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Most undergo cervical examinations weekly or every 2 weeks to assess effacement and dilatation symptoms glaucoma 50 mg cyclophosphamide buy visa. Unfortunately, rapid effacement and dilation can develop despite such precautions (Witter, 1984). When either technique is performed prophylactically, women with a classic history of cervical incompetence have excellent outcomes (Caspi, 1990; Kuhn, 1977). For either vaginal or abdominal cerclage, there is insufficient evidence to recommend perioperative antibiotic prophylaxis (American College of Obstetricians and Gynecologist, 2016b,i). Thomason and coworkers (1982) found that perioperative tocolytics failed to arrest most labor. Some operators do not use potentially irritating antiseptic solution on the exposed amnionic membranes and instead use warm saline (Pelosi, 1990). Although steps are described subsequently, a thorough and illustrated review of cerclage technique is provided by Hawkins (2017). Continuation of suture placement in the body of the cervix so as to encircle the os. The suture is tightened around the cervical canal sufficiently to reduce the diameter of the canal to 5 to 10 mm, and then the suture is tied. A second suture placed somewhat higher may be of value if the first is not in close proximity to the internal os. A transverse incision is made in the mucosa overlying the anterior cervix, and the bladder is pushed cephalad. A 5-mm Mersilene tape on a swaged-on or Mayo needle is passed anterior to posterior. This diminishes the distance that the needle must travel submucosally and aids tape placement. The tape is snugly tied anteriorly, after ensuring that all slack has been taken up. During placement, the suture is placed as high as possible and into the dense cervical stroma. Rescue cerclage with a thinned dilated cervix is more difficult and risks tissue tearing and membrane puncture. Replacement of the prolapsed amnionic sac back into the uterus will usually aid suturing (Locatelli, 1999). Options include steep Trendelenburg or filling the bladder with 600 mL of saline through an indwelling Foley catheter. However, these steps may carry the cervix cephalad and away from the operating field.

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Major trauma- especially abdominal-can cause fetal loss treatment bronchitis 50 mg cyclophosphamide purchase with visa, but is more likely as pregnancy advances (Chap. Nutrition Sole deficiency of one nutrient or moderate deficiency of all does not appear to increase risks for abortion. Dietary quality may play a role, as miscarriage risk may be reduced in women who consume a diet rich in fruits, vegetables, whole grains, vegetable oils, and fish (Gaskins, 2015). With regard to maternal weight, underweight is not associated with a greater miscarriage risk (Balsells, 2016). Social and Behavioral Factors Lifestyle choices reputed to be associated with a higher miscarriage risk are most often related to chronic and especially heavy use of legal substances. The most commonly used is alcohol, with its potent teratogenic effects discussed in Chapter 12 (p. That said, an increased miscarriage risk is only seen with regular or heavy use (Avalos, 2014; Feodor Nilsson, 2014). Approximately 10 percent of pregnant women admit to cigarette smoking (Centers for Disease Control and Prevention, 2016). It seems intuitive that cigarettes could cause early pregnancy loss (Pineles, 2014). Excessive caffeine consumption-not well defined-has been associated with a higher abortion risk. Reports link heavy intake of approximately five cups of coffee per day-about 500 mg of caffeine-with a slightly greater abortion risk (Cnattingius, 2000; Klebanoff, 1999). Studies of "moderate" intake-less than 200 mg daily-did not indicate increased risk (Savitz, 2008; Weng, 2008). In contrast, in one prospective cohort of more than 5100 gravidas, caffeine was linked to miscarriage but not in a dose-response relationship (Hahn, 2015). Currently, the American College of Obstetricians and Gynecologists (2016e) has concluded that moderate consumption likely is not a major abortion risk and that any associated risk with higher intake is unsettled. Also, a higher miscarriage risk was found for dental assistants exposed to more than 3 hours of nitrous oxide daily if there was no gas-scavenging equipment (Boivin, 1997). Paternal Factors Increasing paternal age is significantly associated with an greater risk for abortion (de La Rochebrochard, 2003). In the Jerusalem Perinatal Study, this risk was lowest before age 25 years, after which it progressively increased at 5-year intervals (Kleinhaus, 2006). The etiology of this association is not well studied, but chromosomal abnormalities in spermatozoa likely play a role (Sartorius, 2010). Spontaneous Abortion Clinical Classification Threatened Abortion this diagnosis is presumed when bloody vaginal discharge or bleeding appears through a closed cervical os during the first 20 weeks.

