Abnormal Implantation Research Articles

Etiology of placenta accreta after laparoscopic myomectomy

Placenta accreta spectrum (PAS) is an umbrella term for a variety of pregnancy complications due to abnormal placental implantation, including placenta accreta, placenta increta and placenta percreta. During the past several decades, the prevalence of PAS has been increasing, and the clinical importance of this disease is significant because of the severe complications. In this review, we summarized the available evidence-based data for PAS in various aspects: prevalence, risk factors, pathogenesis, clinical presentation and prenatal screening, and clinical management. Meanwhile, we provided a series of prospects in each section for further studies on PAS. Moreover, we first present a visualized workflow for the management of PAS from three steps: predelivery, during delivery and postdelivery.

Imaging Unusual Pregnancy Implantations: Rare Ectopic Pregnancies and More.

The purpose of this article is to review key clinical issues and imaging features of unusual pregnancy implantations. Examples from different imaging modalities are provided to increase interpreting physicians' familiarity with the appearance and potential complications of unusual ectopic, cesarean scar, heterotopic, and rudimentary horn pregnancies. Abnormal pregnancy implantations are life-threatening. Interpreting physicians' familiarity with the appearance of unusual pregnancy implantations is critical for early identification and initiation of appropriate therapy.

Management of Amniotic Sheet with a Hammock-like Placenta

An amniotic sheet is a septation in the amniotic cavity with a perforation that allows amniotic fluid to pass through. Although the incidence of abnormal placental implantation is higher in such cases, the management recommendations remain unclear. We report a case of an amniotic sheet with a hammock-like placenta located in the center of the uterine cavity. A 25-year-old woman with a history of two dilation and curettage procedures was found to have an amniotic cavity separated by a septum that contained part of the placenta. At gestational Week 32, magnetic resonance images revealed that the placenta was attached from the anterior to posterior uterine walls and resembled a hammock hanging in the center of the uterus. Subsequently, continuous intravenous administration of ritodrine hydrochloride and magnesium sulfate were given. The pregnancy was extended to Week 36. Elective cesarean section was performed, and a 3212-g female infant was delivered. Thus, owing to the risk of umbilical cord complications and placental injury secondary to premature rupture of membranes, aggressive and careful perinatal management is required in such cases.

Профілактика перинатальної патології у жінок з аномаліями розвитку матки

Placenta increta is an effect of abnormal implantation in decidua or into the myometrium. This condition is very rare in obstetric practice, but it is associated with about 7% of deaths among pregnant women. The pathology of placenta complicates, according to different sources, 1/533 to 1/40 000 pregnancies. Due to the increasing number of cesarean section number of increta placenta grows also. Pathogenesis of placenta increta is still completely unknown. Diagnosis and treatment are an important clinical problem. Conservative treatment depends on the administration of methotrexate in a variety of doses and hysterectomy. Since there is no standard protocol of clinical treatment every qualification to this type of treatment should be considered carefully. Key words: placenta increta, pathogenesis, diagnosis, conservative treatment, methotrexate, hysterectomy, bleeding, pregnancy.

Role of MRI versus ultrasound in the assessment of placental abnormalities and diseases

PurposeTo highlight the role of ultrasound (US) and magnetic resonance imaging (MRI) in detecting placental abnormalities and diseases. Patients and methodsThis prospective study included fifty pregnant females with placental abnormalities (40 patients with abnormal placental location and/or implantation and 10 patients with other variable placental abnormalities). All the patients underwent US and MRI examination and detailed assessment of the placenta was performed. Operative findings, histopathology and/or follow-up were the gold standard for diagnosis in all cases. ResultsThe cases statistically evaluated in this study were gravid females with placenta previa at high risk of coexisting placental adhesive disorders (n=39/50). The sensitivity and specificity of US were 68% and 78.57% respectively while those of MRI were 80% and 85.71% respectively in their ability to diagnose placental invasion. In placental hematoma cases, MRI confirmed the diagnosis due to the high sensitivity and specificity of MRI in detecting different ages of blood. In cases of molar pregnancy presence/absence of myometrial invasion was correctly detected in all cases by MRI. ConclusionMagnetic resonance imaging is complementary to Ultrasound and it is important for the accurate diagnosis of placental abnormalities especially placenta previa and the seriously co-existing placenta accreta.

