Re: Placenta percreta
From: art fougner, md (evsono@pipeline.com)
Mon Jun 14 10:16:05 2004
Steve
your patients were in good hands. kudos.
art
At Sun, 13 Jun 2004, Steve & Eryl Raymond wrote:
>
>In 30 years of Obstetrics I have never encountered a true case of
>percreta until this weekend. The patient aged 30 with two previous
>Lower Segment Caesars presented on Friday at 24 weeks with bleeding,
>at a district hospital near here. The fetal heart was still present
>and the uterus tender, with ultrasound evidence of a "haematoma" in
>the anterior low-lying placenta, and estimated fetal weight about 700
>grams. Initial advice to the resident was to rupture the membranes
>and deliver - that this was essentially a mid-trimester miscarriage.
>About five hours later they rang again to say that she had not dilated
>beyond 3cm and this time it was a new doctor who had seen the patient
>and informed me that the previous doctor had missed the fact that she
>had had two caesars, and had given Cytotec. The bleeding was minimal
>but I asked him to transfer to our hospital as the progress was
>unsatisfactory. Overnight she made a few more centimetres dilatation
>progress and the fetal heart disappeared. On opening the abdomen the
>placenta was found to have gone right through the lower segment into
>the bladder and down into the anterior vaginal wall. It was
>impossible to see the anatomy properly as the bleeding from this area
>was just horrendous. I had to excise a strip of bladder wall along
>with the uterus, and then try to get sutures around the top of the
>vagina which would be haemostatic. The control of bleeding from this
>area was particularly tenuous. In the end we packed and came out.
>She has had six units of cross-matched blood and three of ONEG, and
>has produced about 50 ml urine all day today! I was very glad I had
>put on a long apron and gumboots! But I fear that the prolonged
>hypotension and hypovolaemia indicate a very poor prognosis.
>
>Just to remind me that Obstetrics can be fun I rushed to a ruptured
>uterus this afternoon, and spent another happy hour and a half
>performing another hysterectomy and packing of pelvis, because the
>rupture went through the Left uterine artery pedicle and I couldn't
>locate the torn ends. Even a ligation of internal Iliac didn't seem
>to slow down the bleeding much.
>
>Steve Raymond
--
art fougner, md
ich bin ein New Yorker
