Successful treatment of placenta percreta trough a combinatioral treatment incolving a Bakri balloon an metotrexate: a case report

Pełen tekst

(1)4 6 % ' ) 4 3 + 0 Á ( 3 ; ) poł oż n i c two. . . . . . !. ". !. . . . $. %. &. $. &. . &. '. &. (. . #. DOI: 10.17772/gp/57867. Jakub Kornacki, Jana Skrzypczak. Zastosowanie badania dopplerowskiego w drugiej połowie ciąży.. : ZLĊNV]RĞFL FLąĪ SRZLNáDQ\FK V,8*5 W\SX ,, ]DOHFD VLĊ HOHNW\ZQHFLĊFLHFHVDUVNLHSU]HGW\JRGQLHPFLąĪ\>@ :,,,W\SLHV,8*5REHFQRĞü]PLHQQHJRSU]HSá\ZXZWĊWQL F\SĊSRZLQRZHMPQLHMV]HJRSáRGXMHVWZ\QLNLHPREHFQRĞFLGX ĪHMDQDVWRPR]\WĊWQLF]RWĊWQLF]HM>@7HQW\S]DEXU]HĔFHFKXMH VWRVXQNRZRZ\VRNLRGVHWHNQLHVSRG]LHZDQHMĞPLHUFLPQLHMV]HJR SáRGX RN

(2) RUD] ]QDF]Q\ RGVHWHN RN

(3) SyĨQLHMV]\FK SRXURG]HQLRZ\FKXV]NRG]HĔQHXURORJLF]Q\FKXZLĊNV]HJRSáR GX>@=Z\NOH]DOHFDVLĊZW\PW\SLH]DEXU]HĔHOHNW\ZQH]D NRĔF]HQLHFLąĪ\SRXNRĔF]HQLXW\JRGQLD>@. Re f ere nces 1. Figueras F, Gratacos E. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther. 2014, 36, 86-98. 2. Valsky DV, Eixarch E, Martinez JP, [et al.]. Selective intrauterine growth restriction in Monochorionic twins: pathophysiology, diagnostic approach and management dilemmas. Semin Fetal Neonatal Med. 2010, 15, 342-348. 3. Rampello S, Frigerio L, Ricci E, [et al.]. Transabdominal uterine arteries Dopler at 12-14th and 20-24 th week of gestation and pregnancy outcome: A prospective study. Eur J Obstet Gynecol Reprod Biol. 2009, 147, 135-138. 4. Velauthar L,Plana MN, Kalidindi M, [et al.]. First-trimester uterine artery Doppler and adverse pregnancy outcome: a meta-analysis involving 55974 women. Ultrasound Obstet Gynceol. 2014, 43, 500-507. 5. Llubra E, Carreras E, Gratacos E, [et al.]. Maternal History and Uterine Artery Doppler in the Assessment of Risk for Development of Early- and Late –Onset Preeclampsia and Intrauterine Growth Restriction. Obstet Gynecol Int. 2009, ID 275613, 6 pages. =DVWRVRZDQLHEDGDQLDGRSSOHURZVNLHJRZFLąĪ\ MHGQRNRVPyZNRZHMSRZLNáDQHM7$36. 6. Gallo DM, Poon LC, Akolekar R, [et al.]. Prediction of Preeclampsia by Uterine Artery Doppler at 20-24 weeks. Fetal Diagn Ther. 2013, 34, 241-247.. 2FHQDGRSSOHURZVND369ZWĊWQLF\ĞURGNRZHMPy]JXMHVW QLH]EĊGQ\P EDGDQLHP Z GLDJQRVW\FH WHJR SRZLNáDQLD Z RNUH VLH SUHQDWDOQ\P .U\WHULDPL UR]SR]QDQLD 7$36 Vą 369 0&$ !0R0XGDZF\L3690&$0R0XELRUF\>@%H] ZJOĊGQHZDUWRĞFL369ZWĊWQLFDFKĞURGNRZ\FKPy]JXREXSáR GyZ Z\NRU]\VW\ZDQH Vą PLĊG]\ LQQ\PL Z NODV\¿NDFML VWRSQLD ]DDZDQVRZDQLD7$36>@ =HVSyáWHQMHVWU]DGNLP RN

