1. Adherent placenta occurs when there is a defect in the decidua basalis, resulting in abnormal invasion of the placenta directly into the uterus.
2. Diagnosis is usually made using ultrasound and MRI to detect irregularities in the placenta and loss of tissue planes between the placenta and uterus.
3. Treatment depends on the extent of invasion and patient desires, ranging from conservative surgeries like resection to hysterectomy, with the goal of managing blood loss and preserving the uterus if possible.
Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.Cervicopexy is fertility conserving surgical management of prolapse.
Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.Cervicopexy is fertility conserving surgical management of prolapse.
Adherent placenta occurs when there is a defect in the decidua basalis, Resulting in an abnormal invasion of the placenta directly into the substance of the uterus
Endometriosis is a disease restricted usually to the female genital tract. Involvement of the bowel by this disease can lead to a diagnostic dilemma due to the great variation in the symptomatology. Awareness of the pathophysiology, clinical features and diagnostic modalities is of utmost importance to decide the modality of treatment. Hormonal manipulation and surgical resection are the two modalities of treatment. The choice depends upon critical analysis of clinical and radiological findings and the desire to have pregnancy in cases associated with infertility.
Adherent placenta occurs when there is a defect in the decidua basalis, Resulting in an abnormal invasion of the placenta directly into the substance of the uterus
Endometriosis is a disease restricted usually to the female genital tract. Involvement of the bowel by this disease can lead to a diagnostic dilemma due to the great variation in the symptomatology. Awareness of the pathophysiology, clinical features and diagnostic modalities is of utmost importance to decide the modality of treatment. Hormonal manipulation and surgical resection are the two modalities of treatment. The choice depends upon critical analysis of clinical and radiological findings and the desire to have pregnancy in cases associated with infertility.
Vesicouterine Fistula Following Cesarean Delivery – Ultrasound Diagnosis and ...Michelle Fynes
Vesicouterine fistulae are uncommon, with most units reporting 1–5 cases over 5–15 year periods. To date there has been a paucity of case reports regarding this problem and only a few case series. In this report we outline the presentation and management of a vesicouterine fistula complicating a repeat Cesarean delivery, specifically describing the role of transvaginal ultrasound.
A case report of cervical ectopic pregnancy misdiagnosed as cervical miscarriageApollo Hospitals
Cervical pregnancy is a rare variety of ectopic gestation. The aetiology is obscure. Diagnosis may be difficult unless the clinician/the radiologist is conscious of the entity. The evaluation of first trimester vaginal bleeding or pelvic pain is an important task for the emergency physician. The early identification of an ectopic pregnancy can help prevent significant morbidity and mortality for patients seeking emergency care. We present the case of a patient found to have a cervical ectopic pregnancy.
Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a
great challenge to the attending surgeon. There are various variants of embryological abnormality of the
processes vaginalis manifesting in different forms. Understanding the embryological development of the
processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical
option for treating these rare cases.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Dehradun #ℂall #gIRLS Oyo Hotel 9719300533 #ℂall #gIRL in Dehradun
ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANI
1. ADHERENT PLACENTA
Diagnosis & Management
Dr. Shashwat K. Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : drshashwatjani@gmail.com
3. INTRODUCTION
Adherent placenta occurs
when there is a defect in the decidua basalis ,
Resulting
in an abnormal invasion of the placenta
directly into the substance of the uterus.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 3
5. INCIDENCE
It varies widely all over the world.
Increased dramatically over the last 3 decades
( Because of Increase in LSCS rate … ).
A.C.O.G. 1 Per 2500 deliveries.
Accreta : 75 -78 %
Increta : 15 – 18 %
Percreta : 5 -7 %
22-Dec-14 Dr Shashwat Jani. 99099 44160. 5
6. Associated Condition :
Placenta Previa
Previous Surgeries such as …
- Cesarean Section - D & C
- Myomectomy - M.R.P.
- Synecolysis - Cornual Resection
Uterine Malformation
Septic Endometritis
22-Dec-14 Dr Shashwat Jani. 99099 44160. 6
7. Risk Factors :
High Parity
Advanced Maternal Age
Down Syndrome
High level of Maternal Serum AFP.
High level of Maternal free Beta hcg.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 7
8. ETIOLOGY :
Defective decidual formation :
- Partial / total absence of decidua basalis
- Imperfect development of fibrinoid layer
(Nitabuch layer)
- Placental villi are attached to the myometrium
22-Dec-14 Dr Shashwat Jani. 99099 44160. 8
10. Interestingly,
the sex ratio associated with placenta
accreta favors females, which is opposite to
the normal sex ratio in the general
population, which favors males…
22-Dec-14 Dr Shashwat Jani. 99099 44160. 10
11. DIAGNOSIS
Earliest diagnosis of Adherent
Placenta is must to avoid any
catastrophic emergency in future.
Antenatal diagnosis is the single
most important factor in improving the
outcome in MAP.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 11
13. USG
• First-line investigation for
suspected placental invasion of the
myometrium.