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Timing of Scheduled Cesarean Delivery Adverse neonatal sequelae from neonatal immaturity with elective delivery before 39 completed weeks are appreciable (Clark 97140 treatment code purchase cyclophosphamide on line amex, 2009; Tita, 2009). To avoid these, assurance of fetal maturity before scheduled elective surgery is essential as outlined by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) and discussed in Chapter 31 (p. To assist with this and other components of cesarean delivery planning, the American College of Obstetricians and Gynecologists (2011, 2014b) has created Patient Safety Checklists to be completed before the planned surgery. Preoperative Care If cesarean delivery is scheduled, a sedative may be given at bedtime the night before surgery. In general, no other sedatives, narcotics, or tranquilizers are administered until after the fetus is born. In one small randomized trial, no benefits were gained from a presurgical enema (Lurie, 2012). Uncomplicated patients may have moderate amounts of clear liquids up to 2 hours before surgery (American Society of Anesthesiologists, 2016). The woman scheduled for repeat cesarean delivery typically is admitted the day of surgery and evaluated by the obstetrical and anesthesia teams. An antacid is given shortly before regional analgesia or induction of general anesthesia. Once the woman is supine, a wedge beneath the right hip and lower back creates a left lateral tilt to aid venous return and avoid hypotension. Data are insufficient to determine the value of fetal monitoring before scheduled cesarean delivery in women without risk factors. At minimum, fetal heart sounds should be documented in the operating room prior to surgery. An electrosurgical grounding pad is placed near the surgical incision and typically on the lateral thigh. An indwelling bladder catheter is typically placed at Parkland Hospital to collapse the bladder away from the hysterotomy incision, to avert urinary retention secondary to regional analgesia, and to allow accurate postoperative urine measurement. Small studies show that catheterization may be withheld in hemodynamically stable women to minimize urinary infections (Abdel-Aleem, 2014; Li, 2011; Nasr, 2009). The risk of venous thromboembolism is increased with pregnancy and almost doubled in those undergoing cesarean delivery (James, 2006). Accordingly, for all women not already receiving thromboprophylaxis, the American College of Obstetricians and Gynecologists (2017d) recommends initiation of pneumatic compression hose before cesarean delivery. Recommendations between organizations vary, and the American College of Chest Physicians suggests only early ambulation for women without risk factors who are undergoing cesarean delivery (Bates, 2012). For women already receiving prophylaxis or those with increased risk factors, they support escalation of prophylaxis. Last, the Royal College of Obstetricians and Gynaecologists (2015) are the most conservative and suggest pharmacological prophylaxis for the largest proportion of patients. These various methods and recommendations are discussed in Chapter 52 and are shown in Table 52-6 (p.

