Bilateral Renal Cortical Necrosis with Chronic Renal Failure as a Result of Placenta Percreta in a Twin Pregnancy - A Case Report.
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ABSTRACT:
SUBMITTER: Biener A
PROVIDER: S-EPMC4168530 | biostudies-literature | 2012 Nov
REPOSITORIES: biostudies-literature
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Bilateral Renal Cortical Necrosis with Chronic Renal Failure as a Result of Placenta Percreta in a Twin Pregnancy - A Case Report.
Geburtshilfe und Frauenheilkunde 20121101 11
A 22-year-old gravida II, para I, with a twin pregnancy was diagnosed with placenta praevia totalis et percreta in 25 GW. After consideration of various modes of delivery a C-section was performed with retention of the placenta percreta in situ when vaginal bleeding occured in 28 GW. Following 8 dosages of methotrexate given on an outpatient basis, the patient suddenly developed acute renal failure necessitating dialysis. This was due to a bilateral renal cortical necrosis after disseminated int ...[more]
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Project description:Introduction and importance: Placenta percreta is an abnormal of placentation disorder that causes firm and deep attachment of placenta into myometrium due to absent decidua basalis and leads to significant morbidity and mortality due to severe hemorrhage. Presentation of case A 28-year, old women gravida 2 para 1 + 0 with previous one Lower segment caesarean section (LSCS), presented to emergency department of HFH with complaint of per vaginal bleeding. It was a twin pregnancy and was a rare case of complex placenta percreta with invasion into left broad ligament and urinary bladder in a woman having twin pregnancy. Placental invasion into bladder was diagnosed pre-operatively on USG scan, however; the broad ligament involvement was diagnosed intraoperatively. Patient underwent hysterectomy and internal iliac artery ligation to control hemorrhage soon after delivery of twins with T2 being IUD and patient shifted to ventilatory support but unfortunately due to massive hemorrhage and hemodynamic instability patient did not survive. Discussion Placenta percreta is a subtype of placenta accreta spectrum disorder that is associated with significant morbidity and mortality depending upon nature and extent of placental invasion. Preoperative diagnosis and management can be of significant value in preventing obstetrics related morbidity. A multidisciplinary approach is required in management of such cases and due to involvement of surrounding structures including urinary bladder. Conclusion Placenta percreta is a rare disorder of placentation that poses significant life-threatening risk of bleeding and maternal mortality and multidisciplinary approach can be of benefit in such cases. Highlights • Placenta percreta is a rare disorder that poses significant life-threatening risk to maternal as well as fetal wellbeing.• Early diagnosis can reduce mortality and morbidity.• A multidisciplinary approach is required in management of such cases of complex nature.
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Project description:Rationale & Objective Pregnancy-associated renal cortical necrosis is a critical illness with a poor prognosis. We aimed to describe the clinical and magnetic resonance imaging (MRI) characteristics of a case series of patients with acute kidney injury in the setting of pregnancy-associated renal cortical necrosis. Study Design Case series. Setting & Participants Seventeen patients from a single center diagnosed by nonenhanced functional MRI and/or kidney pathology. Results All patients presented with postpartum acute kidney injury stage 3. Of the 17 patients, 15 (88%) had pregnancy-associated atypical hemolytic uremic syndrome, 11 (65%) had postpartum hemorrhage, 7 (41%) had preeclampsia/hemolysis elevated liver enzymes low platelet count syndrome, and 4 (24%) had disseminated intravascular coagulation. On T2-weighted MRI, the diffuse phenotype showed outer cortex swelling in the early phase, with a dark signal rim involving the inner cortex and Bertin column, which became more apparent over time along with cortical thinning, substantially decreasing T2 signal intensity. The focal phenotype showed focally distributed hypointense signals in the cortex. After 8-101 (median: 60) months of follow-up, 4 individuals had estimated glomerular filtration rates ≥60 mL/min/1.73 m2, 6 had estimated glomerular filtration rates of 15-60 mL/min/1.73 m2, and 7 had kidney failure requiring kidney replacement therapy. The diffuse phenotype was present in all of the individuals who remained kidney replacement therapy dependent. Limitations Retrospective study; small sample size. Conclusions Different forms of pregnancy-associated thrombotic microangiopathy were the major causative diseases in our pregnancy-associated renal cortical necrosis case series. Nonenhanced functional MRI may provide valuable data for establishing diagnosis and kidney prognosis.
