Interesting cases

Placenta previa centralis suspected accreta without hysterectomy (uterine preservation)

Placenta previa is known to be one of the challenges in obstetrics, as we have to balance between minimizing blood loss and uterine preservation for future fertility. Another challenge is that it sometimes comes with morbidly adherent placenta which represents a serious condition in terms of diagnosis and surgery. As referral center, we face many similar cases per month and today we are going to talk about one particular case that represents an achievement.

A 36 years old lady, in her fifth pregnancy, medically free with previous 4 cesarean sections.

Her first presentation to our clinic was at a gestational age of 34 weeks, known to have placenta previa suspected accreta, she was worried about risk of hysterectomy.

She was advised to do MRI to confirm diagnosis of accreta, she attended to our clinic for a second opinion.

Ultrasound examination revealed: fetus with transverse lie, back anterior, placenta previa centralis, no signs of morbidly adherent placenta by Ultrasound (no increased vascularity in placental bed and no placental vacuolations)

She was asymptomatic (no abdominal pain and no vaginal bleeding)

Cesarean-Section was booked at 37 weeks of gestation, dexamethazone was given.

Laboratory investigations were sent for, HB:9.6, so decision was taken to admit patient one day pre-operation for blood transfusion and preparation for surgery.

A day before surgery she was admitted, a total of 6 units Packed RBCs were prepared, she was given 2 units increasing her hemoglobin to 11.6 and 4 units were kept standby.

On the day of surgery 4 units were in the OR before starting surgery, uterotonic drugs were prepared.

Under general anesthesia, Low transverse abdominal incision was done, intraoperative ultrasound was done for placenta mapping, upper transverse uterine incision was done, baby delivered by breech extraction, placenta was delivered smoothly, 2 defects were detected in the lower uterine segment at the site of previous scars (dehiscence) and both were repaired after bladder mobilization.

Estimated blood loss was 4 Liters and the patient received 4 units of Packed RBCs intaopiratively.

Patient was discharged 2 days later, HB repeated before discharge 11.3 with complete uterine preservation.

Intrauterine fetal death, presentation of thrombophilia

It is well known that intrauterine fetal death has many reasons and well-established risk factors, some of these factors are modifiable (smoking, use of certain drugs, obesity), and others are non-modifiable (maternal age, chromosomal translocations), other causes can be dealt with by administration of certain medical treatments that are found to be effective based on clinical trials (like anticoagulation in cases of thrombophilia). Many cases of Intra Uterine Fetal Death remain unexplained and thus management in subsequent pregnancies will be empirical trying to address all possible sinister causes.

Let’s talk about another interesting case,

22 years old primigravida presented to our clinic, she was diagnosed during her pregnancy with gestational hypertension (Blood Pressure controlled on methyldopa 250 mg three times daily) with no previous history of surgeries, gestational age upon presentation: 31 weeks, her pregnancy was uncomplicated with no previous hospital admissions.

Level 2 Ultrasound examination was done at 20 weeks of gestation and showed growth on the lower limit of normal and bilateral choroid plexus cysts.

Cell free fetal DNA testing was done during this pregnancy and also showed the fetus to be chromosomally normal.

She presented complaining of decreased fetal movements of 2 weeks duration (in terms of frequency and intensity), her Blood Pressure readings at home ranged between (120/70-140/90).

At our clinic her Blood Pressure reading was 180/110 (repeated multiple times, appropriate cuff size), she was symptomatic (complaining of headache).

Ultrasound examination: revealed dead fetus, breech, measurements with 28-29 weeks, and no amniotic fluid.

Vaginal examination: closed long thick posterior cervix.

She was immediately admitted and blood tests/urine analysis were sent.

Blood Pressure stabilization was started, she was given a total of 15 mg hydralazine and one-tab nifedipine 30 mg and her BP dropped to 155/93.

Laboratory testing showed proteinuria +3, otherwise normal tests.

She was given a loading dose of magnesium sulfate (4 g over 15 minutes) and immediately transferred to theatre for delivery via c-section (indication being severe pre-eclampsia and unfavorable cervix).

Intraoperatively the fetus was found to be macerated, morphologically normal, thrombosis was noted throughout the umbilical cord and thrombosis was also noted in the placenta and placental bed.

Post-operation she was kept on magnesium sulfate for eclampsia prophylaxis for 24 hours and her Blood Pressure was controlled using anti-hypertensive medications.

Given the above-mentioned findings: the patient had thrombophilia and will be needing thrombophilia testing and anticoagulation in her subsequent pregnancies (aspirin and Low Molecular Weight Heparin)

A rare case of Hydatid cyst in pregnancy

A 26 year old PG presented at 5 weeks gestational age as antenatal visit ; on ultrasound intrauterine gestational sac seen with left ovary with around five enlarged follicles ,

Patient as a foreigner came at gestational age 35 weeks with MRI report of left adnexea with multiple small thin walled cysts largest 7 x6 cm ,

The fetus was oblique in lie so caesarean planned at 38 weeks

Intraop there was a mass in the uterine wall around 7x 6 cm , after the baby was delivered the mass was excised as it was adherent to the bladder anteriorly , the left uterine wall laterally and the vagina caudally reaching the vaginal introitus .

After that repair of the uterus , bladder and vagina was done through the pfennestiel incision , the pat is doing well and she was discharged on albendazole 400 mg 1x2 for 28 days