Objective. Placenta accreta is a life-threatening problem that is rising in incidence in the developed world. The increased risk of placenta accreta in women with placenta previa and 1 or more prior cesarean deliveries is well established and prompts careful sonographic evaluation. Our objective was to emphasize that accreta is also identified at sites other than cesarean scars. Methods. Two cases of placenta accreta without placenta previa seen in association with uterine scarring from myomectomy and uterine fibroids are described. Results. The sonographic and magnetic resonance imaging findings of accreta are reviewed in the classic setting of prior cesarean deliveries as well as myomectomy and uterine fibroids. Conclusions. We suggest that when the placenta overlies any uterine abnormality, a careful search for invasive placentation is warranted. Key words: accreta; sonography, fibroids; sonography, placenta. Maternal-Fetal Medicine, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada (A.A.) lacenta accreta occurs when there is a defect in the decidua basalis, allowing the anchoring villi to adhere to the myometrium. The frequency of abnormal placentation has increased 10-fold over the last 20 years and is now observed in 9.3% of women with placenta previa or in 1 per 533 deliveries. Received June 5, 2008, from the Department of1 Cesarean delivery is probably the most common cause of decidual defects, and the increase in placenta accreta may be attributed primarily to the rising cesarean delivery rate, which has risen to greater than 30% in the United States at the time of writing. Among those with previous cesarean deliveries who have placenta previa or a lowlying anterior placenta, the risk of placenta accreta increases from 24% for a single cesarean delivery to 67% for 4 cesarean deliveries.2 Other risk factors for accreta include subserosal uterine myomas, previous myomectomy, Asherman syndrome, maternal age older than 35 years, smoking, and elevated α-fetoprotein levels. 3,4 Massive hemorrhage at the time of delivery is the most important clinical issue in cases of placenta accreta.
A woman in her 50s presented with left auricular pain and malaise after failed treatment with a series of antibiotics (ceftriaxone, dicloxacillin, cefpodoxime, sulfamethoxazoletrimethoprim, and ciprofloxacin) for presumed cellulitis. The pain began with a small lesion on her left auricle after minor blunt trauma. She had no fevers, chills, arthritis, or other lesions. On examination, her left auricle was red and swollen with sparing of the lobule-a classic presentation for perichondritis. There was no fluid collection or skin ulceration, and the bony ear canal was normal. Results from an exhaustive autoimmune workup (tests for white blood cell count, cardiolipin level, IgG level, IgM level, rheumatoid factor blood test, hepatitis B virus, hepatitis C virus, creatinine level, antineutrophil cytoplasmic antibodies test, antinuclear antibodies test, cryoglobulin test, liver function test, C-reactive protein, erythrocyte sedimentation rate) were unremarkable. Previous skin swab cultures had grown Enterobacter aerogenes (susceptible to ciprofloxacin), but pain and edema acutely worsened with new onset of drainage and crusting despite ciprofloxacin treatment (Figure , A). Given the refractory course, biopsy specimens were obtained (Figure , B). Diagnosis D. Cutaneous leishmaniasis of the auricle
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