• The most useful modalities for
evaluating placental position and
implantation are transabdominal and
transvaginal ultrasonography
22-Dec-14 Dr Shashwat Jani. 99099 44160. 13
14. USG CRITERIA
1st Trimester :
G. Sac located in the lower uterine segment
(rather than the fundus), next to or lower than
the Prev. CS scar.
2nd & 3rd Trimester :
Presence of irregular lacunae within the placenta
Loss of retro placental clear space
Loss or disruption of the white line – Bladder line
22-Dec-14 Dr Shashwat Jani. 99099 44160. 14
15. Moth – eaten
OR
Swiss Cheese
Appearance
22-Dec-14 Dr Shashwat Jani. 99099 44160. 15
Obliteration of clear space
between placenta and
uterine wall
16. Reliability :
• Sensitivity - 93%
• Specificity - 79%
The use of power Doppler, color Doppler, or three-
dimensional imaging does not significantly improve
the diagnostic sensitivity compared with that
achieved by grayscale Ultrasonography alone.
[ Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by
transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol
2000;15:28–35. ]
22-Dec-14 Dr Shashwat Jani. 99099 44160. 16
17. 3 D USG
Diagnostic Criteria :
Irregular intraplacental vascularization
with tortuous confluent vessels crossing
placental width.
Hypervascularity of uterine serosa–
bladder wall interface.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 17
18. Colour Doppler
Diffuse or focal
intraparenchymal
lacunar flow.
Vascular lakes with
turbulent flow.
Hypervascularity of
serosa-bladder
interface.
Prominent
subplacental venous
complex.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 18
19. M.R.I.
No more sensitive than USG , But used as an adjunct
to USG , when there is strong clinical suspicion of
accreta.
MRI achieves better images than Ultrasonography in
- Posteriorly sited MAP and
- With prior myomectomy,
( Because the ultrasound beam is impeded by the fetal
head in the former and by the scar tissue in the latter )
22-Dec-14 Dr Shashwat Jani. 99099 44160. 19
20. M.R.I. Criteria
Uterine bulging into the
bladder
Heterogeneous signal
intensity within the placenta
Presence of intra placental
bands on the T2W imaging
Abnormal placental vascularity
Focal interruption of the
myometrium
22-Dec-14 Dr Shashwat Jani. 99099 44160. 20
21. Laboratory Findings :
• Several series and case reports have reported
an association between placenta accreta and
otherwise unexplained elevations in second
trimester MSAFP concentration (>2 or 2.5 multiples
of the median [MOM]).
• Although an elevated MSAFP level supports an
ultrasound-based diagnosis of placenta accreta, it is
an inconsistent finding and is not useful by itself for
diagnosis of accreta.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 21
22. Histology
Post Partum specimen shows :
Placental villi anchored directly on, or invading into
or through, the myometrium, without an intervening
decidual plate.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 22
23. Treatment :
A multidisciplinary team approach is relevant
in managing these patients in order to reduce
morbidity and mortality associated with MAP.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 23
24. Particular consideration should be given to
anticipation and management of massive
hemorrhage,
including
- availability of packed cells,
- platelets,
- fresh frozen plasma,
- cryoprecipitate, and
- activated factor VII.
Interventional Radiology and cell saver
technology are useful.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 24
25. At present , placenta accrete can be
managed in three ways:
( 1 ) Carry out a hysterectomy;
( 2 ) Leave the placenta in situ ; and
( 3 ) Resect the invaded tissues with the entire placenta
restoring uterine anatomy.
Each one has weaknesses and strengths,
dependent on the condition itself and the specific
preferences taken by the surgeon and the team.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 25
26. Women who have had a previous CS who also
have either placenta previa or an anterior placenta
underlying the old CS scar at 32 weeks of gestation
are at increased risk of placenta accreta and should
be managed as if they have placenta accreta, with
appropriate preparations for surgery made.
(RCOG 2011)
Elective delivery by caesarean section at 34–35
weeks of gestation for suspected placenta accreta
(ACOG 2012).
22-Dec-14 Dr Shashwat Jani. 99099 44160. 26
27. Conservative
In case of
( focal defect / moderate blood Loss / fertility to be
preserved )
Localized Resection with uterine repair
Over sewing of the ut. Defect
Blunt dissection followed by curetting the uterine
cavity
Uterus fails to contract (Multipara) :
Hysterectomy
22-Dec-14 Dr Shashwat Jani. 99099 44160. 27
28. Non Surgical
Leave the Placenta in situ to resorb with
methotrexate therapy
Ligation of the Ut. And Int. iliac artery
Fluoroscopic bilateral UAE
Argon beam coagulation for haemostasis
Insertion of occluding Balloons in the Int. iliac
art. (Bilat)
22-Dec-14 Dr Shashwat Jani. 99099 44160. 28
29. Surgical
Cesarean Hysterectomy.
Hysterectomy and partial / total resection of
bladder
Subtotal Hysterectomy with removal of large part
of placenta and Prophylactic occlusive Balloon
catheter in int. iliac art.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 29
30. An Elective controlled condition is preferred
rather than an emergency condition without
adequate preparations.
