胎盘植入患者的大量输血策略

胎盘植入的发生率随着剖宫产率的增加呈平行增长趋势。胎盘植入是造成严重产后出血的主要因素之一,据报道,胎盘植入尤其是胎盘位于子宫前壁瘢痕部位的患者平均出血量为3 000～5 000 ml,其中约有90%需要输血,有40%的患者输血超过10 U红细胞悬液。输血是严重产后出血中降低孕产妇死亡率的重要手段。本文主要对胎盘植入患者大量输血的评估、准备和成分输血治疗进行介绍,以指导临床合理输血治疗,改善胎盘植入患者的预后。     

55例胎盘植入患者预后相关因素的分析

目的:探讨影响胎盘植入患者预后的相关因素。方法:选择1998年1月至2008年1月在中山大学附属第一医院分娩,经过产后病理证实的胎盘植入患者55例,用回顾性病例统计分析方法研究患者的既往流产次数、产前、产后出血量、产前超声是否诊断胎盘植入以及胎盘植入合并前置胎盘类型之间的关系,分析这些因素与胎盘植入的严重并发症,即围产期全子宫切除之间的关系。结果:患者植入性前置胎盘的类型、产前、产后出血量及围产期全子宫切除术均与既往流产次数无关(P>0.05)。胎盘植入患者产前彩色多普勒超声诊断阳性率与胎盘前壁附着有关(P<0.05),与产前、产后出血量、胎盘植入面积无关(P>0.05)。患者行围产期全子宫切除术与产前出血量、胎盘植入面积相关(P=0.000),且与合并中央型前置胎盘相关(P<0.05)。结论:胎盘植入患者合并前壁前置胎盘时超声诊断相对容易。胎盘植入面积和产前出血量对预测胎盘植入患者预后有重要的指导意义。有产前出血的植入性中央型前置胎盘患者的预后可能较差,应做好围产期全子宫切除术的准备。     

胎盘植入患者胎盘原位保留治疗

胎盘原位保留是治疗胎盘植入的一种保守性疗法,随着辅助治疗技术的进步,使胎盘原位保留治疗的疗效逐渐获得肯定。本文就胎盘原位保留的治疗方法和辅助疗法及其适应证、禁忌证、并发症以及疗效的评估进行讨论。     

胎盘植入的风险评估与诊治策略

底蜕膜受损或缺失时绒毛膜绒毛直接接触或侵入子宫肌层形成胎盘植入。这种胎盘异常附着的状态根据侵入的深度分为粘连型、植入型和穿透型,可导致不良围生结局,如大量产后出血、输血和凝血障碍,严重时需子宫切除甚至危及生命。胎盘植入的诊断与风险评估主要依靠超声,磁共振检查是重要的补充检查方法。建立胎盘植入风险分级评估标准,有利于个体化围生期治疗方案的制定。对于植入型及穿透型胎盘植入患者,需要依靠多学科支持。术中选择合适入路、压迫子宫、阻断血管和胎盘原位保留等方式减少出血可有效避免子宫切除,保留生育功能。但为了保证母亲安全,条件不允许时则应果断切除子宫。     

胎盘植入患者血管栓塞治疗

胎盘植入是严重威胁母胎健康的疾病,其治疗手段尚未统一,目前血管栓塞治疗为治疗手段之一。胎盘植入患者预防与治疗产后出血的血管栓塞方法包括：术前预防性血管球囊闭塞术、术中及术后血管栓塞术。血管栓塞的优势为减少手术失血量与输血量,术后并发症及住院时间等。但同时也存在发生一定并发症的风险,包括盆腔内感染、器官缺血、发热、白细胞升高、组织神经疼痛、血管栓塞等。血管栓塞的应用还有待临床大样本的研究进一步评价。     