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Am J Obstet Gynecol 45:796 symptoms 3dp5dt 50 mg cyclophosphamide order otc, 1943 World Health Organization: Eliminating female genital mutilation. Lancet 367:1835, 2006 World Health Organization: Guideline: delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. Geneva, World Health Organization, 2012 Wuest S, Raio L, Wyssmueller D, et al: Effects of female genital mutilation on birth outcomes in Switzerland. Am J Dis Child 127:128, 1974 Zahalka N, Sadan O, Malinger G, et al: Comparison of transvaginal sonography with digital examination and transabdominal sonography for the determination of fetal head position in the second stage of labor. It is true that in a certain number of cases extraction through an imperfectly dilated cervix is possible, but this is usually effected only at the cost of deep cervical tears. Whitridge Williams (1903) Near term, the fetus typically has spontaneously assumed a cephalic presentation. Conversely, if the fetal buttocks or legs enter the pelvis before the head, the presentation is breech. This fetal lie is more common remote from term, as earlier in pregnancy each fetal pole has similar bulk. At term, breech presentation persists in approximately 3 to 5 percent of singleton deliveries (Cammu, 2014; Lyons, 2015; Macharey, 2017). With a frank breech, lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head. With a complete breech, both hips are flexed, and one or both knees are also flexed. As a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal. Of term breech fetuses, the neck may be extremely hyperextended in perhaps 5 percent, and the term stargazing fetus is used (Cimmino, 1975). With these, fetal or uterine anomalies may be more prevalent and are sought if not previously identified (Phelan, 1983). With this hyperextension, vaginal delivery can result in injury to the cervical spinal cord. Thus, if identified at term, this is an indication for cesarean delivery (Westgren, 1981). That said, flexion itself may be implicated, as cases of spinal cord injury have been reported following uneventful cesarean delivery of such fetuses (Hernandez-Marti, 1984). With transverse lie and similar hyperextension of the fetal neck, the term flying fetus is applied. Other than early gestational age, risk factors include extremes of amnionic fluid volume, multifetal gestation, hydrocephaly, anencephaly, structural uterine abnormalities, placenta previa, pelvic tumors, and prior breech delivery. One study found that following one breech delivery, the recurrence rate for a second breech presentation was 10 percent, and for a subsequent third breech it was 28 percent (Ford, 2010). Examination Leopold maneuvers to ascertain fetal presentation are discussed in Chapter 22 (p.

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Int Urogynecol J Pelvic Floor Dysfunct 20(11):1361 treatment sciatica order 50 mg cyclophosphamide fast delivery, 2009 Duggal N, Mercado C, Daniels K, et al: Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol 111(6):1268, 2008 Dupuis O, Ruimark S, Corinne D, et al: Fetal head position during the second stage of labor: comparison of digital vaginal examination and transabdominal ultrasonographic examination. J Obstet Gynaecol Res 40: 1877, 2014 Elfaghi I, Johansson-Ernste B, Rydhstroem H: Rupture of the sphincter ani: the recurrence rate in second delivery. J Obstet Gynaecol Res 38(5):787, 2012 Endler M, Saltvedt S, Cnattingius S, et al: Retained placenta is associated with pre-eclampsia, stillbirth, giving birth to a small-for-gestational-age infant, and spontaneous preterm birth: a national register-based study. Obstet Gynecol 127(5):951, 2016 Gardberg M, Stenwall O, Laakkonen E: Recurrent persistent occipito-posterior position in subsequent deliveries. Obstet Gynecol 95:43, 2000 Ghi T, Youssef A, Martelli F, et al: Narrow subpubic arch angle is associated with higher risk of persistent occiput posterior position at delivery. Am J Obstet Gynecol 168:489, 1993 Goldberg H, Stupp P, Okoroh E, et al: Female genital mutilation/cutting in the United States: updated estimates of women and girls at risk, 2012. Obstet Gynecol 89:913, 1997 Gonik B, Allen R, Sorab J: Objective evaluation of the shoulder dystocia phenomenon: effect of maternal pelvic orientation on force reduction. Am J Obstet Gynecol 177:463, 1997 Grant A, Gordon B, Mackrodat C, et al: the Ipswich childbirth study: one year follow up of alternative methods used in perineal repair. Int Urogynecol J Pelvic Floor Dysfunct 19(3):441, 2008 Groutz A, Hasson J, Wengier A, et al: Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium. Lancet 379(9827):1721, 2012 Gungor S, Kurt E, Teksoz E, et al: Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section: a prospective randomized controlled trial. Hagerstown, Lippincott, 1990 Hoffman M: A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol 119(part 1): 386, 2011 Hoopmann M, Abele H, Wagner N, et al: Performance of 36 different weight estimation formulae in fetuses with macrosomia. Int J Gynaecol Obstet 127(2):152, 2014a Karbanova J, Rusavy Z, Betincova L, et al: Clinical evaluation of peripartum outcomes of mediolateral versus lateral episiotomy.