(4) SLHUZRWQ\PSRZLNáDQLHP ZFLąĪ\EOLĨQLDF]HMMHGQRNRVPyZNRZHM>@ĝZLDGRPRĞüPRĪ OLZRĞFLZ\VWąSLHQLDWHJRSRZLNáDQLDQDND]XMHZ\NRQ\ZDQLHED GDQLD GRSSOHURZVNLHJRZ W\PRFHQ\369 Z 0&$ Z NDĪGHM FLąĪ\MHGQRNRVPyZNRZHM. 7. Phupong V, Dejthevaporn T, Tanawattanacharoen S, [et al.]. Predicting the risk of preeclampsia and small for gestational age infants by uterine artery Doppler in low-risk women. Arch Gynecol Obstet. 2003, 268, 158-161. 8. Baschat AA. Neurodvelopment following fetal growth restriction and its relationship with antepartum parameters of placental dysfunction. UOG. 2011, 37, 501-514. 9. Galan HL. Timing Delivery of the Growth-Restricted Fetus. Semin Perinatol. 2011, 35, 262-269. 10. Acharya G. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. UOG. 2009, 33, 628-633. 11. Del Rio M, Martinez JM, Figueras F, [et al.]. Doppler assessment of the aortic isthmus and perinatal outcome in preterm foetuses with severe intrauterine growth restriction. UOG. 2008, 31, 41-47. 12. Abdelrazzaq K, Yeniel AO, Ergenoglu AM, [et al.]. Fetal aortic isthmus Doppler measurements for prediction of perinatal morbidity and mortality associated with fetal growth restriction. Acta Obstet Gynecol Scand. 2013, 92, 656-661. 13. Unterscheider J, Daly S, Geary MP [et al.]. Predictable progressive Doppler deterioration in IUGR: does it really exist? AJOG. 2013, 209, 539.e1-7. 14. Ropacka-Lesiak M, Bręborowicz G. Postępowanie w ciąży powikłanej wewnątrzmacicznym ograniczeniem wzrastania płodu. Ginekol Pol. 2012, 83, 373-376.. Podsumowanie %DGDQLHGRSSOHURZVNLHMDNNROZLHNF]ĊVWRQDGXĪ\ZDQHMHVW SRGVWDZRZ\PEDGDQLHPGLDJQRVW\F]Q\PZZ\EUDQ\FKSDWROR JLDFKSRáRZ\FLąĪ\3RGVWDZRZ\PLZVND]DQLDPLGRMHJRZ\ NRQ\ZDQLD MHVW ,8*5 XZDUXQNRZDQ\ QLHZ\GROQRĞFLą áRĪ\VND ]OXEEH]ZVSyáLVWQLHQLDVWDQXSU]HGU]XFDZNRZHJRSRGHMU]HQLH QLHGRNUZLVWRĞFL X SáRGX RUD] SRZLNáDQLD FLąĪ\ EOLĨQLDF]HM MHG QRNRVPyZNRZHM:DUW\PSRGNUHĞOHQLDMHVWNRQLHF]QRĞüZW\FK SU]\SDGNDFKRFHQ\SU]HSá\ZXNUZL]DUyZQRZQDF]\QLDFKWĊWQL F]\FKMDNLĪ\OQ\FKSáRGXRUD]MHGQRF]HVQDĞZLDGRPRĞüZ\VWĊ SRZDQLDUyĪQ\FKZDULDQWyZSURJUHVML]PLDQKHPRG\QDPLF]Q\FK XSáRGX :RGQLHVLHQLXGR,8*5ZDUW\PSRGNUHĞOHQLDVą]DOHFHQLD FRGRZ\NRU]\VW\ZDQLD'RSSOHUDZUyĪQLFRZDQLX,8*5L6*$ 3RGREQLH MDN Z WU\PHVWU]H FLąĪ\ WDNĪH Z MHM SRáRZLH RFH QD SU]HSá\ZyZ Z WĊWQLFDFK PDFLF]Q\FK ]QDMGXMH SU]\GDWQRĞü Z SUHG\NFML Z\VWąSLHQLD ,8*5 L VWDQX SU]HGU]XFDZNRZHJR ]ZáDV]F]DLFKZF]HVQ\FKSRVWDFL. 15. Mari G, Hanif F, Drennan , [et al.]. Staging of intrauterine growth-restricted fetuses. J Ultrasound Med. 2007, 26, 1469-1477. 16. Mari G. Middle cerebral artery peak systolic velocity for the diagnosis of fetal anemia: the untold story. UOG. 2005, 25, 323-330. 17. Mari G, Adrignolo A, Abuhamad AZ [et al.]. Diagnosis of fetal anemia with Doppler ultrasound in the pregnancy complicated by maternal blood group immunization. UOG. 1995, 5, 400-405. 18. Mari G, Deter RL, Carpenter RL, [et al.]. Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization. Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses. N Engl J Med. 2000, 342, 9-14. 19. Hermann M, Poissonier MH, Grange G. Cerebral Doppler velocimetry to predict fetal anemia after more than three intravenous fetal exchange transfusions. Transfusion. 2014, 54, 29682973. 20. Ropacka-Lesiak M, Bręborowicz GH. Aktualne wytyczne dotyczące postępowania w zespole TTTS. Ginekol Pol. 2014, 85, 619-623. 21. Quintero RA, Morales WJ, Allen MH [et al.] Staging of twin-twin transfusion syndrome. J Perinatol. 1999, 19, 550-555. 22. Sueters M, Oepkes D. Diagnosis of twin-to-twin transfusion syndrome, selective fetal growth restriction, twin anemia-polycythemia sequence, and twin reversed arterial perfusion sequence. Best Pract Res Clin Obstet Gynaecol. 2014, 28, 215-226. 23. Papanna R, Moise Jr KM. Twin-to-twin transfusion syndrome: management of stage I Disease. In: Kilby MD, Oepkes D,Johnson A, (eds.). Fetal Therapy. Scientific Basis and Critical Appraisal of Clinical Benefits. Cambridge. 2013, 184-186. 24. Gratacos E, Van Schoubroeck D, Carreras E, [et al.]. Transient hydropic signs in the donor fetus after fetoscopic laser coagulation in severe twin-twin transfusion syndrome: incidence and clinical relevance. UOG. 2002, 19, 449-453. 25. Gratacos E, Lewi L, Munoz A, [et al.]. A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin. UOG. 2007, 30, 28-34.. Oświadczenie autorów 1. Jakub Kornacki – autor koncepcji i założeń pracy, przygotowanie manuskryptu i piśmiennictwa – autor zgłaszający i odpowiedzialny za manuskrypt. 2. Jana Skrzypczak – współautor tekstu pracy, ostateczna weryfikacja i akceptacja manuskryptu.. 26. Ishi K, Murakoshi T, Takahashi Y, [et al.]. Perinatal outcome of monochorionic twins with selective intrauterine growth restriction and different types of umbilical artery doppler under expectant management. Fetal Diagn Ther. 2009, 26,157-161. 27. Quintero RA, Bornick PW, Morales WJ, [et al.]. Selective photocoagulation of communicating vessels in the treatment of monochorionic twins with selective growth retardation. Am J Obstet Gynecol. 2001, 185, 689-696. 28. Vanderheyden TM, Fichera A, Pasquini L, [et al.]. Increased latency of absent end-diastolic flow in the umbilical artery of monochorionic twin fetuses. UOG. 2005, 26, 44-49.. Źródło finansowania: Praca nie była finansowana przez żadną instytucję naukowo-badawczą, stowarzyszenie ani inny podmiot, autorzy nie otrzymali żadnego grantu.. 29. Slaghekke F, Kist WJ, Oepkes D, [et al.]. Twin anemia-polycythemia sequence: diagnosis criteria, classification, perinatal management and outcome. Fetal Diagn Ther 2010, 27, 181190.. Konflikt interesów:. +_^Y\dc XSO dQ¨K]dKT UYX»SU^_ SXÔ\O]éa Y\Kd XSO Y^\dcWKVS ŞKNXOQY. wynagrodzenia związanego z powstawaniem pracy.. 630. . . . . . . . . .

