When is the ideal time to remove cerclage in cases requiring cesarean hysterectomy for placenta accreta spectrum?

Placenta accreta spectrum (PAS) presents one of the highest risks to pregnancy and often requires a cesarean hysterectomy for management, but the challenges associated with this surgery often cause severe obstetric haemorrhaging and high rates of maternal morbidity. Shirodkar cerclage is usually performed in cases with cervical insufficiency, a short cervix with previous preterm birth, etc., to decrease the preterm birth rate. It is recommended that Shirodkar cerclage is removed when the patient approaches term, but the ideal timing of removal for patient for whom cesarean hysterectomy is planned is not clear. Here, authors present a case of PAS in whom Shirodkar cerclage that was difficult to remove at the timing of cesarean hysterectomy. After cesarean hysterectomy, the patient had a vaginal abscess and required antibiotic therapy for approximately two weeks. In the light of our case, authors discuss the timing of removal of cerclage in the cases of PAS

Successful management of placenta percreta by cesarean hysterectomy with transverse uterine fundal incision

Placenta accreta presents one of the highest risks to pregnancy, and its more severe variant, placenta percreta, is particularly risky. The incidence of both conditions is increasing. Placenta percreta requires a cesarean hysterectomy for management, but the challenges associated with this surgery often result in severe obstetric hemorrhaging and high rates of maternal morbidity. Several recent obstetric studies have reported on the usefulness of the transverse uterine fundal incision for the management of placenta accreta and its variants. However, these reports included only a few cases of placenta percreta. Here we present a case of placenta percreta covering the anterior uterine wall that was successfully managed using a transverse fundal incision, which avoided incising the placenta at delivery and thus reduced maternal blood loss. After delivery, the patient underwent a total abdominal hysterectomy without the need for a blood transfusion. We conclude that a transverse uterine fundal incision can be very useful for the management of placenta percreta of the anterior uterine wall

Transarterial embolization for convexity dural arteriovenous fistula

Background: Convexity dural arteriovenous fistulae (dAVF) usually reflux into cortical veins without involving the venous sinuses. Although direct drainage ligation is curative, transarterial embolization (TAE) may be an alternative treatment. Case Description: Between September 2018 and January 2021, we encountered four patients with convexity dAVFs. They were three males and one female; their age ranged from 36 to 73 years. The initial symptom was headache (n = 1) or seizure (n = 2); one patient was asymptomatic. In all patients, the feeders were external carotid arteries with drainage into the cortical veins; in two patients, there was pial arterial supply from the middle cerebral artery. All patients were successfully treated by TAE alone using either Onyx or N-butyl cyanoacrylate embolization. Two patients required two sessions. All dAVFs were completely occluded and follow-up MRI or angiograms confirmed no recurrence. Conclusion: Our small series suggests that TAE with a liquid embolic material is an appropriate first-line treatment in patients with convexity dAVFs with or without pial arterial supply

Time-dependent and site-dependent morphological changes in rupture-prone arteries : ovariectomized rat intracranial aneurysm model

OBJECTIVE The pathogenesis of intracranial aneurysm rupture remains unclear. Because it is difficult to study the time course of human aneurysms and most unruptured aneurysms are stable, animal models are used to investigate the characteristics of intracranial aneurysms. The authors have newly established a rat intracranial aneurysm rupture model that features site-specific ruptured and unruptured aneurysms. In the present study the authors examined the time course of changes in the vascular morphology to clarify the mechanisms leading to rupture. METHODS Ten-week-old female Sprague-Dawley rats were subjected to hemodynamic changes, hypertension, and ovariectomy. Morphological changes in rupture-prone intracranial arteries were examined under a scanning electron microscope and the association with vascular degradation molecules was investigated. RESULTS At 2–6 weeks after aneurysm induction, morphological changes and rupture were mainly observed at the posterior cerebral artery; at 7–12 weeks they were seen at the anterior Willis circle including the anterior communicating artery. No aneurysms at the anterior cerebral artery–olfactory artery bifurcation ruptured, suggesting that the inception of morphological changes is site dependent. On week 6, the messenger RNA level of matrix metalloproteinase–9, interleukin-1β, and the ratio of matrix metalloproteinase–9 to the tissue inhibitor of metalloproteinase–2 was significantly higher at the posterior cerebral artery, but not at the anterior communicating artery, of rats with aneurysms than in sham-operated rats. These findings suggest that aneurysm rupture is attributable to significant morphological changes and an increase in degradation molecules. CONCLUSIONS Time-dependent and site-dependent morphological changes and the level of degradation molecules may be indicative of the vulnerability of aneurysms to rupture

CP asymmetries of B to phi K_S and B to eta' K_S in SUSY GUT Model with Non-universal Sfermion Masses

We analyze CP asymmetries of B \to \phi K_S and B \to \eta' K_S in a supersymmetric grand unified theory in which only the third generation sfermions contained in 10(Q, U^c, E^c) of SU(5) can have a different mass from the others. One of the advantages of this nonuniversal mass model is that the first two generation sfermion masses can be large whereas both (left and right handed) stops are light so as to stabilize the weak scale. Therefore, we studied a minimal supersymmetric standard model parameter region in which a fine tuning in Higgs sector is relaxed owing to light masses of stops, gluino and higgsinos. In such a parameter region, the chargino contribution is as important as the gluino one. We show that the CP asymmetries of B \to \phi K_S and B \to \eta' K_S can deviate from their standard model predicted values by O(0.1) because of constructive interference between gluino and chargino contributions.Comment: 22 pages, 5 figure