[摘要] 目的 分析前置胎?P伴胎盘植入的危险因素,并探讨宫颈子宫下段环形缝合术对前置胎盘伴胎盘植入的母婴结局影响。 方法 对2013年8月~2017年2月我院收治的364 例前置胎盘患者进行回顾性分析,其中前置胎盘伴胎盘植入者75 例(观察组),仅单纯为前置胎盘者 289例(对照组),分析前置胎盘伴胎盘植入的危险因素。75 例前置胎盘伴胎盘植入患者中25例术中行宫颈子宫下段环形缝合术(环形组),50例行传统手术(传统组),比较两组患者母婴结局。 结果 孕次、流产史、剖宫产史、前置胎盘类型是前置胎盘伴胎盘植入发生的单危险因素(P0.05)。两组新生儿出生1 min、5 min Apgar评分比较,差异有统计学意义(P0.05)。 结论 孕次、流产史、剖宫产史、前置胎盘类型是前置胎盘伴胎盘植入的独立危险因素。宫颈子宫下段环形缝合术可有效减少前置胎盘伴胎盘植入对母婴的危害。
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[关键词] 前置胎盘;胎盘植入;危险因素;宫颈子宫下段环形缝合术
[中图分类号] R719.8 [文献标识码] B [文章编号] 1673-9701(2018)06-0056-04
[Abstract] Objective To analyze the risk factors of placenta accreta combined with placenta previa and to investigate the effect of cervical suture of lower uterine segment on maternal and infant outcomes. Methods A retrospective analysis was performed on 364 cases of placenta previa admitted from Anhui Medical University Affiliated Anqing Municipal Hospital between August 2013 and February 2017. Among them, 75 cases combined with placenta accrete were chosen as observation group, 289 cases only with placenta previa were chosen as control group, analyzed risk factors of placenta previa combined with placenta accreta. Among the total 75 cases of placenta previa combined with placenta accrete,25 cases were treated with annular suturing of the lower uterine segment of the cervix(annular group) and 50 cases were treated with conventional operation(traditional group). Maternal and infant outcomes were compared between the two groups. Results The times of gravidity, abortion history, cesarean section record and type of placenta previa were the single risk factors of placenta previa combined with placenta accreta(P0.05). Apgar scores at 1 minute and 5 minutes after birth were statistically significant in both groups(P0.05). Conclusion Pregnancy times, abortion record, cesarean section record and placenta previa types are independent risk factors for placenta previa combined with placenta accreta. Lower cervical uterine annular suture can effectively reduce damage of placenta previa combined with placenta accreta to mother and child. 目前众多研究者发现前置胎盘伴植入的发生与产次、流产史、剖宫产史、前置胎盘类型相关[6-10],也有部分学者研究发现年龄≥35岁、辅助生殖技术[11-14]及妊娠期高血压等[9]也为其高危因素。考虑其原因为多次孕产史、剖宫产使子宫内膜完整性受到损害,尤其是剖宫产,使再次妊娠时子宫下段蜕膜形成不良,胎盘为了增加自身血供一方面增大自身面积,另一方面增加胎盘血管长入子宫肌层深度,从而形成前置胎盘及胎盘植入。完全性前置胎盘者胎盘完全覆盖宫颈内口,胎盘位置低,而子宫下段肌层菲薄,血供差,增加了前置胎盘及胎盘植入的发生。本研究前置胎盘患者中甚至发现胎盘主体位于宫颈管内,低至宫颈外口者,术中剥离胎盘时出血汹涌,明显增加了手术难度。本研究结果显示孕次、流产史、剖宫产史、前置胎盘类型是前置胎盘伴胎盘植入的独立危险因素。
剖宫产是前置胎盘伴胎盘植入终止妊娠的主要方式,术中如何迅速娩出胎儿、有效控制植入面出血是处理的重点问题。除按摩子宫、药物促宫缩(缩宫素、麦角碱、前列腺素、钙剂等)等基础治疗外,切口位置、止血方式的选择等是取得良好结局的重点。2015年胎盘植入诊治指南中总结了预防产时及产后出血的主要措施包括血管阻断术、子宫压迫缝合术和宫腔填塞等[15]。目前国内外研究报道较多的止血方法如子宫动脉介入栓塞治疗、球囊封堵、宫颈提拉式缝合、B-lynch缝合、Bakri球囊及各种创新缝合术式等[16-19]。球囊封堵、介入治疗对操作者技术水平要求高且费用相对昂贵,有异位栓塞引起相应并发症风险。前置胎盘出血部位主要为子宫下段及宫颈内口处,如何单纯有效对出血部位进行止血值得深思。国内学者杨慧霞[20]提出止血带捆绑下子宫下段环形蝶式缝扎术,肖先绪等[21]采用改良B-lynch缝合治疗前置胎盘出血,均是对容易出血的子宫下段进行压迫缝合,效果确切。
本研究采用的宫颈子宫下段环形缝合术是在宫颈提拉式缝合术基础上进行改造,以宫颈组织为依托将宫颈组织与子宫下段创面缝合在一起,无需提拉宫颈,减少宫颈撕裂伤。另外,本研究中发现子宫切口位置选择及止血带应用至关重要。妊娠期胎盘血供丰富,传统手术如胎盘“打洞”会增加医源性出血,胎儿短时间内急性缺血缺氧,容易导致其预后不良。本研究的前置胎盘中如进腹探查证实为胎盘植入,尤其凶险性前置胎盘伴植入患者,均采用宫体部纵切口,避免切入胎盘,迅速娩出胎?汉笫战糁寡?带,使手术视野相对清晰。下推膀胱,根据胎盘位置调整止血带位置,伴膀胱植入下推困难者需行膀胱壁部分切除。研究中有1例患者胎盘主体位于宫颈管内达宫颈外口,使宫颈子宫下段膨大呈桶状,故行宫颈管前壁切开,彻底剥离胎盘后行宫颈子宫下段环形缝合术。本研究中25例患者均成功保留子宫,母儿预后良好。但本文中采用的宫体部剖宫产使再次妊娠风险明显增加,对于有再次生育要求者不建议行宫体部剖宫产。
综上所述,前置胎盘伴胎盘植入严重影响母儿预后,重在预防。多产、流产、剖宫产及中央性前置胎盘是其发生主要危险因素。宫颈子宫下段环形缝合术操作简单、止血效果确切,值得临床推广应用。
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(收稿日期:2017-11-22)