Transvaginal Drainage of Pelvic Collections: a 5-year Retrospective Review in a Tertiary Gynaecology Centre

such cases at our institution. Materials and Methods: A search was performed to retrospectively identify all patients with abnormal placental implantation and pre-operative balloons placed between January 1st 2006 and June 30th 2013 at our institution. Data extracted included demographics, hemoglobin levels, blood transfusions, pathology and need for hysterectomy. Results: 17 patients fulfilled the criteria, representing one of the largest samples ever published of this type of study. The indication for pre-operative balloon placement was placenta accreta in 11 patients, placenta increta in 1 patient and placenta percreta in 5 patients. Intra-operative balloon inflation was performed in 11 (65%) patients: 6 (65%) with placenta accreta, 1 (100%) with placenta increta (100%), and 4 (80%) with placenta percreta. The estimated operative blood loss for patients in whom the balloons were inflated was 750-4000mL (average 1450mL) versus 800-3000mL (average 1825mL) in patients in whom the balloons were not inflated (p1⁄40.65). The average drop in hemoglobin between the group with and without inflation of balloon was 22Hgb/L and 31Hgb/L, respectively (p1⁄40.21). Conclusion: Despite a trend toward decrease blood loss in patients with balloon inflation our data fails to demonstrated a statistically significant difference. While the data may seem to indicate the lack of usefulness of this technique, since the balloons are only inflated during surgery if bleeding is deemed excessive, both groups are not easily comparable. Assuming the surgeon’s impression of increased bleeding was correct, then balloon inflation may have been the only reason that this group of patients did not lose on average more blood than the other group. Carefully designed prospective studies will likely be needed to prove the usefulness of this technique.

Placenta accreta located in the posterior wall of the uterus: a case report

It is thought that abnormal invasive implantation of the placenta occur as a result of the defect came decidua basalis only in women who have a history of cesarean section previously. Massive obstetric hemorrhage has increased in placenta accreta. Despite the ultrasound, doopler ultrasound and magnetic resonance, in early pregnancy weeks the diagnosis of plecenta accreta is reduced. Therefore, the presence of life-threatening vaginal bleeding in early pregnancy we have to suspect from placenta accreta. We will publish here, the second trimester uterine placenta accreta cases showing the placement of the rear well.

Interstitial Implantation of the Placenta presenting with Retained Placenta after Vaginal Delivery at Term

We report an unusual case of an interstitially-implanted pregnancy presenting with retained placenta after normal vaginal delivery of a live fetus at term. A 32 year-old primigravida, with no previous uterine surgery or instrumentation underwent induction of labour at term for suspected intrauterine growth retardation. The placenta was retained after normal vaginal delivery. Manual removal of the placenta under anaesthesia was attempted but unsuccessful. Exploratory laparotomy and hysterotomy were performed for removal of the placenta, which was found to be implanted in the right cornual region of the uterus. This part of the uterus was sacculated, thinned out and poorly-contracted after the removal of the placenta, resulting in postpartum hemorrhage necessitating uterotonics, compression sutures and placement of a B-lynch suture. This case highlights the need to consider abnormal implantation sites when the placenta is retained in a low risk patient.

591: Maternal total cell free DNA in preeclampsia and IUGR: evidence for differences in maternal and fetal response for abnormal implantation

591: Maternal total cell free DNA in preeclampsia and IUGR: evidence for differences in maternal and fetal response for abnormal implantation

Scar Ectopic Pregnancy.

