References

Elliott MA, Tefferi A. 2003. Thrombocythemia and pregnancy.

Best practice and research. Clinical Haematology 16:227–242.

Harrison C. 2005. Pregnancy and its management in the

Philadelphia negative myeloproliferative diseases. British Journal

of Haematology 129:293–306.

Tefferi A. 2006. Essential thrombocythemia: scientific advances

and current practice. Current Opinion in Hematology 13:93–98.

Correspondence: K. Dinas, 13 Oreopulu Street, Thessaloniki, 54632, Greece. E-mail: konstantinosdinas@yahoo.gr

DOI: 10.1080/01443610801931444

Successful pregnancy outcome after pre-term premature rupture ofmembranes at 17 weeks’ gestation

S. ALTANIS, S. BEGUM & J. HALL

Department of Obstetrics and Gynaecology, Stoke Mandeville Hospital, Aylesbury, UK

Case report

A 35-year-old primigravida presented at 17 weeks with a history of

rupture of membranes. Clinical examination showed obvious

leakage of liquor. An ultrasound showed a single pool of amniotic

fluid 1.8 cm and there was no apparent fetal structural

abnormality. White blood cells and C-reactive protein were normal

on admission. A low vaginal swab showed evidence of strepto-

coccus group B. She was prescribed erythromycin for 10 days.

The couple was counselled regarding maternal and fetal risks

and they opted to continue with the pregnancy.

A full blood count and C-reactive protein were repeated twice

weekly and a low vaginal swab was taken on a weekly basis until the

time of delivery. None of them demonstrated any evidence of

infection during the rest of the pregnancy.

Serial ultrasound scans showed normal fetal growth. Both initial

and average amniotic fluid index (AFI) measurements were

1.8 cm. The variation of the AFI during pregnancy is shown in

Figure 1. At 28 weeks’ gestation, she had a small antepartum

haemorrhage and was given steroids.

At 33 weeks the patient went into spontaneous labour and had a

vaginal breech delivery of a live female infant weighing 2,155 g.

She was born in good condition with Apgar scores of 5, 8, 9 at 1, 5

and 10 min, respectively. Umbilical cord arterial pH was 7.34 and

venous pH was 7.37.

The neonate was admitted to the neonatal intensive care unit

because of respiratory distress and required intubation for the first

20 h of her life. She was also given a single dose of surfactant. The

neonatal examination was normal apart from a left positional

talipes requiring physiotherapy. Intravenous antibiotics were given

for 5 days. There was no other neonatal complication and she was

discharged home on day 17.

Follow-up appointments at 4 and 8 months of age showed

normal growth and development. Occasional wheezing was treated

with salbutamol.

Discussion

Spontaneous rupture of membranes before viability is a rare but

serious complication of pregnancy. It poses a formidable dilemma

to parents and clinicians whether to proceed with the pregnancy or

not.

Once the diagnosis has been established, the clinician should

confirm the gestational age and exclude the possibility of

chorioamnionitis. An ultrasound is essential in order to assess

the initial amniotic fluid index and ensure that there are not any

fetal structural abnormalities.

After the initial assessment, a further consultation should follow,

so that the parents can be informed about the results, the risks and

the management options.

Winn et al. (2000) demonstrated that the significant determi-

nants of the perinatal outcome are:

1. gestational age at rupture of the membranes

2. latency period between rupture and delivery

3. initial or the average amniotic fluid index.

Figure 1. Variation of the amniotic fluid index (AFI) between pre-

term premature rupture of membranes and delivery.

Pre-term delivery before viability or intrauterine fetal demise

accounts for the majority of the cases with poor outcome. Falk

et al. (2004) reported that 15 out of 21 women with pre-term

premature rupture of membranes (PPROM) at less than 20 weeks,

delivered before 24 weeks. In that study, the median latency period

was only 8 days.

Although a long latency period may reduce the perinatal

mortality, it increases the risk of pulmonary hypoplasia. Farooqi

et al. (1998) reported a median latency period of 72 days in 10

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women with PPROM, between 14 and 19 weeks. In this group

there were six neonatal deaths due to pulmonary hypoplasia within

the first 24 h of life.