胎盘植入的高强度聚焦超声治疗

胎盘植入是产科严重并发症之一,可引起产后出血、产褥感染、凝血功能障碍,甚至危及母婴生命,其临床处理颇为棘手,而现有的治疗手段均存在不同程度的局限性与弊端。高强度聚焦超声是一种非侵入性治疗技术,已广泛应用于临床多个领域,将其引入胎盘植入的产后治疗,开启了胎盘植入保守治疗的新篇章。     

胎盘植入性疾病孕妇Triple-P手术后的再次妊娠结局分析

目的探讨Triple-P手术治疗严重胎盘植入性疾病(PAS)孕妇的安全性以及对再次妊娠的影响。方法回顾性分析2015年1月至2017年12月, 于广州医科大学附属第三医院以及郑州大学第一附属医院诊断为PAS且行Triple-P手术治疗孕妇11例的再次妊娠情况。结果截至2021年12月, 共11例孕妇因PAS行Triple-P手术治疗后再次妊娠, 再次妊娠与Triple-P手术的中位时间间隔为3年(2～3年)。11例孕妇中, 7例于孕36周及以后分娩, 终止妊娠的中位孕周为38周, 4例于孕12周内终止妊娠。7例近足月分娩孕妇中, 1例(1/7)再次发生PAS, 且合并前置胎盘。此7例孕妇的分娩方式均为剖宫产术, 中位产后出血量为300 ml(200～450 ml), 仅1例孕妇需要输血。11例孕妇均未转入重症监护病房, 无子宫破裂、膀胱损伤、产褥期感染, 无新生儿不良结局。结论严重PAS孕妇行Triple-P手术治疗后, 由经验丰富的多学科团队严格管理, 可以考虑再次妊娠, 再次妊娠的结局较好。     

产后胎盘植入保守治疗成功1例

患者，女，27岁，孕足月于2004年8月21日在家中分娩一女婴，产时、产后出血不多，产后约1h胎盘未娩出即来我院，严密消毒下行阴道检查胎盘未剥离，行人工剥离胎盘未成功，又行清宫钳夹，术中胎盘粘连紧，考虑患者阴道出血量不多，即给予缩宫素、甲氨蝶呤、己烯雌酚等药物保守治疗。产后8天家属强烈要求出院。     

子宫动脉化疗栓塞术治疗胎盘植入合并产后出血的安全性和临床疗效

目的 探讨子宫动脉化疗栓塞术治疗胎盘植入合并产后出血患者的安全性和临床疗效.方法 选择2006年12月至2009年9月于中山大学附属第二医院妇产科住院的23例胎盘植入合并产后出血患者,其中阴道持续少量出血9例,急性大出血14例,出血时间平均为(8±6)d,出血量平均为(980±660)ml,所有患者均经彩色多普勒超声(彩超)检杏并诊断为胎盘植入.对23例患者先行髂内动脉造影,确认子宫动脉后再将导管超选择送入子宫动脉远端,经导管以甲氨蝶呤(用量根据植入胎盘的体积和患者体表面积确定,即25～50 mg/m~2体表面积)和明胶海绵颗粒行双侧子宫动脉化疗栓塞(UACE)术.UACE术后48 h内复查彩超,对胎盘与子宫分界模糊、存在异常血流(范围>1 cm×1 cm)的患者采用经腹彩超引导下,经阴道在胎盘植入部位子宫体多点注射甲氨蝶呤.上述介入治疗后随访3～26个月(平均12个月),期间观察患者阴道出血、胎盘组织排出、血人绒毛膜促性腺激素(hCG)水平、子宫恢复情况、月经周期变化、并发症或副反应等情况.结果 (1)疗效:23例患者共行UACE术24次,术后止血时间平均为(3.5±1.3)min.UACE术后复查彩超显示病变处血流信号减少,23例患者中,5例植入的胎盘组织于介入治疗后完全自行排出,16例胎盘组织未排出而行清宫术,清宫术中出血量平均为(40±28)ml,2例行子宫次全切除术.21例(21/23,91%)保留了子宫.(2)随访:随访时间平均12个月.所有患者血hCG于胎盘完全排出后1～13 d恢复正常,保留子宫的21例患者2～3个月恢复正常月经周期,3个月后复查彩超示子宫基本恢复正常大小.随访期间主要副反应是盆腔疼痛、发热等栓塞后综合征,无其他并发症.结论 UACE术及配合彩超引导下的局部注入甲氨蝶呤治疗胎盘植入合并产后出血具有安全、微创、止血迅速、可保留子宫等优点,有较高的临床应用价值.彩超检查有助于评价胎盘植入的UACE术前后的血流变化.     