Scar ectopic pregnancy is the rarest form of ectopic pregnancy and has been increasingly diagnosed all over the world. This is a life-threatening form of abnormal implantation of embryo within the myometrium and fibrous tissues in a previous scar on the uterus, especially following caesarean section. With the increasing rate of caesarean section, there is a substantial increase in this condition with better understanding of this disease. The early and accurate diagnosis with timely management can prevent pregnancy complications such as haemorrhage, uterine rupture and can preserve fertility.

Endovascular management of massive post-partum haemorrhage in abnormal placental implantation deliveries.

To retrospectively evaluate safety and efficacy of pelvic artery embolisation (PAE) in post-partum haemorrhage (PPH) in abnormal placental implantation (API) deliveries. From January 2009 to November 2013, 12 patients with API and intractable intraoperative PPH underwent PAE after caesarean delivery to control a haemorrhage (in four of these cases after hysterectomy). Arterial access was obtained prior to the delivery; PAE was performed in the obstetrics operating room by an interventional radiologist that was present with an interventional radiology (IR) team during the delivery. PAE was successful in preventing bleeding and avoid hysterectomy in four cases (group A). Uterine atony and disseminated intravascular coagulation caused failure of PAE requiring hysterectomy in four patients (group B). PAE prevented bleeding post-hysterectomy in the remaining four cases (group C). Technical success (cessation of contrast extravasation on angiography or occlusion of the selected artery) was 100%. Maternal and foetal mortality and morbidity were 0%. PAE is a minimal invasive technique that may help to prevent hysterectomy and control PPH in API pregnancies without complications. Embolisation should be performed on an emergency basis. For such cases, an IR team on standby in the obstetrics theatre may be useful to prevent hysterectomy, blood loss and limit morbidity. • Endovascular treatment is a validated technique in post-partum haemorrhage. • Abnormal placental implantation is a risk factor for post-partum haemorrhage. • We propose an interventional radiologist standby in the delivery room.

Abnormal implantation in day 3 versus day 5 embryo transfers in fresh IVF cycles: an analysis from the society for assisted reproductive technology database

Abnormal implantation in day 3 versus day 5 embryo transfers in fresh IVF cycles: an analysis from the society for assisted reproductive technology database

The Role of Inflammatory Pathways in Implantation Failure: Chronic Endometritis and Hydrosalpinges.

The process of implantation is highly complex and involves a delicate interplay between the embryo and the appropriate maternal environment. The failure to implant is thought to be due to maternal factors or embryonic factors. Inflammation can be a part of the normal physiologic process during implantation; however, there are also pathologic entities that adversely affect uterine receptivity. This review will focus on chronic endometritis and hydrosalpinges as two specific inflammatory processes that contribute to implantation failure. For both chronic endometritis and hydrosalpinges, we will review the diagnosis, pathophysiology, and effect on implantation following treatment. The existing literature conclusively demonstrates that hydrosalpinges should be addressed by either laparoscopic salpingectomy or proximal tubal occlusion prior to in vitro fertilization. The picture for chronic endometritis is less clear since the diagnosis and treatment of chronic endometritis are not standardized, and there are no available randomized controlled trials on this topic. Future studies may target gene expression arrays as a method for further elucidating the role of inflammatory markers in normal and abnormal implantation processes.

