, organismcontaining microabscesses in the placental membranes, and placental membrane cultures that were positive for E. coli. Since lung involvement was minimal and intervillitis absent, a likely portal of entry into the fetus would be the umbilical vein, a contention supported by the occurrence of numerous organisms within the lumen and wall of the umbilical vein. That the portal of entry was vascular is strongly supported by the marked intravascular location of the organisms in all organs. The origin of the E. coli in the insulin-dependent diabetic mother was either a documented E. coli urinary tract infection or a consequence of the extensive effort required to induce labor. The correlation of postmortem radiographic, morphologic, microscopic, and bacteriologic studies in this stillborn fetus led us to conclude that E. coli was the source of "gas" production and that E. coli should be
considered as a possible etiologic agent in excessive "gas"production in stillborn fetuses. REFERENCES
l. Holm OF. Occurrence of free gas in the fetus in cases of intrauterine death. Acta Radio! 1957;48:257. 2. Jones B. Massive gas embolism in E. coli septicemia. Gastrointest Radioll981;6:16l.
Placenta percreta associated with a second-trimester pregnancy termination Mark D. Hornstein, M.D., Jonathan M. Niloff, M.D., Philip F. Snyder, M.D., and Fredric D. Frigoletto, M.D. Department of Obstetrics and Gynecology, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
Placenta percreta is a rare and potentially serious complication of pregnancy. Three types of invasive placentation have been described: placenta acreta, in which the chorioric villi invade the decidua but not the myometrium; placenta increta, in which the villi invade the myometrium; and placenta percreta, in which the villi penetrate through the myometrium, reach the serosa, and often rupture into the peritoneal cavity. 1 The reported incidence of invasive placenta varies Reprint requests: Mark D. Hornstein, M.D., Department of Obstetrics and Gynecology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
Fig. I. Photograph of hysterectomy specimen. The probe locates the site of rupture of the cornual pregnancy. from one in 540 to one in 93,000 pregnancies, 2 but only 7 5 instances of placenta percreta have been reported in the literature. Placenta percreta usually becomes apparent in the third trimester, with only rare cases reported earlier in pregnancy. This report describes the first case of a placenta percreta occurring in an asymptomatic woman at the time of an elective secondtrimester pregnancy termination. A 40-year-old, gravida 1, para 0, black woman was admitted at 15 weeks' gestation by ultrasound determination for pregnancy termination. Past medical history was unremarkable. Physical examination revealed a uterus of 16 weeks' gestation with an anterior leiomyoma; otherwise examination was normal. Laminaria were placed in the cervix the evening prior to the procedure. A suction curettage was performed with a 16 mm cannula a~d a Nesacaine paracervical block. Intravenous analgesia and sedation were provided with 0.05 mg of fentanyl and 5 mg of diazepam. The procedure was accomplished uneventfully until, upon removal of the suction cannula, the patient became unresponsive, diaphoretic, tachycardiac with a heart rate of 140 bpm, and hypotensive with a systolic blood pressure of 50 mm Hg. Despite aggressive fluid resuscitation, she remained hypotensive. The abdomen became distended, and the hematocrit was 20 mg/100 mi. At emergency laparotomy, 2 L of fresh blood was evacuated from the peritoneal cavity. The left cornual region of the uterus was enlarged in a bulbous fashion and surrounded by a large hemorrhagic area with a tract leading into the endome-
Communications in brief
Volume 150 Number 8
1003
the majority of such patients, she was primigravid. Given the increasing frequency of cesarean sections, a greater number of women may be at risk for this entity. Clinicians should be aware of this complication and its associated risk factors when evaluating patients for midtrimester pregnancy terminations. Although a rare complication, placenta percreta should be considered in the differential diagnosis of patients with postabortal abdominal pain and shock, as well as in women with atypical abdominal pain during labor. REFERENCES l. Irving FD, Hertig AT. A study of placenta accreta. Surg
Gynecol Obstet 1937;64: 178. 2. Fox H. Placenta accreta. Obstet Gynecol Surv 1972;27:475.
Investigation of obstructive jaundice by an ultra-thin-caliber endoscope: A new technique for potential use in pregnancy Simon Bar-Meir, M.D., and Siegfried Rotmensch, M.D. Department of Gastroenterology, The Edith Wolfson Hospital, Holon, Israel
Fig. 2. Photomicrograph of uterine cornu demonstrating trophoblastic invasion into the serosa.
trial cavity (Fig. 1). A total abdominal hysterectomy was performed. The patient's subsequent course was uneventful and she was discharged home on the sixth postoperative day. She was transfused with a total of five units of packed red blood cells. Pathologic evaluation revealed a 5 by 5 by 3 em purplish red bulge in the uterine cornu with a central perforation. Histologic examination demonstrated a ruptured cornual pregnancy with placenta percreta (Fig. 2). An invasive placenta has been associated with poorly developed or absent decidua. Previously described antecedent risk factors include a uterine scar, usually from a cesarean section, uterine curettage, manual removal of the placenta, and placenta previa. 2 These factors may partially account for the advanced maternal age and high parity also commonly observed in patients with an invasive placenta. However, increasing age alone may lead to a progressive inadequacy of the decidua and account for the increased risk among these patients. Placenta percreta usually presents with severe abdominal pain during labor, the diagnosis being made at laparotomy. Occasionally, patients may have pain for a number of days prior to frank rupture. This diagnosis is rarely made until late in pregnancy. This is the first report of placenta percreta associated with a second-trimester pregnancy termination. This patient had only one of the usual risk factors associated with invasive placenta, advanced maternal age. Unlike
Common bile duct obstruction accounts for 6% of all cases of jaundice in pregnancy.' Since surgical intervention is mandatory, a definitive diagnosis should be obtained before mother and fetus are exposed to the potential risks of operation. In nonpregnant patients the evaluation includes ultrasonography and either endoscopic retrograde cholangiopancreatography or percutanous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography are the most informative and reliable methods, but involve massive xray exposure, which is undesirable in pregnancy. Unnecessary operations can be avoided in 10% to 15% of jaundiced patients by preoperative endoscopic retrograde cholangiopancreatography. A recently developed ultrathin fiberoptic endoscope (2.3 mm in diameter) can be used as an alternative diagnostic tool prior to operation without the necessity for x-ray exposure. The so-called "baby scope" (Fig. l) is introduced through the biopsy channel of a sideviewing duodenoscope into the duodenum. After the papilla of Vater is identified, insertion of the baby scope into the common bile duct is attempted. Examination of the duct system, sometimes including the intrahepatic branches, under direct endoscopic vision follows (Fig. 2). Presented at the Eighth Congress of the Israel Association of Obstetrics and Gynecology, Haifa, Israel, May 2-4, 1984. Reprint requests: Simon Bar-Meir, M.D., Department of Gastroenterology, The Edith Wolfson Hospital, Holon 58100, Israel.