PDF(Pubmed)
Abstract：
Approximately two-thirds of the patients with a cesarean scar pregnancy (CSP) will develop placenta accreta spectrum (PAS). PAS occurs when the placenta attaches too deeply to the uterine wall, and sometimes, the placenta can extend beyond the uterus, invading surrounding organs. PAS is commonly managed with a cesarean hysterectomy, and these deliveries are often complicated by maternal and fetal morbidity and mortality. However, delaying hysterectomy and using chemotherapeutic agents may be a safe and beneficial alternative. We describe the case of a 32 -year-old G3P2002 with a history of two prior cesarean sections (CS) who was referred to our Maternal Fetal Medicine department due to the concern of a gestational sac embedded in the anterior uterine wall in the cesarean scar. Magnetic resonance imaging (MRI) findings at 33 weeks confirmed that the patient had developed placenta percreta extending into the sigmoid colon. We also describe the case of a 30-year-old G6P4104 with a history of four prior CS who was referred to our department for concern of a pregnancy complicated by CSP. This patient had an MRI performed at 23 weeks that showed placenta percreta invading the bladder. Patients one and two were managed with a staged procedure, with CS followed by a delayed laparoscopic and abdominal hysterectomy, respectively, to minimize bowel and bladder injury. After the CS, the patients subsequently received a five-day course of intravenous (IV) etoposide 100mg/m2, and at six weeks postpartum, the patients had a hysterectomy, both showing resolution of the placenta invasion into the surrounding organs on postpartum MRI and confirmed by tissue pathology reports. Our cases present the challenge in diagnosis and management of the most severe presentation of PAS that varies from the generally accepted management recommendations. Delayed hysterectomy with chemotherapy can be a reasonable, conservative surgical approach in the most severe types of PAS. As in our cases, this management could improve maternal and fetal morbidity and mortality.
摘要：
大约三分之二的剖宫产瘢痕妊娠（CSP）患者会发生胎盘植入谱（PAS）。当胎盘与子宫壁太深时，就会发生PAS，有时,胎盘可以延伸到子宫之外,入侵周围的器官。PAS通常通过剖宫产子宫切除术来管理，这些分娩通常因孕产妇和胎儿的发病率和死亡率而变得复杂。然而,延迟子宫切除术和使用化疗药物可能是一种安全和有益的选择.我们描述了一例32岁的G3P2002，有两次剖宫产（CS）的病史，由于担心孕囊嵌入子宫前壁中而被转诊到我们的母胎医学部。剖宫产疤痕。33周时的磁共振成像（MRI）检查结果证实，该患者已发展为延伸至乙状结肠的胎盘。我们还描述了一例30岁的G6P4104，有四次CS病史，因担心妊娠并发CSP而被转诊至我们部门。该患者在23周时进行了MRI检查，显示胎盘穿孔侵入膀胱。患者1和2通过分阶段的程序进行管理，CS，然后延迟腹腔镜和腹式子宫切除术，分别,减少肠和膀胱损伤。在CS之后,患者随后接受了为期5天的静脉注射(IV)依托泊苷100mg/m2，并在产后6周，病人做了子宫切除术,两者均在产后MRI上显示胎盘侵入周围器官的消退，并通过组织病理学报告证实。我们的病例在诊断和管理最严重的PAS表现方面面临挑战，这与普遍接受的管理建议不同。延迟子宫切除术配合化疗可以合理,最严重类型的PAS的保守手术方法。就像我们的案子一样,这种管理可以提高孕产妇和胎儿的发病率和死亡率.