(5). . . . . . . . . . . . . . .

(6). . . . . . . . . . .

(7) . . . . . !. ". !. . . . $. %. &. $. &. (. . '. &. (. ). #. DOI: 10.17772/gp/58974. 4 6 % ' ) / % > 9 - 7 8 = ' > 2 ) g i n e kol og i a. Successful treatment of Placenta Percreta through a combinatorial treatment involving a Bakri Balloon and Methotrexate – a case report Skuteczne leczenie balonem Bakriego i metotreksatem z powodu łożyska przerośniętego: opis przypadku 1HUPLQ$NGHPLU1$ULI6HUKDQ&HYULR÷OX16HOoXNg]GHQ1<DVHPLQ*QG]2*|NoHQøOKDQ1 i1 2. Departments of Obstetrics and Gynecology, Faculty of Medicine, Sakarya University, Sakarya, Turkey Department of Radiology, Faculty of Medicine, Sakarya University, Sakarya, Turkey. Abstract Placental percreta is a complication involving an abnormally deep placental attachment to the myometrium, resulting in obstetric hemorrhage and peripartum hysterectomy. A 38-year-old pregnant woman, with a history of 2 Cesarean births, myomectomy, 9 pregnancies, and 6 spontaneous abortions, was admitted after experiencing intrauterine fetal death, which occurred at 19 weeks gestation. The patient was referred to our institution after 8 days of unsuccessful medical treatment. Doppler ultrasonography and vacuum curettage revealed possible signs of abnormal placentation. Because of the unsuccessful separation of the placenta and massive bleeding, we used a Bakri Balloon to treat excessive bleeding during the acute phase, followed by the conservative administration of parenteral methotrexate to treat the spontaneous involution of the placenta at 7 weeks of conservative therapy. Bakri Balloon and methotrexate application to treat bleeding after curettage is a useful choice in placenta percreta and hemorrhage after abortion.. Key words: placenta percreta / hemorrhage / methotrexate / therapy /. Corresponding author: Nermin Akdemir, MD Departments of Obstetrics and Gynecology Faculty of Medicine, Sakarya University Serdivan, Sakarya, Turkey tel: 0090 5066005960 e-mail:drnerminakdemir@yahoo.com. . . . . . . . . Otrzymano: 30.08.2014 Zaakceptowano do druku: 30.10.2014. . . . . . . . . .