A midline incision will facilitate better exposure,
especially if placenta Percreta is suspected.
Leaving the placenta undisturbed until
completion of the hysterectomy would prevent
unnecessary hemorrhage.
In cases where MAP is associated with placenta
previa, total hysterectomy is preferred to a subtotal
hysterectomy.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 30
31. Uterine Incision:
It is best to avoid cutting through a
MAP because of the possibility of massive
haemorrhage.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 31
32. 22-Dec-14 Dr Shashwat Jani. 99099 44160. 32
Various modifications of the uterine
incision to avoid the placenta have been
reported…
- Classical incision,
- High transverse incision,
- Fundal incision,
- Fundal transverse incision
33. remember
The presence of pericervical or lower-segment
varicose veins proper of placenta praevia can be
confused with the neovascularization of placenta
accreta.
Surgical exploration will make a differential
diagnosis, thus avoiding unnecessary hysterectomies.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 33
34. Excision of placental site
It is possible to "excise the placental site".
This is done by inverting the uterus in order
to provide good access to the placental site.
If the area of placental attachment is focal
and the majority of the placenta has been
removed, then a "wedge resection" of the
area can be performed.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 34
35. Balloon Catheterization
Pre-operative placement of arterial catheters
in internal iliac artery
After delivery balloons are inflated to achieve
temporary homeostasis
Selective arterial embolization (SAE) if
necessary. . .
Bil. Int. iliac artery ligation is performed prior
to peripartum hysterectomy where
Interventional Radiology is not available.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 35
36. Placement of occlusion balloon catheters
into both internal iliac arteries.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 36
37. Methotrexate
A folate antagonist, acts primarily
against rapidly dividing cells and
therefore is effective against proliferating
trophoblasts.
First described by Arulkumaran et al
in 1986. They reported administration 50
mg of methotrexate as an intravenous
infusion on alternate days and the
placental mass was expelled on 11th
postnatal day.
However, more recently, others
have argued that, after delivery of the
fetus, the placenta is no longer dividing
and therefore, methotrexate is of no
value.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 37
38. Methotrexate has been used in varying
doses and routes, however, there are no
randomized trials and no standard protocol
regarding its dosage.
The outcome when the placenta is left in
place after methotrexate administration varies
widely; it ranges from expulsion at 7 days to
progressive resorption in roughly 6 months.
Mtx – 50 mg IM + Folic Acid 6mg IM on
alternate day till β HCG comes to zero.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 38
39. Other Modalities
Tamponade of the placental implantation site
with inflated Intra Uterine balloon catheter bags.
Lower Segment Compression Sutures
Pelvic pressure sponge packing.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 39
40. Follow up…
1.- Ultrasound exams & Vascularity
2.- hCG titers weekly till become Zero.
3.- Daily Temps, Other S&S of infection
4.- Bleeding
5.- Coagulation profile
Antibiotic Maximum for 10 days.
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41. 22-Dec-14 Dr Shashwat Jani. 99099 44160. 41
Resources Patient, clinical and
anatomic features
Decision Definitive treatment
Limited
experience
or expertise, poor
resources or no
facilities for safe
patient transfer
lower segment invasion
vaginal bleeding with high
suspicion of accreta
Possibility of percreta
Extraplacental
hysterotomy,
Placental left in
situ
Followed by
uterine closure
Delayed hysterectomy
or conservative procedure
according clinical
and surgical status
Qualified and
experienced
team, adequate
hospital
resources
No desire for future
pregnancy
Tissue destruction> 50% of
uterine circumference
Intractable haemorrhage
DIC
Resective surgery
Subtotal hysterectomy
for upper segment lesions
Total hysterectomy
for lower segment
and cervical involvement
Qualified and
experienced
team,
adequate
hospital
resources
Desire for future
pregnancy
Destruction < 50% of
uterineaxial circumference
Minor coagulation
disorders
Conservative
surgery
1-Placenta in situ with or wit
MXT
2-One step surgery
OR
3- Two step surgery
42. Bladder Involvement
First , Involve UROLOGIST.
Preoperative Ureteric
stenting aids in identifying
the ureters, which will
help reduce ureteric
injuries.
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43. Care must be taken during
surgery not to attempt to
dissect the bladder off the
lower uterine segment
which results in torrential
bleeding.
Anterior bladder wall
incision is particularly
helpful in defining
dissection planes and the
location of the ureters.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 43
44. Reality :
Even today, the ground reality is
that a majority of morbidly adherent
placenta are diagnosed during the
third stage of labour or during
caesarean section and which results
in adverse consequences including
exanguinating haemorrhage.
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45. To Conclude…
Caesarean hysterectomy was the
cornerstone in the management in the past.
Antenatal diagnosis permits effective and
safe conservative approaches today.
The use of methotrexate, monitoring with
serum hCG and follow up with USG is backed
only by conflicting evidence.
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