胎盘植入性疾病的危险因素及妊娠结局分析

目的探讨胎盘植入性疾病的危险因素及妊娠结局。 方法回顾性分析2009年1月至2017年12月广州医科大学附属第三医院/广州重症孕产妇救治中心围产资料数据库中信息完整的单胎妊娠孕妇48 650例临床资料,将这些孕妇分为胎盘植入性疾病组和非胎盘植入性疾病组,分析胎盘植入性疾病的危险因素及其妊娠结局。 结果单因素分析显示,年龄≥35岁、高中教育水平及以下、孕次≥3次、经产妇、人工流产史、剖宫产史、体外受精－胚胎移植受孕、合并前置胎盘是胎盘植入性疾病的相关危险因素(P<0.05)。多因素logistic回归分析显示,胎盘植入性疾病的独立危险因素为剖宫产史(OR＝2.254,95%CI：1.917～2.650)、体外受精－胚胎移植受孕(OR＝1.591,95%CI：1.212～2.089)、合并前置胎盘(OR＝28.282,95%CI：24.338～32.866);与非胎盘植入性疾病产妇相比,患有胎盘植入性疾病产妇早产、剖宫产、产后出血、弥散性血管内凝血、产褥期感染、子宫切除、低出生体重儿、新生儿Apgar评分相对较低(1 min)、产妇入住重症监护病房的发生率明显升高(P<0.05)。 结论剖宫产史、辅助生殖受孕、合并前置胎盘是引起胎盘植入性疾病的独立危险因素,胎盘植入性疾病的妊娠结局不良。     

Outcomes of subsequent pregnancies after conservative treatment for placenta accreta

Objective

To estimate the association between conservative treatment for placenta accreta and subsequent pregnancy outcomes.

Methods

In a retrospective study, data were analyzed on women who received conservative treatment for placenta accreta (removal of the placenta with uterine preservation) at a tertiary hospital in Jerusalem, Israel, between 1990 and 2000. Data were collected on subsequent pregnancies and neonatal outcomes until 2010, and compared with those from a matched control group of women who did not have placenta accreta.

Results

A total of 134 women were included in both groups. Placenta accreta occurred in 62 (22.8%) of 272 subsequent deliveries in the study group for which data were available and 5 (1.9%) of 266 in the control group (relative risk [RR] 12.13; 95% confidence interval [CI] 4.95–29.69; P < 0.001). Early postpartum hemorrhage occurred in 23 (8.6%) of 268 deliveries in the study group and 7 (2.6%) of 268 in the control group (RR 3.29; 95% CI 1.43–7.53; P < 0.001). The odds ratio for recurrent placenta accreta in subsequent deliveries in the study group was 15.41 (95% CI 6.09–39.03; P < 0.001).

Conclusion

Although subsequent pregnancies after conservative treatment for placenta accreta were mostly successful, the risk of recurrent placenta accreta and postpartum hemorrhage is high in future deliveries.     