(8). . . . . . . . . . . . . . .

(9). . . 631.

(10) *. +. ,. -. .. /. ,. 0. 1. 2. 3. 4. 5. -. 0. 6. . .. . . . . . !. ". !. . . . $. %. &. $. &. (. . '. &. (. ). #. DOI: 10.17772/gp/58974. g i n e kol og i a. Nermin Akdemir et al. Successful treatment of Placenta Percreta through a combinatorial treatment involving a Bakri Balloon and Methotrexate – a case report.. Streszczenie Łożysko przerośnięte jest powikłaniem polegającym na zbyt głębokim, nieprawidłowym przyrośnięciu łożyska do myometrium, skutkującym krwotokiem położniczym i okołoporodowym usunięciem macicy. Kobieta ciężarna 38 letnia, po dwóch cięciach cesarskich, miomektomii, 9 ciążach i 6 poronieniach samoistnych została przyjęta z powodu obumarcia wewnątrzmacicznego w 19 tygodniu ciąży. Pacjentka została przekazana do naszego ośrodka po 8 dniach nieskutecznego leczenia. Badanie dopplerowskie oraz odessanie zawartości macicy wykazało oznaki prawdopodobnie nieprawidłowego zagnieżdżenia się łożyska. Z powodu nieskutecznej próby oddzielenia łożyska i masywnego krwotoku użyto balonu Bakriego celem leczenia ostrej fazy krwotoku a następnie podawano pozajelitowo metotreksat aby uzyskać samoistną inwolucję łożyska. Balon Bakriego oraz metotreksat jako terapia krwotoku po łyżeczkowaniu macicy jest przydatnym wyborem w przypadku łożyska przerośniętego oraz krwotoku po indukowanym poronieniu.. Słowa kluczowe: áRĪ\VNRSU]HURĞQLĊWH/ NUZRWRN/ metotreksat / leczenie /. Introduction. HQFLQJ LQWUDXWHULQH IHWDO GHDWK ZHHNV JHVWDWLRQ

(11) 7UHDWPHQW WKURXJKWKHDSSOLFDWLRQRILQWUDYDJLQDOPLVRSURVWRO ȝJ

(12) DW WLPHVDGD\IRUGD\VZDVXQVXFFHVVIXOLQRWKHUKRVSLWDOV'RS SOHU XOWUDVRXQG UHYHDOHG WKDW GHIRUPHG LQWUDXWHULQH IHWDO GHDWK ZLWKDQK\GUDPQLRVRFFXUUHGDWZHHNVJHVWDWLRQDFFRUGLQJWR WKHIHPXUOHQJWK'RSSOHUXOWUDVRXQG 0RUHRYHUWKH'RSSOHUXOWUDVRXQGUHYHDOHG[FPODFX QDUUHJLRQVFRPSDFWHGZLWKSODFHQWDDQG[FPEORRGÀRZ ZLWK D SXOVDWLOLW\ LQGH[ RI DQG DUWHULDO UHVLVWLYLW\ LQGH[ RI FRQVLVWHQWZLWKP\RPHWULXPLQYDVLRQ05,VKRZHGUHVXOWV FRQVLVWHQWZLWKSODFHQWDSHUFUHWD )LJXUH$

