tailieunhanh - Tình huống sản khoa - Tình huống 9

Tham khảo tài liệu 'tình huống sản khoa - tình huống 9', y tế - sức khoẻ, y dược phục vụ nhu cầu học tập, nghiên cứu và làm việc hiệu quả | CASE 8 A 35-year-old Ỉ5 P4 woman at 39 weeks gestation is undergoing a vaginal delivery. She had a history of a previous myomectomy and one prior low transverse cesarean delivery. The delivery of the baby is uneventful. The placenta does not deliver after 30 min and a manual extraction of the placenta is undertaken. The placenta seems to be firmly adherent to the uterus. What is the most likely diagnosis What is your next step in management for this patient 82 CASE FILES OBSTETRICS AND GYNECOLOGY ANSWERS TO CASE 8 Placenta Accreta Siiiiinicirv A 35-year-old G5 P4 woman at term with a prior history of a myomectomy and cesarean delivery is undergoing a vaginal delivery. The retained placenta is firmly adherent to the uterus when there is an attempt at manual extraction. Most likely diagnosis Placenta accrcta. Next step in management for this patient Hysterectomy. Analysis Objectives 1. Know the risk factors for and the clinical diagnosis of placenta accreta. 2. Understand that hysterectomy is usually the best treatment for placenta accreta. Considerations This patient has had two previous uterine incisions which increases the risk of placenta accreta. The placenta is noted to be very adherent to the uterus which is the clinical definition of placenta accreta although the histologic diagnosis requires a defect of the decidua basalis layer. The usual management of true placental accreta is hysterectomy since attempts to remove a firmly attached placenta often lead to hemorrhage and or maternal death. Conservative management of placenta accreta such as removal of as much placenta as possible and packing the uterus often leads to excess mortality as compared to immediate hysterectomy. CLINICAL CASES 83 APPROACH TO PLACENTA ACCRETA Definitions Placenta accreta Abnormal adherence of the placenta to the uterine wall due to an abnormality of the decidua basalis layer of the uterus. The placental villi are attached to the myometrium. Placenta increta The abnormally implanted