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If relaxation is detected treatment centers for drug addiction order cyclophosphamide australia, the uterus should be massaged through the abdominal wall until it remains contracted. This may be detected early by uterine enlargement during fundal palpation in the first postdelivery hours. Because the likelihood of significant hemorrhage is greatest immediately postpartum, even in normal births, the uterus is closely monitored for at least 1 hour after delivery. If regional analgesia or general anesthesia was used for labor or delivery, the mother should be observed in an appropriately equipped and staffed recovery area. An attendant should be present for at least the first time, in case the woman becomes syncopal. The many confirmed advantages of early ambulation include fewer bladder complications, less frequent constipation, and reduced rates of puerperal venous thromboembolism. As discussed on page 655, deep-vein thrombosis and pulmonary embolism are common in the puerperium. In an audit of puerperal women at Parkland Hospital, the frequency of venous thromboembolism was found to be 0. Risk factors and other measures to diminish the frequency of thromboembolism are discussed in Chapter 52 (p. With breastfeeding, the level of calories and protein consumed during pregnancy are increased slightly as recommended by the Food and Nutrition Board of the National Research Council (Chap. If the mother does not breastfeed, dietary requirements are the same as for a nonpregnant woman. We recommend oral iron supplementation for at least 3 months after delivery and hematocrit evaluation at the first postpartum visit. As noted earlier, profound drops in estrogen levels follow removal of the placenta. Reminiscent of the menopause, postpartum women may experience hot flushes, especially at night. Importantly, severe headaches should be differentiated from spinal headache or hypertensive complications. Alternatively, Midrin combines isometheptene mucate, which is a sympathomimetic agent; dichloralphenazone, which is a mild sedative; and acetaminophen and is compatible with breastfeeding. Instead of Midrin, a triptan, such as sumatriptan (Imitrex), can effectively relieve headaches by causing intracranial vasoconstriction. Perineal Care the woman is instructed to clean the vulva from anterior to posterior-the vulva toward the anus. A cool pack applied to the perineum may help reduce edema and discomfort during the first 24 hours if there is a perineal laceration or an episiotomy. Most women also appear to obtain a measure of relief from the periodic application of a local anesthetic spray.

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This practice is associated with an increased cesarean delivery rate compared with intermittent fetal heart rate auscultation medications starting with p purchase 50 mg cyclophosphamide visa. In many more cases, concern for an abnormal or "nonreassuring" fetal heart rate tracing prompts cesarean delivery. Rates of labor induction continue to rise, and induced labor, especially among nulliparas, raises the cesarean delivery rate. Rates of cesarean delivery in women with preeclampsia have increased, whereas labor induction rates for these patients have declined. Elective cesarean deliveries are increasingly being performed for various indications that include maternal request, concern for pelvic floor injury associated with vaginal birth, and reduction of fetal injury rates. Assisted reproductive technology is more widely used than in the past and is associated with greater cesarean delivery rates (Reddy, 2007). Malpractice litigation related to fetal injury during spontaneous or operative vaginal delivery continues to contribute to the present cesarean delivery rate. In broad terms, cesarean delivery has higher maternal surgical risks for the current and subsequent pregnancies compared with spontaneous vaginal birth. This is balanced against lower rates of perineal injury and short-term pelvic floor disorders. For the neonate, cesarean delivery offers lower rates of birth trauma and stillbirth but greater rates of initial respiratory difficulties. Maternal Mortality and Morbidity For the mother, death attributable solely to cesarean delivery is rare in the United States. In a metaanalysis of 203 studies, Guise and coworkers (2010) reported a maternal mortality rate of 13 per 100,000 with elective repeat cesarean delivery compared with 4 per 100,000 women undergoing a trial of labor after prior cesarean. Similar to mortality rates, the frequencies of some maternal complications are increased with all cesarean compared with vaginal deliveries. Villar and associates (2007) reported that maternal morbidity rates increased twofold with cesarean compared with vaginal delivery. In addition, anesthetic complications, which also rarely include death, have a greater incidence with cesarean compared with vaginal delivery (Cheesman, 2009; Hawkins, 2011). Adjacent organs infrequently may be injured, which is described in detail on page 583. Women who undergo a cesarean delivery are much more likely to be delivered by a repeat operation in subsequent pregnancies. For women undergoing subsequent cesarean, the maternal risks just described are even greater (Cahill, 2006; Marshall, 2011; Silver, 2006). As an advantage, cesarean delivery is associated with lower rates of urinary incontinence and pelvic organ prolapse than is vaginal birth (Glazener, 2013; Gyhagen, 2013a,b; Handa, 2011; Leijonhufvud, 2011). Rates of anal incontinence appear uninfluenced by delivery route (Fritel, 2007; Nelson, 2010). Protective advantages persist to some degree over time, but cesarean delivery is not totally protective. Moreover, longitudinal studies suggest that initial pelvic floor advantages gained from cesarean delivery are lost as women age (Dolan, 2010; MacArthur, 2011, 2013; Nelson, 2010).