(13) 7KHEORRGWHVWUH VXOWVZHUHQRUPDO7KHSHOYLFH[DPLQDWLRQUHYHDOHGDFPFHUYL FDORSHQLQJDQGSODFHQWDOWLVVXHLQWKHFHUYL[9DFXXPFXUHWWDJH ZDVSHUIRUPHGXQGHUWKHJHQHUDODQHVWKHVLD$IWHUUHPRYDORIWKH IHWXVWKHUHZDVQRVHSDUDWLRQRIWKHSODFHQWD)RUWKHKHPRVWDVLV RIPDVVLYHEOHHGLQJZHXVHGXWHURWRQLFDJHQWVXWHULQHPDVVDJHV DQGD%%7LQÀDWHGZLWKFFRIVDOLQH$SSUR[LPDWHO\FF RIEORRGZDVORVWGXULQJYDFXXPFXUHWWDJH7KHUHIRUHXQLWVRI IUHVKO\GRQDWHGZKROHEORRGXQLWVRIHU\WKURF\WHVXVSHQVLRQ DQG XQLWV IUHVK IUR]HQ SODVPD ZHUH WUDQVIXVHG WR WKH SDWLHQW DIWHU RSHUDWLRQ GXULQJ YDFXXP FXUHWWDJH$IWHU WUDQVIXVLRQ WKH KHPRJORELQOHYHOVZHUHHOHYDWHGIURPPJGOSUHRSHUDWLYHWR PJGO$WRWDOFFEORRGORVVZDVGHWHFWHGIURP%%7DW KRXUVDIWHURSHUDWLRQ7KH%DNUL%DOORRQZDVGHÀDWHGFF DWKRXUVSRVWRSHUDWLYHO\EHFDXVHWKHGUDLQHGEORRGUHPDLQHG EHORZ FF IRU DW OHDVW KRXUV +RZHYHU PDVVLYH EOHHGLQJ VWDUWHG DW KRXUV DIWHU WKH EDOORRQ ZDV UHGXFHG DQG WKH %DNUL %DOORRQ ZDV VXEVHTXHQWO\ UHLQÀDWHG WR LWV LQLWLDO YROXPH 2Q WKHVHFRQGSRVWRSHUDWLYHGD\FFRIEORRGZDVREVHUYHGLQ WKH%DNUL%DOORRQGUDLQDJH7KH%DNUL%DOORRQUHPDLQHGLQWKH XWHUXVEHFDXVHRIFRQWLQXDOEORRGGUDLQDJH 2QWKHWKLUGSRVWRSHUDWLYHGD\FFRIGUDLQHGEORRGZDV REVHUYHGLQWKH%DNUL%DOORRQ7KH%DNUL%DOORRQZDVUHPRYHG LQWKHRSHUDWLQJURRP7UHDWPHQWZLWKFHIWULD[RQH J[

(14) DQG PHWURQLGD]ROH PJ[

(15) ZDVLQLWLDWHGGXULQJWKHSRVWRSHUD WLYHSHULRG0LQLPDOEOHHGLQJZDVGHWHFWHGGXULQJWKHIROORZXS SHULRG 2Q WKH IRXUWK SRVWRSHUDWLYH GD\ LQIRUPHG FRQVHQW ZDV REWDLQHG IURP WKH SDWLHQW DQG D PXOWLSOH GRVH RI PJNJGD\ PHWKRWUH[DWHZDVDGPLQLVWHUHGHYHU\RWKHUGD\IRUGD\V GD\V DQG

(16) 7KHDSSOLFDWLRQRIPJNJGD\IROLFDFLGZDV. 3ODFHQWDSHUFUHWDLVDFRPSOLFDWLRQLQYROYLQJDQFKRULQJSOD FHQWDOYLOOLWKDWSHQHWUDWHWKHP\RPHWULXPLQWRWKHXWHULQHVHURVD RUDGMDFHQWRUJDQVUHVXOWLQJLQDPRUELGO\DGKHUHQWSODFHQWD>@ 3ODFHQWDOLPSODQWDWLRQDEQRUPDOLWLHVDUHFKDUDFWHUL]HGDV

(17) SOD FHQWD DFFUHWD ZKHUH FKRULRQLF YLOOL DWWDFK WR WKH P\RPHWULXP UDWKHUWKDQWKHGHFLGXD

(18) SODFHQWDLQFUHWDZKHUHFKRULRQLFYLOOL SHQHWUDWHLQWRWKHP\RPHWULXPDQG

(19) SODFHQWDSHUFUHWDZKHUH FKRULRQLFYLOOLSHQHWUDWHWKHP\RPHWULXPLQWRWKHXWHULQHVHURVD RUDGMDFHQWRUJDQV>@)URPWKHSUHYDOHQFHRISOD FHQWD DFFUHWD ZDV VLQFH WKHQ WKH SUHYDOHQFH KDV LQ FUHDVHGDQGWKHFXUUHQWSUHYDOHQFHRISODFHQWDDFFUHWDLV >@$EQRUPDOLWLHVRISODFHQWDOLPSODQWDWLRQDUHFRPPRQLQSD WLHQWVZLWKXWHULQHVXUJHU\DQGSODFHQWDSUHYLDOHDGLQJWRVHYHUH PDWHUQDOPRUELGLW\DQGSRVWSDUWXPEOHHGLQJWKDWPLJKWUHTXLUH HPHUJHQF\K\VWHUHFWRP\>@7KHLQFUHDVHLQ&HVDUHDQELUWKV PLJKWUHÀHFWWKHREVHUYHGLQFUHDVHLQWKHLQFLGHQFHRISODFHQWD SHUFUHWD REVHUYHG LQ UHFHQW \HDUV 'RSSOHU XOWUDVRXQG >@ DQG PDJQHWLFUHVRQDQFHLPDJLQJ 05,

