前置胎盘伴胎盘植入行子宫切除27例临床分析

目的 总结前置胎盘伴胎盘植入的危险因素、诊断和治疗经验,为胎盘植入的早期诊断及规范治疗提供指导.方法 回顾性分析2010年1月至2012年12月广州医学院第三附属医院前置胎盘伴胎盘植入并行子宫切除的27例患者临床特点及母婴结局（本研究遵循的程序符合广州医学院第三附属医院人体试验委员会制定的伦理学标准,得到该委员会批准,征得受试对象知情同意,并与之签署临床研究知情同意书）.结果 研究结果提示：27例中,81.5%（22/27）有人工终止妊娠术史及刮宫史,有1次剖宫产史者为85.2%（23/27）,≥2次剖宫产者为14.8%（4/27）;中央性前置胎盘为92.6%（25/27）,部分性和边缘性前置胎盘各为3.7%（1/27）;11.1%（3/27）在本院产前检查,88.9%（24/27）由外院转诊至本院.本组患者的诊断方式100.0%（27/27）行彩色多普勒超声检查,88.9%（24/27）行MRI检查,前置胎盘并胎盘植入彩色多普勒超声诊断的灵敏度为48.1%（13/27）,MRI诊断的灵敏度为87.5%（21/24）.本组患者剖宫产终止妊娠的平均孕周为（35.53±2.55）孕周.胎盘植入直径≥8 cm 为77.8%（21/27）,穿透性植入为48.1%（13/27）.手术出血量为800～9 300 mL,其中,择期手术17例,术中平均出血量为（1 796.7±560.89）mL;急诊手术10例,术中平均出血量为（2 538.9±600.90）mL,择期手术患者比急诊手术患者的术中出血量明显减少,差异有统计学意义（P〈0.05）.输RBC（8.07±5.24）U、血浆（622.22±569.3）mL.本组患者40.0%（4/10）急诊手术术后入ICU监护,100.0%（27/27）痊愈出院.结论 剖宫产术史、人工终止妊娠术史及刮宫史是前置胎盘伴胎盘植入的高危因素;胎盘植入直径≥8 cm或穿透性植入,或伴失血性休克,应果断及时切除子宫挽救患者生命;规范术前准备,可减少严重产后出血发生.

Investigate the Clinical Characteristics of Applying Hysterectomy in 27 Cases with Placenta Previa and Accrete

Objective To summarize the high risk factors,diagnosis and treatment experience of placenta previa with accrete and provide guides of early diagnosis and standard treatment. Methods A total of 27 cases that were diagnosed as placenta praevia with accrete and underwent the hysterectomy from January 2010 to December 2012 in the Third Affiliated Hospital of Guangzhou Medical College were retrospectively analyzed about clinical characters of the patients and outcomes of maternal and fetal.The study protocol was approved by the Ethical Review Board of Investigation in Human Beings of the Third Affiliated Hospital of Guangzhou Medical College.Informed consent was obtained from each participating patient. Results There were 81.5%（22/27） cases with history of abortion or curettage,85.2%（23/27）had cesarean section once,14.8%（4/27） had cesarean section more than once; The rate of central placenta previa was 92.6% （25/27）,and the rate of partial placenta previa and marginal placenta previa was 3.7%（1/27）,respectively.11.1%（3/27）took prenatal care in our hospital and 88.9%（24/27）transferred from other hospitals.100.0%（27/27）took color Doppler ultrasonography,88.9%（24/27）took MRI,the sensitivity of color Doppler ultrasonography for placenta previa with accrete was 48.1%（13/27）and the sensitivity of MRI was 87.5%（21/24）.The average termination of pregnancy weeks were 35.53±2.55 weeks. The placenta accreta diameter more than 8 cm were 77.8%（21/27）,the penetrative placenta accreta were 48.1%（13/27）; Intraoperative blood loss were 800-9 300 mL.The average blood loss was （1 796.7±560.89）mL in the 17 cases of selective operation, and （2 538.9±600.90）mL in the 10 cases of emergency operation,the blood loss was decreased significantly in selective operation（P〈0.05）.It was transfused RBC（8.07±5.24）units and fresh frozen plasma （622.22±569.3）mL averagely. The incidence of maternal ICU admission in emergency operation were 40.0%（4/10）.All patients recovered without organ dysfunction. Conclusions History of abortion and cesarean section were high risk factors of placenta previa with accrete. In the case of placenta previa with accrete which area covering 8 cm diameter or more,penetrative placenta accrete or active bleeding accompany hemorrhagic shock,hysterectomy should be applied promptly.If we standardize the preoperative preparation,the incidence of postpartum hemorrhage could be decreased.