Sonographic detection of placenta accreta in the second and third trimesters of pregnancy

OBJECTIVE: The purpose of this study was to determine whether ultrasonography can detect placenta accreta reliably in at-risk patients. STUDY DESIGN: All patients with a previous cesarean delivery and an anterior placenta or placenta previa were evaluated prospectively at each visit for sonographic signs of placenta accreta (interruption of the posterior bladder wall-uterine interface, absence of the retroplacental clear zone, and placental lacunae). RESULTS: This evaluation involved 2002 patients over a 12-year period. Of the 14 patients with a confirmed diagnosis of placenta accreta who had ultrasound examinations between 15 and 20 weeks of gestation, the diagnosis was suspected strongly in 86% of the patients (12/14 patients). There were 18 false-positive cases (54.5%; 18/33 patients), most of which were due to a lack of visualization of the echolucent area between the placenta and the myometrium (obliteration of the 'clear space') during the third trimester. The presence of multiple linear irregular vascular spaces within the placenta (placental lacunae) was the diagnostic sign with the highest positive predictive value for placenta accreta. CONCLUSION: Placenta accreta can be detected as early as 15 to 20 weeks of gestation in most at-risk patients by visualization of irregular vascular spaces within the placenta (placental lacunae). Obliteration of the retroplacental 'clear space' is not a reliable diagnostic sign for placenta accreta.     

Alternative management of placenta accreta

A 27-year-old lady presented at 32 weeks gestation complaining of shortness of breath, headache, palpitations and feeling generally unwell for 1 day. Her current pregnancy was complicated by major placenta praevia. Because she developed worsening symptoms of pre-eclampsia and raised blood pressure, a decision was made to deliver her by an elective Caesarean section. The Caesarean section was complicated by a morbidly adherent placenta. There was no plane of cleavage between the placenta and the uterine wall. She had severe haemorrhages of 2.5 l following delivery, and to stem the bleeding, a B-lynch suture was placed and a Rusch tamponade balloon was inserted to achieve haemostasis. Although her condition improved and she did not have any further bleeding, she developed infection 3 weeks later and had a hysterectomy. We present this case to demonstrate that balloon tamponade and B-lynch suture are valuable developments in management of obstetric haemorrhage due to placenta accreta.     

Placenta accreta and percreta: a review of 5 cases

Five cases of placenta accreta and percreta are reviewed. Three cases, one a recurrence in the same patient, presented with acute abdominal pain; in one case perforation resulting from placenta percreta was discovered at laparotomy. In another case, placenta accreta was recognized during cesarean delivery. Total or subtotal hysterectomy was performed in three cases; piecemeal removal of placental tissue and closure of the tear was performed in two of the patients. There were no maternal deaths, but the infants were stillborn in three cases of perforation or uterine rupture.     

早期妊娠胎盘绒毛植入——附一例报道及文献复习

总结和探讨早期妊娠胎盘绒毛植入的发生。临床特点和处理方法。方法对１例早期妊娠胎盘绒毛植入,人工流产术中发生大出血者的资料进行回顾性分析并复习文献。结论剖宫产术是早期妊娠胎盘绒毛植入的高危因素。     

Management of placenta accreta: morbidity and outcome

OBJECTIVE: The aim of the study was to evaluate our results in the management of placenta accreta. STUDY DESIGN: In a retrospective study we reviewed cases of placenta accreta diagnosed in two university teaching hospitals between 1993 and 2003. For a subgroup of patients a conservative approach was attempted. In this procedure placenta was left in place until spontaneous resorption. RESULTS: Fifty cases (0.12%) of placenta accreta were observed in 41, 119 deliveries during the study period. Of the 50 cases, 24 patients (48%) were managed by the standard approach and 26 patients (52%) underwent conservative treatment. Additional surgical or medical treatment was performed in 35 of the 50 patients (70%). There was no maternal death. Overall hysterectomy rate was 40%, 10 patients were transferred to intensive care unit (20%), 7 had fever (14%), 5 had endometritis (10%) and 19 patients had blood transfusion (38%). Conservative treatment did not lead to hysterectomy in 21 cases (80.7%) and failed in 5 (19.3%). During the follow-up period, 3 women had successful pregnancy. CONCLUSION: Analysis of management of placenta accreta shows that for a subgroup of selected patients a conservative approach could preserve subsequent fertility without evident increase in morbidity.