(20) >@DUHW\SLFDOO\XVHGIRUWKH GLDJQRVLVRIWKLVFRQGLWLRQ 0DLQJRDORIWUHDWPHQWDQGIROORZXSDIWHU&HVDUHDQVHFWLRQ LVWRUHGXFHLQWUDRSHUDWLYHDQGSRVWRSHUDWLYHEOHHGLQJ3RVWSDU WXPKHPRUUKDJHLVWUHDWHGWKURXJKXWHULQHGHYDVFXODUL]DWLRQRU RSHUDWLYHSURFHGXUHVVXFKDV%/\QFKEUDFHVXWXUH%DNUL%DO ORRQ 7DPSRQDGH %%7

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ase report $ \HDUROG ZRPDQ ZLWK D KLVWRU\ RI SUHJQDQFLHV DERUWLRQVSDULWLHVOLYHELUWKV &HVDUHDQVHFWLRQVDWDQG \HDUVEHIRUH

(22) DQGDP\RPHFWRP\LQWKHSULRU\HDUZDVUHIHUUHG WR RXU J\QHFRORJ\ DQG REVWHWULFV RXWSDWLHQW FOLQLF DIWHU H[SHUL. 632. . . . . . . . . .

(23). . . . . . . . . . . . . . .

(24). . . . . . . . . . .

(25) . . . . . !. ". !. . . . $. %. &. $. &. (. . '. &. (. ). 7. #. DOI: 10.17772/gp/58974. 8. 9. :. ;. <. 9. =. >. ?. @. A. B. :. =. C. ;. gin ekol ogi a. Nermin Akdemir et al. Successful treatment of Placenta Percreta through a combinatorial treatment involving a Bakri Balloon and Methotrexate – a case report.. DGPLQLVWHUHGHYHU\RWKHUGD\IRUGD\V GD\VDQG

(26) 7KH KHPDWRORJLFDO DQG ELRFKHPLFDO PHDVXUHPHQWV UHPDLQHG ZLWKLQ WKHQRUPDOOLPLWVGXULQJKRVSLWDOIROORZXS7KHUHZDVQREOHHG LQJGXULQJWKHIROORZXSSHULRGDQGWKHEORRGȕK&*OHYHOZDV RQWKHWKSRVWRSHUDWLYHGD\ 2Q WKH WK SRVWRSHUDWLYH GD\ PJ RI IHUURXV JO\FLQH VXOIDWH [

(27) DQGPJRIFLSURÀR[DFLQ [

(28) ZHUHDGPLQLV WHUHGDQGWKHSDWLHQWZDVGLVFKDUJHGZLWKDKHDOWK\FRQGLWLRQ 'XULQJ WKH IROORZXS H[DPLQDWLRQ QR SDWKRORJ\ ZDV GHWHFWHG DQG VSRQWDQHRXV SODFHQWDO LQYROXWLRQ RFFXUUHG DIWHU ZHHNV RI FXUHWWDJH DV GHWHFWHG XVLQJ 'RSSOHU XOWUDVRXQG DQG 05, )LJXUH%

(29) 7KHSDWLHQWZDVFRPSOHWHO\KHDOWK\DIWHU PRQWKV DFFRUGLQJ WR WKH ȕK&* OHYHO DQG 'RSSOHU XOWUDVRXQG H[DPLQDWLRQ. Discussion &RPELQHG WUHDWPHQW XVLQJ %%7 DQG FRQVHUYDWLYH PHWKR WUH[DWHWKHUDS\ZDVVXFFHVVIXOLQWKHSUHVHQWVWXG\%DNUL%DOORRQ LVFXUUHQWO\XVHGIRUDWRQ\RIWKHXWHUXVDVVRFLDWHGZLWKVHYHUH EOHHGLQJ,QWKLVVWXG\ZHGHVFULEHGWKH¿UVWFRPELQDWRULDOXVH RI%%7DQGFRQVHUYDWLYHPHWKRWUH[DWHWUHDWPHQWIRUWKHPDQDJH PHQWRISODFHQWDSHUFUHWDUHVXOWLQJIURPVHFRQGWULPHVWHUREVWHW ULFEOHHGLQJ $EQRUPDOLWLHVRISODFHQWDOLPSODQWDWLRQ SDUWLFXODUO\SODFHQ WDSHUFUHWD