Severe oligohydramnios is also an independent predictive factor

of pulmonary hypoplasia (Winn et al. 2000) and neonatal death

(Kilbride et al. 1996).

Chorioamnionitis and placental abruption are potential

complications that can affect both maternal and fetal well-being.

Because of the poor prognosis, it is not uncommon for parents that

have found themselves in this unfortunate situation to opt for

termination of pregnancy. However, in the decision-making

process, other factors such as cultural, religious, past obstetric

history or history of subfertility may influence the parental decision

in favour of expectant management.

In the presented case, the parents opted for expectant

management despite the poor prognostic factors – most notably

significant oligohydramnios. Although the latency period was 17

weeks, there was no evidence of pulmonary hypoplasia during

the immediate neonatal period. Follow-up at 4 and 8 months

showed normal development and growth with no major

impairment.

We acknowledge that this case represents the minority of

cases with PPROM prior to viability; nevertheless it demon-

strates that there is a definite possibility of uncompli-

cated neonatal survival even in the presence of poor prognostic

factors.

References

Falk SJ, Campbell LJ, Lee-Parritz A et al. 2004. Expectant

management in spontaneous preterm premature rupture of

membranes between 14 and 24 weeks’ gestation. Journal of

Perinatology 24:611–616.

Farooqi A, Holmgren PA, Engberg S et al. 1998. Survival and 2-

year outcome with expectant management of second trimester

rupture of membranes. Obstetrics and Gynecology 92:895–901.

Kilbride HW, Yeast J, Thibeault DW. 1996. Defining limits of

survival: lethal pulmonary hypoplasia after midtrimester pre-

mature ruptures of membranes. American Journal of Obstetrics

and Gynecology 175:675–681.

Winn H, Chen M, Amon E et al. 2000. Neonatal pulmonary

hypoplasia and perinatal mortality in patients with midtrimester

rupture of amniotic membranes – A critical analysis. American

Journal of Obstetrics and Gynecology 182:1638–1644.

Correspondence: S. Altanis, Department of Obstetrics and Gynaecology, The Womens’ Centre John Radcliffe Hospital, Oxford, OX3 9DU.

E-mail: sgaltanis@doctors.org.uk

DOI: 10.1080/01443610801931535

Placenta percreta

M. IBRAHIEM, R. KERIAKOS & M. BATWALA

Sheffield Teaching Hospitals

Case report

A 36-year-old woman in her second pregnancy booked for her

antenatal care at 13 weeks’ gestation. She previously had one

miscarriage at 20 weeks’ gestation without any complications or

surgical interventions. Her booking blood tests and scans were

normal. At 20 weeks, anomaly scans showed a high anterior

placenta. She had an uneventful pregnancy, apart from suspected

pre-term labour at 29 weeks’ gestation, for which she had tocolytic

and steroids. At 34 weeks’ gestation, she was admitted with a

history of constant severe upper abdominal pain more on the left

side. She was feeling unwell with vomiting and had had no fetal

movements for 24 h, however; there was no vaginal bleeding.

On examination, she looked unwell, and was hypotensive (80/60

mmHg). Abdominal examinations revealed tenderness all over

with guarding and rigidity. CTG showed a fetal heart rate of 90–

100 with reduced variability. Fetal heart was confirmed on portable

scan. The impression was that of concealed placental abruption.

Four units of cross-matched blood were ready. She had an

emergency caesarean section. At laparotomy, there was an intra-

peritoneal haemorrhage of 600 ml. A live male infant weighing

2,350 g was delivered by lower segment caesarean section He had

Apgar scores of 1, at 1 min, and 4, at 5 min. Placenta percreta was

found perforating the uterine fundus (Figures 1 and 2). A sub-total

abdominal hysterectomy was performed. There were no post-

operative complications and no transfusion was required. The

histopathology confirmed the surgical diagnosis of placenta

percreta adherent to the myometrium of fundus.

Discussion

Placenta accreta represents a specific abnormality of placentation

in which placental villi attach directly to the myometrium without

the intervening decidua. Furthermore, the placental villi may

invade and even penetrate the myometrium, conditions known as

placenta increta and percreta, respectively. Placenta accreta is the

Figure 1. Placenta percreta at the top of the uterine fundus.

238 Obstetric case reports

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