Placenta accreta spektra traucējumi pacientei bez ķeizargrieziena operācijas anamnēzē. Klīniskais gadījums.
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Date
2022
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Rīgas Stradiņa universitāte
Rīga Stradiņš University
Rīga Stradiņš University
Abstract
Cerviko-istmikāla grūtniecība ir rets ārpusdzemdes grūtniecības veids, kad augļa ola implantējas starp anatomisko un histoloģisko dzemdes kakla iekšējo muti. Galvenās komplikācijas ir saistītas ar asiņošanu no dzimumceļiem grūtniecības laikā, priekšlaicīgām dzemdībām un asociāciju ar placenta accreta spectrum traucējumiem (placentas piestiprināšanās patoloģiju), kas var rezultēties ar masīvu asins zudumu un histerektomiju. Ņemot vērā iespējamās komplikācijas, grūtniecību rekomendē pārtraukt pēc medicīniskām indikācijām. Nav standartizētu vadlīniju pēc kurām rīkoties gadījumos, ja paciente izvēlas grūtniecību turpināt. Šādās situācijās grūtniecību ir iespējams prolongēt tikai pēc rūpīgas konsultācijas ar pacienti.
Paciente grūtniecības laikā kopumā tiek hospitalizēta trīs reizes. Sākotnēji ambulatori veiktā ginekoloģiskā ultrasonogrāfijā tiek konstatēta cervikālā/ apakšējā segmenta grūtniecība ar saīsinātu dzemdes kaklu līdz 15 mm, tāpēc paciente tika nosūtīta uz stacionāru. Otrajā hospitalizācijas reizē galvenā sūdzība ir spontāna asiņošana no dzimumceļiem bez sāpēm. Ambulatorā USG izmeklējumā vizualizē placenta praevia totalis, ir aizdomas par placenta accreta patoloģiju, tāpēc tiek veikts magnētiskās rezonanses izmeklējums, kurā apstiprinās placenta accreta spektra patoloģija bazālajā segmentā. Trešajā hospitalizācijas reizē paciente sūdzas par asiņošanu un sāpēm vēdera lejas daļā, mugurā.
Pamata diagnoze: Graviditas III in septimae 29+4. Partus II praematurus operativus. Placenta praevia totalis. Placenta accreta spectrum. Komplikācijas, sarežģījumi: Anaemia secundaria. Nervus peroneus dziļš bojājums.
Tika veikta gan farmakoloģiska, gan ķirurģiska iejaukšanās. Asiņošanas mazināšanai paciente saņēma traneksāmskābi. Ar aizdomām par priekšlaicīgām dzemdībām, uzsākta augļa respiratora distresa profilakse un tokolīze. Sākoties aktīvai dzemdību darbībai un izteiktai asiņošanai ar recekļiem, paciente saņēma magnija sulfātu augļa neiroprotekcijai. Grūtniecību nolemts atrisināt ar akūtu ķeizargriezienu, sadarbojoties ar invazīviem radiologiem. Piedzima dzīva neiznesta meitene ar svaru 1580 g, augumu 43 cm, pēc Apgares skalas 6/7 balles. Uz dzemdes priekšējās sienas vizualizēti placentas asinsvadi, tāpēc placenta tiek atstāta dzemdes dobumā. Veic totālu histerektomiju un dzemdes artēriju embolizāciju. Asins zudums pirms operācijas 1000 ml, intraoperatīvi - 5000 ml. Tika uzsākts hemotransfūzijas protokols.
Placenta accreta spektra traucējumus var sastapt pacientēm ar cervico-istmikālu grūtniecību bez ķeizargrieziena anamnēzē. Šādu pacientu aprūpe prasa kontroversiālu pieeju un multidisciplināras komandas darbu, jo var rezultēties ar priekšlaicīgām dzemdībām, masīvu asiņošanu, histerektomiju vai pat letālu iznākumu.