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Project description:Identifying bicornuate uterus can be challenging especially as a cause of early pregnancy bleeding. On ultrasonographic examination, it is difficult to misdiagnose pregnancy in a bicornuate uterus as an ectopic pregnancy due to the continuity of the endometrium. A rudimentary horn of a bicornuate uterus in early pregnancy can occasionally be misdiagnosed for an ectopic pregnancy especially when compounded by severe abdominal pains and supportive sonographic evidence. Myometrial invasive grading of placenta may be necessary for emergency preparedness and consenting. Hemihysterectomy is lifesaving when percreta has caused severe postpartum haemorrhage.We present a 24-year-old primigravida who presented to the maternity department with severe abdominal pains at 35 weeks. She was pale on clinical examination and haemodynamically unstable. She underwent emergency caesarean section with a preoperative diagnosis of concealed abruptio placentae. Intraoperatively we encountered a bicornuate uterus, delivered a fresh stillbirth, and noted a placenta percreta. A hemihysterectomy was done and she recovered after transfusion without complications.A gravid horn of a bicornuate uterus may present as an ectopic pregnancy; careful assessment at laparotomy or laparoscopy is required to prevent inadvertent surgical termination of pregnancy. Placental myometrial invasive assessment is important for delivery emergency preparedness.
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Project description:Accidental oral detergent ingestion usually causes mild gastrointestinal manifestations including nausea, vomiting and diarrhea as well as upper airway irritation. There are a limited number of reported oral detergent ingestions leading to acute kidney injury, mainly due to rhabdomyolysis. We present an ultimately fatal case of laundry detergent ingestion leading to biopsy proven severe cortical necrosis and irreversible renal damage. Detergent ingestion was associated with widespread endothelial injury leading to a picture of thrombotic microangiopathy. Among the detergent ingredients ingested by the patient, sodium borate raised the highest concern as a potential toxin exacerbated further by severe hypovolaemia and consequent decrease in renal toxin excretion. As sodium borate is dialyzable, haemodialysis should be a consideration early after laundry detergent ingestion.
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Project description:Pernicious placenta previa with placenta percreta (PP) is a catastrophic condition during pregnancy. However, the underlying pathogenesis remains unclear. In the present study, the placental tissues of normal cases and PP tissues of pernicious placenta previa cases were collected to determine the expression profile of protein-coding genes, miRNAs, and lncRNAs through sequencing. Weighted gene co-expression network analysis (WGCNA), accompanied by miRNA target prediction and correlation analysis, were employed to select potential hub protein-coding genes and lncRNAs. The expression levels of selected protein-coding genes, Wnt5A and MAPK13, were determined by quantitative PCR and immunohistochemical staining, and lncRNA PTCHD1-AS and PAPPA-AS1 expression levels were determined by quantitative PCR and fluorescence in situ hybridization. The results indicated that 790 protein-coding genes, 382 miRNAs, and 541 lncRNAs were dysregulated in PP tissues, compared with normal tissues. WGCNA identified coding genes in the module (ME) black and ME turquoise modules that may be involved in the pathogenesis of PP. The selected potential hub protein-coding genes, Wnt5A and MAPK13, were down-regulated in PP tissues, and their expression levels were positively correlated with the expression levels of PTCHD1-AS and PAPPA-AS1. Further analysis demonstrated that PTCHD1-AS and PAPPA-AS1 regulated Wnt5A and MAPK13 expression by interacting with specific miRNAs. Collectively, our results provided multi-omics data to better understand the pathogenesis of PP and help identify predictive biomarkers and therapeutic targets for PP.