(30) KDYHEHHQDVVRFLDWHGZLWKVHYHUHPDWHUQDOPRUELGLW\ FDXVLQJSRVWSDUWXPEOHHGLQJWKDWPLJKWUHTXLUHHPHUJHQF\K\V WHUHFWRP\ ,Q UHFHQW \HDUV WKH LQFUHDVHG LQFLGHQFH RI SODFHQWD SHUFUHWDPLJKWUHÀHFWDQLQFUHDVHLQ&HVDUHDQELUWKV>DQG@ $VWKLVFDVHSODFHQWDSHUFUHWDFDQEHGLDJQRVHGLQHDUO\JHV WDWLRQDOZHHNVXVLQJ'RSSOHUXOWUDVRXQGDQG05,%RWKGLDJQRV WLFPHWKRGVDUHDOVRLPSRUWDQWWRROVIRUWKHUDSHXWLFPRQLWRULQJ ,W LV SRVVLEOH WR UHGXFH LQWUDRSHUDWLYH DQG SRVWRSHUDWLYH EOHHGLQJ WKURXJK WKH GHYDVFXODUL]DWLRQ RI WKH XWHUXV %/\QFK EUDFHVXWXUHK\SRJDVWULFDUWHU\OLJDWLRQLQWUDXWHULQH%%7DSSOL FDWLRQDQGWKHFRPELQHGXVHRIXWHULQHDUWHU\HPEROL]DWLRQ3, arte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¿QLWH GLDJQRVLV XVLQJ FRORU 'RSSOHU XOWUDVRQRJUDSK\05,DQGF\VWRVFRS\WRDVVHVVWKHULVNIDFWRUV EHIRUHK\VWHUHFWRP\>@,QDUHWURVSHFWLYHVWXG\6HQWLOKHVHWDO. . . . . . . . . . . . . . . . . .

(31). . . . . Figure 1A: MRI shows the placenta percreta before the treatment. The sagittal T2-weighted cross-section noncontrast image shows the heterogeneous intensity and lobulated contoured mass lesions, consistent with placenta percreta, along the anterior-inferior of the uterine corpus.. Figure 1B: MRI image after the treatment. The T2-weighted contrast-enhanced sagittal plane cross-section image after methotrexate treatment of the uterine corpus shows significant reductions in the sizes of the lesions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

(32) DIWHUPHWKR WUH[DWHWUHDWPHQW>@ $QRWKHUVWXG\VKRZHGWKDW%%7FRXOGEHXVHGDVDQDOWHU QDWLYH WUHDWPHQW IRU KHPRG\QDPLF VWDEOH SDWLHQWVZLWK LQDFWLYH EOHHGLQJ>@. . . . . . . . . . .

(33). . . 633.

(34) *. +. ,. -. .. /. ,. 0. 1. 2. 3. 4. 5. -. 0. 6. . .. . . . . . !. ". !. . . . $. %. &. $. &. (. . '. &. (. ). #. DOI: 10.17772/gp/58974. g i n e kol og i a. Nermin Akdemir et al. Successful treatment of Placenta Percreta through a combinatorial treatment involving a Bakri Balloon and Methotrexate – a case report. K O M U N I K A T. ,Q FRQFOXVLRQ SDWLHQWV ZLWK SODFHQWD SHUFUHWD FDQEH PDQ DJHG WKURXJK FRQVHUYDWLYH WUHDWPHQW ZLWK %%7 DQG SDUHQWHUDO PHWKRWUH[DWHLQLWLDOGLDJQRVHVDQGIROORZXSH[DPLQDWLRQVXVLQJ VHULDO'RSSOHUXOWUDVRXQGDQG05,DQGDVVHVVPHQWVRIWKHEORRG ȕK&*OHYHOVDUHDOVRUHTXLUHG )XUWKHUPRUH ZHOOGHVLJQHG VWXGLHV DUH QHHGHG FRQFHUQLQJ WKHWUHDWPHQWRISODFHQWDOLPSODQWDWLRQGLVRUGHUV. D. Authors’ contribution: 1. Nermin Akdemir – concept, analysis, interpretation of data and article draft, critically revision of the manuscript, corresponding author. 2. Arif Serhan Cevrioğlu – analysis and interpretation of data. 3. Selçuk Özden – analysis and interpretation of data, revised critically article. 4. Yasemin Gündüz – analysis and interpretation of data. 5. Gökçen İlhan - acquisition of data, analysis and interpretation of data.. E. F. G. H. I. J. K. F. L. H. G. M. L. F. E. N. O. 9TVÎNQMIMRJSVQYNIQ]MõG^ÜSROS[MI4SPWOMIKS8S[EV^]WX[E +MRIOSPSKMG^RIKSFÊHÂSXV^]Q][EPMć+MRIOSPSKMÊ4SPWOÂĆ TS[GÎêRMINW^]QSTÜEGIRMYWOÜEHOMG^ÜSROS[WOMIN[SHTS[MIHRMQ 3HH^MEPI48+. Authors’ statement ³ >RS] S] ^Y MO\^SPc ^RK^ ^RO Z_LVSMK^SYX aSVV XY^ `SYVKÔ ^RO MYZc\SQR^]. of a third party, as understood according to the Act in the matter of copyright and related rights of 14 February 1994, Official Journal 2006, No. 90, Clause 63, with respect to the text, data, tables and illustrations (graphs, figures, photographs); ³ ^RO\O S] XY mMYX»SM^ YP SXÔ\O]^]p aRSMR YMM_\] aROX ^RO K_^RY\ \OWKSX] SX. a financial or personal relationship which unjustly affects his/her actions associated with the publication of the manuscript; ³ KXc ZY]]SLVO \OVK^SYX]RSZ] YP ^RO K_^RY\] aS^R ^RO ZK\^cZK\^SO]. interested in the publication of the manuscript are revealed in the text of the article; ³ ^RO WKX_]M\SZ^ RK] XY^ LOOX Z_LVS]RON SX Y\ ]_LWS^ÔN ^Y KXc Y^RO\. journal. ³ =Y_\MO YP ºXKXMSXQ$ 8YXO. ;]W]ÜOE+MRIOSPSKMM4SPWOMINHSG^ÜSRO´[48+NIWXHSOSR][ERERE TSHWXE[MIPMWXHSWXEVG^SR]GL^TSW^GÎK´PR]GLSHH^MEÜ´[48+HS 6IHEOGNMć+MRIOSPSKMM4SPWOMINĆ 9TVÎNQMITVSWMQ][W^]WXOMGLÊMRXIVIWS[ER]GLSÊOXYEPM^S[ERMI HER]GLEHVIWS[]GL[W[SMGL3HH^MEÜEGL48+ /SW^XVSG^RINTVIRYQIVEX]