Pavel, 45 years: Thus, the Task Force (2013) recommends more frequent prenatal visits if preeclampsia is "suspected. Am J Obstet Gynecol 188:553, 2003 Bunch K, Hope E: An uncommon case of bilateral peroneal nerve palsy following delivery: a case report and review of the literature. This characteristic posture results from the mode of fetal growth and its accommodation to the uterine cavity.

Potros, 21 years: Once headache develops, it is managed aggressively, as expectant management increases hospital-stay lengths and subsequent emergency-room visits (Angle, 2005). Treatment includes antimicrobials and surgical drainage and debridement of devitalized tissue. The patch may be applied to buttocks, upper outer arm, lower abdomen, or upper torso, but the breasts are avoided.

Orknarok, 26 years: Larger tubal ectopic pregnancies may be placed in an endoscopic sac to prevent fragmentation as they are removed through the laparoscopic port site. Br J Anaesth 115(6):815, 2015 Nandagopal M: Local anesthesia for cesarean section. The authors suggested that these levels of uterine activity should be sought before consideration of cesarean delivery for presumed dystocia (Chap.

Cole, 42 years: In contrast, other studies support vaginal delivery as a suitable option at term (Hofmeyr, 2015a). Perinatal mortality rates are disproportionately high in these growth-restricted neonates, but maternal outcomes are not appreciably different (Haddad, 2007; Shear, 2005). At Parkland Hospital, approximately 35 percent of labors are induced or augmented.

Leon, 52 years: N Engl J Med 359:262, 2008 Moya F, Sinha S, Gadzinowski J, et al: One year follow-up of very preterm infants who received lucinactant for prevention of respiratory distress syndrome: results from 2 multicenter randomized controlled trials. In a woman of higher parity with a previously dilated vagina and perineum, two or three expulsive efforts after full cervical dilation may suffice to complete delivery. Am J Perinatol 14(9):555, 1997 Le Ray C, Carayol M, Jaquemin S, et al: Is epidural analgesia a risk factor for occiput posterior or transverse positions during labour Obstet Gynecol 110(4):873, 2007 Lerner H, Durlacher K, Smith S, et al: Relationship between head-to-body delivery interval in shoulder dystocia and neonatal depression.

Georg, 22 years: Balloon-tipped intraarterial catheters to mitigate blood loss and thereby enhance surgical visibility have also gained supporters. According to the American College of Obstetricians and Gynecologists (2016), a normal antepartum fetal test result is highly reassuring that a stillbirth will not occur within 1 week. Blindness from retinal lesions is caused either by serous retinal detachment or rarely by retinal infarction, which is termed Purtscher retinopathy.

Jorn, 56 years: These included clinical findings, cytokine levels, histological findings, and microbial culture results. For those seeking contraception, effective contraceptive methods are available and variably selected (Table 38-1). Compared with preprocedural levels, Barnhart and coworkers (2004b) found declines of 88 percent at day 3 and 82 percent at day 8 following misoprostol administration correlated with a 95-percent rate of successful abortion completion.

Denpok, 30 years: During the 3-year investigation, more than 17,000 labors were managed using universal electronic monitoring, and these outcomes were compared with a similar-sized cohort of women selectively monitored electronically. Small bleeding sites are controlled with needlepoint electrocoagulation, and the incision is left unsutured to heal by secondary intention. Any hematoma can also develop following stretch and rupture of a blood vessel without an associated laceration (Nelson, 2012).