Fetal Growth and Body Proportion during Pre-Eclamptic Pregnancy

Purpose: To evaluate the effects of mild and severe PE on fetal growth and body proportion, measurement at serial ultrasound (US) examinations. Five to 7% of all pregnancies are complicated by preeclampsia (PE). Some forms of intrauterine growth restriction (IUGR) have been etiologically linked to PE, based on similar placental disease- abnormal implantation. Materials and Methods: Women (n=400) who had singleton pregnancies and underwent two or more second- and third-trimester obstetric US examinations were included in our study. The women were divided in three groups: 300 normotensive pregnancies (controls), 67 pregnancies with mild PE (MP) and 33 pregnancies with severe PE (SP). Inadequate fetal growth was defined as growth at or below 10 th percentile. We calculated US measurements between fetuses from normotensive and PE pregnancies (MP and SP). Results: In newborns of women with PE, mean birth weight and length were lower than in births without PE. Fetuses in PE pregnancies from 26 week of gestation (wg) with US scan had lower biometric parameters vs. then of normotensive pregnancies, especially values of abdominal circumference and femur length. In PE pregnancies, there could be faster aging of placenta and oligohydramnion. This is time before clinical onset of PE. Conclusion: Our results support the hypothesis that PE is a heterogeneous disorder which involving placental dysfunction and IUGR, often with asymmetric fetal body proportion and reduced fetal length. The results suggest that US measurements of fetal size are important predictors for PE and birth outcomes.

Ectopic pregnancy after in vitro fertilization: differences between fresh and frozen-thawed cycles

To evaluate whether the uterine environment is associated with the risk of ectopic implantation by comparing outcomes of fresh and frozen-thawed embryo transfers. Retrospective historical cohort. Not applicable. We used the Society for Assisted Reproductive Technologies (SART) database to identify pregnancies that resulted from fresh and frozen blastocyst transfers from 2008 to2011. None. We determined the proportion of ectopic (EP) versus intrauterine-only pregnancies resulting from fresh or frozen embryo transfers in autologous and donor-oocyte cycles. Generalized estimation equation regression models were used to adjust for maternal and treatment characteristics. Among 103,070 cycles that resulted in a clinical pregnancy, 1.38% were ectopic. The odds of EP were 65% lower in women who had a frozen compared with a fresh transfer in autologous cycles. Donor-oocyte transfers had lower odds of EP compared with autologous cycles, with no difference between fresh and frozen donor transfers. Women who had both a fresh and a frozen transfer with autologous oocytes had a higher risk of EP in their fresh cycles compared with their frozen cycles. Embryo transfers in cycles without ovarian hyperstimulation, such as frozen or donor cycles, were associated with lower rates of EP compared with fresh autologous cycles, suggesting that a difference in the tubal-uterine environment contributes to abnormal implantation after IVF.

Should patients with hypertension be screened for psychological distress?

To determine whether fresh embryo transfers are at a higher risk of abnormal implantation compared with frozen embryo transfers while accounting for the embryo stage at transfer.Retrospective cohort study.Not applicable.We used data from the Society for Assisted Reproductive Technologies to identify all fresh and frozen autologous IVF cycles from 2004-2013 resulting in a positive pregnancy test. The cycles were parameterized into a four-level predictor of [1] fresh blastocyst transfer, [2] fresh non-blastocyst transfer, [3] frozen blastocyst transfer, and [4] frozen non-blastocyst transfer.None.We examined a composite outcome of abnormal implantation, defined as biochemical pregnancy, ectopic/heterotopic pregnancy, and first-trimester pregnancy loss. Regression modeling was performed with repeated measures multivariable logistic regression, adjusted for age, parity, number of embryos transferred, infertility diagnosis, and calendar year of treatment.Of 509,938 cycles analyzed, 31.8% resulted in abnormal implantation. Compared with a fresh blastocyst transfer, a fresh non-blastocyst transfer had a 22% increase risk of abnormal implantation, a frozen blastocyst transfer had a 36% increase risk, and a frozen non-blastocyst transfer had a 57% increase risk. When individual outcomes were analyzed, fresh embryo transfers had a lower risk of biochemical pregnancy and pregnancy loss but a higher risk for ectopic/heterotopic pregnancy.Fresh blastocyst transfers had the lowest overall risk of abnormal implantation but a higher risk of ectopic/heterotopic pregnancy. Although embryo cryopreservation is indicated in certain treatment cycles, elective embryo cryopreservation may not be the optimal strategy to adopt for all cycles.

Torsion of term gravid uterus in a pregnancy obtained by intrauterine insemination. A case report.

