ECTOPIC MURAL PREGNANCY

Aim. Systemization and analysis of published data to define terminology, risk factors, diagnostic methods and treatment strategy for ectopic mural pregnancy. Materials and methods. Keyword search of information published on electronic bibliographic databases PubMed and Cochrane Library. Limitations: English language, period till October 31, 2017 inclusive. For analysis we curated studies containing information about risk factors, diagnostic methods and criteria and treatment methods or prospective observation of ectopic mural pregnancy. The studies were divided in following categories: case report, review, clinical trial, randomized clinical investigation, systematic reviews and meta-analyses; abstracts and articles were calculated separately. Results. We found 1425 sources corresponding to the keywords. Among 1006 studies included in the review according to inclusion criteria there were 236 articles and 770 abstracts of which there were 863 case reports, 129 reviews, 5 clinical trials, 4 randomized clinical investigations, 5 systematic reviews. Ectopic mural pregnancy includes different forms with specific risk factors; in some cases pregnancy prolongation till fetus livability is possible. The main diagnostic method is ultrasound. Diagnostic terms and treatment methods are not standardized. Conclusion. Due to the rarity of this pathology and high risk of dangerous complications including fertility loss and lethal outcomes there is a need for a national audit of mural ectopic pregnancies with a database establishment for possible outcomes analysis and an individual prognosis assessment. It is necessary to develop clinical guidelines to raise the level of doctors’ awareness about the rare forms of ectopic pregnancies and improve standards of medical treatments

Ultrasound diagnostic adenomyosis

To evaluate informational content of sonography for diagnosing of adenomyosis and endomyometritis in case of diffuse changes in myometrium 142 fertile patients who undergone transvaginal sonography with Doppler, dilatation and curettage with 4-foci loop biopsy of myometrium or zug-biopsy of endometrium under hysteroscopy control were examined. The control group consisted of 22 patients with male factor infertility. For differential evaluation of ultrasound markers of adenomyosis and endomyometritis discriminate function analysis was used. For further evaluation of predictive potential of the resulting discriminant function the data of ultrasound examination of 86 patients of prospective group were processed. Sonography with the use of the resulting discriminant function has allowed to diagnose adenomyosis with sensibility 96,4%; specificity 91,7%; likelihood ratio of positive result (LR+) 11,61; of negative result (LR-) 0,04; predictive validity of positive test (Р+) 0,964; of negative test (Р-) 0,917. For endomyometritis diagnosing sensibility amounted to 93.9%; specificity - 91,7%; LR+ - 11,31; LR- - 0,07; Р+ - 0,939; Р- - 0,917

Management of Gestation with Abnormal Invasive Placenta Complicated by an Extra-preterm Premature Rupture of Membranes in a Tertiary Perinatal Centre

Aim. Assessment of methods for prolonging gestation after an extra-preterm premature rupture of membranes (PROM) in a patient with abnormal invasive placenta and the efficacy of a multidisciplinary approach for treatment of a combined obstetric pathology in a tertiary perinatal centre.Results. A clinical case is reported of PROM at 22+6 weeks’ gestation in a patient with two caesarean scars on the uterus and abnormal invasive placenta. In a tertiary perinatal centre, pregnancy was prolonged to 36+3 weeks’ term. The period between PROM and delivery was 96 days. A planned caesarean section and metroplasty were performed in the setting of temporary balloon occlusion of common iliac arteries. Blood loss was 75 mL/kg. Placenta increta without chorioamnionitis was confirmed histologically. The patient stayed in the intensive care unit for two days and was discharged home on the 8th day. The newborn was assigned the Apgar score of 6/6. For two days, ventilatory support was rendered in a neonatal intensive care unit. The newborn was diagnosed with congenital pneumonia, the first-degree hypoxic-ischemic damage of the central nervous system and transferred to the second phase of nursing.Conclusions. A multidisciplinary approach and high technology facilities in the setting of a tertiary perinatal centre allow to reduce perinatal losses and provide high-quality care to patients with an increased risk of massive blood loss with the capacity to manage organ-preserving operative delivery with full rehabilitation in the postoperative period

Efficiency of Endovascular Haemostasis at Delivery in Patients with Previa and Placenta Invasion

Aim. Analysis of operative delivery outcomes in pregnant women with abnormal invasive placenta depending on the endovascular treatment for intraoperative haemostasis.Materials and methods. A retrospective study of operative delivery outcomes was performed in 178 patients with placental invasion using ultrasonography (US) data obtained at the Perinatal Centre of the Regional Clinic Hospital No. 2, Ministry of Health of Krasnodar Krai, in the years 2012–2018. In 2012–2014, delivery was managed without endovascular haemostasis (n = 44), and from May 2014 to December 2018 – with prophylactic balloon catheterization of common iliac arteries (n = 134). Upon intraoperative diagnosis of placental invasion, temporary balloon occlusion (TBO, n = 115) and/or uterine artery embolization (UAE, n = 33) were performed. Efficiency of endovascular methods for intraoperative haemostasis was assessed by comparing the degree of placental invasion, amount of blood loss and transfusion, frequency of hysterectomies (HE), duration of surgery, length of stay in intensive care units (ICU) and outcomes for the foetus.Results. Adoption of endovascular methods for intraoperative haemostasis allowed the blood loss (p = 0.02), haemotransfusion (p = 0.012) and HE frequency (p <0.001) to be significantly reduced. In the absence of clinical and histological manifestations of placental invasion, no difference in blood loss was detected between the groups. The amount of blood loss increased with the degree of invasion. Surgery duration in patients with TBO was signifi cantly longer (p = 0.04). No difference was detected between the groups with respect to the ICU length of stay and outcomes for the foetus.Conclusions. Establishment of endovascular haemostasis at the planned delivery of pregnant women with abnormal invasive placenta allows the blood loss and HE frequency to be reduced. Further improvement of US diagnostics of placental invasions is essential in pre-selection of patients for X-ray surgical care