Bram, 59 years: Management Treatment of the woman with a placental abruption varies depending on her clinical condition, gestational age, and the amount of associated hemorrhage. Lancet 375(9713):490, 2010 Lydon-Rochelle M, Albers L, Gorwoda J, et al: Accuracy of Leopold maneuvers in screening for malpresentation: a prospective study. In a later Finnish study, Kankuri and associates (2003) identified bacteremia in only 5 percent of almost 800 women with puerperal sepsis.

Kippler, 43 years: As with convulsions, however, the fetus is likely to recover more quickly in utero once maternal cardiac output is reestablished. Of these, compression of nerve ganglia in the cervix and lower uterine segment by the contracting myometrium is an especially attractive hypothesis. Using this definition, 25,260 live births-3 percent-were complicated by precipitous labor in the United States in 2013 (Martin, 2015).

Kamak, 47 years: There are no data regarding safety and efficacy of contraction patterns in women with a prior cesarean delivery, with twins, or with an overdistended uterus. Last, Goldberg and associates (2015) compared hygroscopic dilation with or without added mifepristone. A metaanalysis of seven randomized trials by Lee (2002a) suggests that the safety profiles of ephedrine and phenylephrine are comparable.

Anog, 51 years: Similar values have been reported for preterm neonates (Dickinson, 1992; Ramin, 1989; Riley, 1993). Pressure is applied with the heel of the hand to the anterior shoulder wedged above and behind the symphysis. For these reasons, paracervical block is not used in situations of potential fetal compromise.

Shawn, 41 years: However, severity is difficult to quantify, and thus deciding which individual woman might benefit most from neuroprophylaxis is difficult. Moderate upward pressure is applied to the fetal chin by the posterior hand covered by a sterile towel. For prophylaxis soon after delivery, recommendations include a single application of either 1-percent silver nitrate solution or 0.

Ressel, 64 years: To augment the last parameter, Burgos and coworkers (2014) administered a preprocedural 2-L intravenous fluid bolus. In 1067 women with uncomplicated term pregnancies delivered at Parkland Hospital, these investigators reported that ambulation did not affect labor duration. As the result of infiltration with serum the former may attain immense proportions and the latter may be increased to three or four times its normal size.

Dolok, 31 years: Am J Obstet Gynecol 182:675, 2000 Zalud I, Janas S: Risks of third trimester amniocentesis. Presumably, in most cases, amnionic fluid is ample to dilute the meconium to permit prompt clearance by normal fetal physiological mechanisms. Laminaria inserted too far through the internal os; the laminaria may rupture the membranes.

Ningal, 40 years: Gradual vacuum creation is advocated by some and is generated by increasing the suction in increments of 0. These findings corresponded with reports during the 1960s that described elevated serum hepatic transaminase levels. This contrasts with a review of 205 cases, in which posterior shoulder delivery yielded greater neonatal injury rates than rotational methods (Leung, 2011b).

Marus, 65 years: Am J Obstet Gynecol 214(5):572, 2016 Sagiv R, Mizrachi Y, Glickman H, et al: Laminaria vs. These triploid zygotes result in some embryonic development, however, it ultimately is a lethal fetal condition (Joergensen, 2014; Lakovschek, 2011). Major Types of Neonatal Intracranial Hemorrhage According to the American College of Obstetricians and Gynecologists (2015), the incidence of intracranial hemorrhage from birth trauma has been substantively lowered by elimination of difficult instrumented vaginal deliveries.

Tukash, 50 years: On vaginal examination, in the early stages of labor, if the side of the thorax can be reached, it may be recognized by the "gridiron" feel of the ribs. Then, over the next half hour or so, as platelet-induced clot retraction develops, the clot becomes quite small. Transfus Med Rev 30(3):116, 2016 Fox K, Shamshirsaz A, Salmanian B, et al: Is interpregnancy interval a predictor of severity of invasion in morbidly adherent placenta Am J Obstet Gynecol 180:1432, 1999 Friederich L, Roman H, Marpeau L: A dangerous development.