(35) OVENS[EMÊKVERMG^RE HPESW´F RMIFÊHÂG]GLG^ÜSROEQM48+MMRWX]XYGNMREVSO[]RSWM 402:%8. >EQ´[MIRMI[VE^ÔWIVSOSTMÂHS[SHY[TÜEX]TVSWMQ]TVÎW]ÜEÄ REEHVIW. 6IHEOGNEć+MRIOSPSKMM4SPWOMINĆ 1EÜKSVÊXE7OS[VSÞWOE 4S^REÞYP4SPRE XIP JE\. Ref erenc e s 1. Lisowski A, Drelichowski S, Słoka-Sutkowska A, [et al.]. Intravascular embolization of the uterine arteries in the treatment of early postpartum hemorrhage: case report. Ginekol Pol. 2012, 82b (2), 146-149.. TSRTXĀ XIP. 2. Levine D, Hulka CA, Ludmir J. Placenta accreata: evaluation with color Doppler US, power Doppler US and MR Imaging. Radiology. 1997, 205, 773-776. 3. Koyama E, Naruse K, Shigetomi H. Combination of B-Lynch brace suture and uterine artery embolization for atonic bleeding after cesarean section in a patient with placenta previa accreta. J Obstet Gynaecol Res. 2012, 38 (1), 345-348.. IQEMP VIHEOGNEKT$KTWOEQTS^RERTP KMRTSP$SRIXIY [[[KMRIOSPSKMETSPWOETP. 4. Kumru P, Demirci O, Erdogdu E, [et al.]. The Bakri balloon for the management of postpartum hemorrhage in cases with placenta previa. Eur J Obstet Gynecol Reprod Biol. 2013, 5. 5. Kayem G, Davy C, Goffinet F, [et al.]. Conservative versus extirpative management in cases of placenta accreta. Obstet Gynecol. 2004, 104 (3), 531–536. 6. Bretelle F, Courbière B, Mazouni C, [et al.]. Management of placenta accreta: morbidity and outcome. Eur Obstet Gynecol Rerod Biol. 2007, 133 (1), 34-39.. ;TÜEXREPIõ]HSOSR][EÄREOSRXS -2+&EROéPÂWOM. 7. Dabalea V, Schultze PM, Mc Duffie RS Jr. Intrauterine balon tamponade in the management of postpartum hemorrhage. Am J Perinatol. 2007, 24 (6), 359-364.. P. Q. P. R. S. R. P. T. S. U. P. R. R. R. R. R. V. U. P. U. S. Q. U. W. P. X. 8. Tocce K, Thomas VW, Teal S. Scheduled hysterectomy for second-trimester abortion in a patient with placenta accreta. Obstet Gynecol. 2009, 113 (2), 568–570. 9. Sentilhes L, Ambroselli C, Kayem G. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010, 115 (3), 526-534.. -RWXVYOGNEHPEEYXSV´[[NÊ^]OYTSPWOMQMERKMIPWOMQ ^RENHYNIWMÊREWXVSRMI. 10. Stein Biscchop CN, Schaap TP, Vogelvang TE. Invasive placentation and uterus preserving treatment modalities: a systematic review. Arch Gynecol Obstet. 2011, 284 (2), 491-502.. [[[KMRIOSPSKMETSPWOETP. 11. Heiskanen N, Kroger J, Kainulainen S, Heinonen S. Placenta percreta: methotrexate treatment and MRI findings. Am J Perinatol. 2008, 25 (2), 91–92.. Y. 634. . . . . . . . . .

(36). . . . . Z. . [. . . . . \. . ]. . [. . . . . .

(37). . . . . . . . . . .

(38)