The rotation of the gravid uterus is a normal finding in the third trimester of pregnancy. However, it is considered to be a pathological condition at greater than 45 degrees rotation along the long axis and is rarely seen in obstetrical practice. A 31-year-old primigravida primiparous at 39 weeks’ gestation with a singleton pregnancy obtained by intrauterine insemination underwent cesarean section for transverse fetal presentation. During laparotomy, uterine torsion of 100 degrees and an abnormal implantation of the uterine adnexa was diagnosed. Torsion was partly corrected intraoperatively and a transverse anterior corporeal incision was performed. Tha patient recovered and was discharged home with her baby on the third postoperative day. Uterine torsion, although an infrequently reported condition, it is a potentially dangerous complication of pregnancy. Prompt recognition and management of this pathology is necessary for better maternal and foetal outcome. <br/><a href=

Cesarean Delivery in the Hybrid Operating Suite

BACKGROUND The increasing cesarean delivery rate and attendant placental implantation abnormalities, coupled with increasing general medical complexity in the obstetric population, has driven innovation to optimize the care of high-risk parturients during delivery. Novel and multidisciplinary approaches and locations may enhance the options available for care. METHODS We reviewed the records of all 11 patients who underwent cesarean delivery in our hybrid operating suite between December 2007 and March 2013 and describe the high-risk cesarean deliveries. RESULTS The most common indication for the use of the hybrid operating suite was an increased risk of hemorrhage, most commonly due to abnormal placental implantation. Other indications included cardiovascular disease and intracranial pathology. CONCLUSION The hybrid operating suite may be an alternative location for obstetric delivery, and our experience suggests that this environment may prove advantageous for patients with a variety of comorbid conditions.

Plasma cancer biomarker multiplex screening and the risk of subsequent preeclampsia

Preeclampsia (PE) is a pregnancy multisystem disorder that is characterized by hypertension and proteinuria that develops after the 20th gestational week (GW). The placenta abnormal implantation process is well known to play a major role in the development of disease [1]. The molecular mechanisms that are involved in normal placental implantation are tightly related to the proliferative and invasive capacity of trophoblast cells and recent evidence suggests a common convergence between PE genes and those involved in tumor progression [2–4].

Restraint stress alters immune parameters and induces oxidative stress in the mouse uterus during embryo implantation

The influence of stress on embryo implantation is not well understood. Prior studies have focused on later gestational stages and the long-term impact of stress on immune function. The objective of this study is to investigate the effects of restraint stress on the immune parameters and the oxidative states of the uterus during implantation. In this study, pregnant CD1 mice were subjected to restraint stress (4 h/d) on embryonic day 1 (E1) and sacrificed on E3, E5, and E7. Maternal plasma corticosterone (CORT) secretion and implantation sites in the uterus were examined. The uterine (excluding embryos) homogenate and uterine lymphocytes were collected to examine oxidative stress states and associated immune parameters. The results demonstrated that restraint stress increased maternal plasma CORT secretion and reduced the number of implantation sites by 15.3% on E5 and by 26.1% on E7. Moreover, restraint stress decreased the density of uterine natural killer (uNK) cells in the endometrium by 22.1–47.9% and increased the density of mast cells in the myometrium by 55.6–76.9%. Restraint stress remarkably decreased the CD3+CD4+ T/CD3+CD8+ T cell ratio (by 26.2–28.9%) and attenuated uterine lymphocyte proliferation and secretion of cytokines. In addition, restraint stress threatened the intracellular equilibrium between oxidants and antioxidants, resulting in decreased glutathione peroxidase (GSH-PX) (32.2% and 45.7%), superoxide dismutase (SOD) (15.5% and 26.1%), and total antioxidant capacity (T-AOC) (18.4% and 18.2%) activities and increased malondialdehyde (MDA) (34.4% and 43.0%) contents on E5 and E7. In conclusion, these findings demonstrate that restraint stress causes abnormal implantation and negatively impacts immune parameters in association with oxidative stress in mice.