Cervico-isthmic pregnancy is a rare ectopic pregnancy form in which a fetal egg is implanted between the anatomical and histological cervical internal os. The main complications are related to vaginal bleeding during pregnancy, premature birth and association with placenta accreta spectrum disorders (pathology of placental attachment), which may result in massive blood loss and hysterectomy. Because of the possible complications, it is recommended that pregnancy should be terminated as medically indicated. There are no standardized guidelines for dealing with patients who choose to continue their pregnancy. In such situations, pregnancy can only be prolonged after careful consultation with the patient. The patient was hospitalized a total of three times during pregnancy. The initial ambulatory gynecologic ultrasonography reveals a cervical/ lower segment pregnancy with a shortened cervix up to 15 mm, which is the reason why patient was admitted to the hospital. During the second hospitalization, the main complaint is spontaneous vaginal bleeding without pain. In the outpatient USG examination, placenta praevia totalis is visualized, the pathology of the placenta accreta is suspected, therefore a magnetic resonance imaging is performed, which confirms the pathology of the placenta accreta spectrum in the basal segment. On the third hospitalization time, the patient complains of bleeding and lower stomach and back pain. Final diagnosis: Graviditas III in septimae 29+4. Partus II praematurus operativus. Placenta praevia totalis. Placenta accreta spectrum. Complications: Anaemia secundaria. Deep damage to the nervus peroneus. Both pharmacological and surgical interventions were performed. The patient received Tranexamic acid to reduce vaginal bleeding. On suspicion of preterm birth, prophylaxis of fetal respiratory distress syndrome has been initiated, as well as tocolysis. At the onset of active labor and severe bleeding with clots, the patient received magnesium sulfate for fetal neuroprotection. It was decided to solve the pregnancy with an acute caesarean section in collaboration with invasive radiologists. Premature live female baby weighting 1580 grams, height 43 cm with Apgar score 6/7 was delivered. Placental vessels were seen in the anterior uterine wall (corresponds with placenta increta), placenta was left in place. Total hysterectomy and embolization of aa.uterinae were performed. Blood loss before surgery was 1000 ml, intraoperative – 5000 ml. A transfusion protocol was initiated. Disorders on the spectrum of placenta accreta may occur in patients with cervico-isthmic pregnancy and no history of caesarean section. Care of such patients requires a controversial approach and the work of a multidisciplinary team, as it can lead to preterm birth, massive bleeding, hysterectomy or even death.
Cervico-isthmic pregnancy is a rare ectopic pregnancy form in which a fetal egg is implanted between the anatomical and histological cervical internal os. The main complications are related to vaginal bleeding during pregnancy, premature birth and association with placenta accreta spectrum disorders (pathology of placental attachment), which may result in massive blood loss and hysterectomy. Because of the possible complications, it is recommended that pregnancy should be terminated as medically indicated. There are no standardized guidelines for dealing with patients who choose to continue their pregnancy. In such situations, pregnancy can only be prolonged after careful consultation with the patient. The patient was hospitalized a total of three times during pregnancy. The initial ambulatory gynecologic ultrasonography reveals a cervical/ lower segment pregnancy with a shortened cervix up to 15 mm, which is the reason why patient was admitted to the hospital. During the second hospitalization, the main complaint is spontaneous vaginal bleeding without pain. In the outpatient USG examination, placenta praevia totalis is visualized, the pathology of the placenta accreta is suspected, therefore a magnetic resonance imaging is performed, which confirms the pathology of the placenta accreta spectrum in the basal segment. On the third hospitalization time, the patient complains of bleeding and lower stomach and back pain. Final diagnosis: Graviditas III in septimae 29+4. Partus II praematurus operativus. Placenta praevia totalis. Placenta accreta spectrum. Complications: Anaemia secundaria. Deep damage to the nervus peroneus. Both pharmacological and surgical interventions were performed. The patient received Tranexamic acid to reduce vaginal bleeding. On suspicion of preterm birth, prophylaxis of fetal respiratory distress syndrome has been initiated, as well as tocolysis. At the onset of active labor and severe bleeding with clots, the patient received magnesium sulfate for fetal neuroprotection. It was decided to solve the pregnancy with an acute caesarean section in collaboration with invasive radiologists. Premature live female baby weighting 1580 grams, height 43 cm with Apgar score 6/7 was delivered. Placental vessels were seen in the anterior uterine wall (corresponds with placenta increta), placenta was left in place. Total hysterectomy and embolization of aa.uterinae were performed. Blood loss before surgery was 1000 ml, intraoperative – 5000 ml. A transfusion protocol was initiated. Disorders on the spectrum of placenta accreta may occur in patients with cervico-isthmic pregnancy and no history of caesarean section. Care of such patients requires a controversial approach and the work of a multidisciplinary team, as it can lead to preterm birth, massive bleeding, hysterectomy or even death.
Description
Medicīna
Medicine
Veselības aprūpe
Health Care
Medicine
Veselības aprūpe
Health Care
Keywords
Placenta accreta spektra traucējumi, Cerviko-istmikāla grūtniecība, Histerektomija, Ķeizargrieziens, Placenta accreta spectrum disorders, Cervico-isthmic pregnancy, Hysterectomy, Cesarean section