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Project description:Placenta percreta is a life-threatening condition that places patients at risk of massive bleeding. It necessitates very complicated surgery and can result in mortality. Caesarean hysterectomy is the accepted procedure worldwide; however, recent studies discussing conservative treatment with segmental resections have been published. Foetal extraction and segmental resection can be performed through the same incision (single uterine incision) or through two different incisions (double uterine incision). In this study, we aimed to evaluate the effectiveness and results of the double incision technique.Twenty-two patients with a diagnosis of placenta percreta who underwent conservative surgery were included. Segmental resection was performed via single incision in ten patients and double incision in twelve patients.There was no difference between the patients who underwent segmental resection via single and double incision in terms of age, gravida, number of previous caesarean deliveries, gestational age at delivery, or rate of elective surgeries. The operation time, transfusion requirement, intensive care unit admission, total hospitalization and success of conservative surgery were comparable between the groups.Based on the outcomes of our study, double uterine incision allows for the safe extraction of the foetus during uterus-preserving surgery in patients with placenta percreta without worsening the results compared to single uterine incision.NCT02702024 , Date of registration: February 26, 2016, retrospectively registered.
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Project description:In placenta percreta cases, large vessels are present on the precrete surface area. As these vessels are not found in normal placentation, we examined their histological structure for features that might explain the pathogenesis of neoangiogenesis induced by placenta accreta spectrum disorders (PAS). In two patients with placenta percreta (FIGO grade 3a) of the anterior uterine wall, one strikingly large vessel of 2 cm length was excised. The samples were formalin fixed and paraffin-embedded. Gomori trichrome staining was used to evaluate the muscular layers and Weigert-Van Gieson staining for elastic fibers. Immunohistochemical staining of the vessel endothelium was performed for Von Willebrand factor (VWF), platelet endothelial cell adhesion molecule (CD31), Ephrin B2, and EPH receptor B4. The structure of the vessel walls appeared artery-like. The vessel of patient one further exhibited an unorderly muscular layer and a lack of elastic laminae, whereas these features appeared normal in the vessel of the other patient. The endothelium of both vessels stained VWF-negative and CD31-positive. In conclusion, this study showed VWF-negative vessel endothelia of epiplacental arteries in placenta accreta spectrum. VWF is known to regulate artery formation, as the absence of VWF has been shown to cause enhanced vascularization. Therefore, we suppose that PAS provokes increased vascularization through suppression of VWF. This process might be associated with the immature vessel architecture as found in one of the vessels and Ephrin B2 and EPH receptor B4 negativity of both artery-like vessels. The underlying pathomechanism needs to be evaluated in a greater set of patients.
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Project description:ObjectivesTo identify factors predicting renal recovery in patients presenting with renal failure secondary to bilateral obstructing urolithiasis.Patients and methodsData from electronic records of consecutive adult patients presenting with bilateral obstructing urolithiasis between January 2007 and April 2011 were retrieved. Ultrasonography of the abdomen, and kidney, ureter, bladder (KUB study) X-ray or abdominal non-contrast computed tomography confirmed the diagnosis. Interventional radiologists placed bilateral nephrostomies. Definitive intervention was planned after reaching nadir creatinine. Renal recovery was defined as nadir creatinine of ?2 mg/dL.ResultsIn all, 53 patients were assessed, 50 (94.3%) were male, and 18 (33.9%) were aged ?40 years. Renal recovery was achieved in 20 patients (37.7%). A symptom duration of ?25 days (P < 0.01), absence of hypertension (P = 0.018), maximum renal parenchymal thickness of >16.5 mm (P = 0.001), and haemoglobin >9.85 g/dL (P < 0.01) were significant on unadjusted analysis. Symptom duration of ?25 days alone remained significant after adjusted analysis. Symptom duration of ?25 days (hazard ratio (HR) 13.83, 95% confidence interval (CI) 4.52-42.26; P < 0.01), parenchymal thickness of ?16.5 mm (HR 5.91, 95% CI 1.94-17.99; P = 0.002), and absence of hypertension (HR 9.99, CI 95% 1.32-75.37; P = 0.026) were significantly related to time to nadir creatinine. Symptom duration of ?25 days (HR 17.44, 95% CI 2.48-122.79; P = 0.004) alone remained significant after adjusted analysis. A symptom duration of ?25 days (P = 0.007) was 22-times more likely to indicate renal recovery.ConclusionsShorter symptom duration (?25 days) is predictive of renal recovery in renal failure secondary to bilateral obstructive urolithiasis.
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Project description:The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.
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