胎盘植入的高危因素及球囊预置阻断技术在预防胎盘植入产后出血中的临床价值

目的:研究影响胎盘植入程度的临床危险因素,评估髂内动脉球囊预置技术在控制不同程度胎盘植入患者产后出血中的价值。方法:收集2012年1月至2019年6月于上海瑞金医院产科剖宫产终止妊娠的胎盘植入孕妇108例,根据胎盘植入肌层的深度分为粘连组(PA组)60例和重度植入组48例。采用单因素分析及多因素logistic回归分析影响胎盘植入程度的临床危险因素。重度植入组(胎盘植入PI组45例+穿透性胎盘PP组3例)中,22例术前诊断,行髂内动脉球囊预置,26例未行髂内动脉球囊预置。比较两组患者的年龄、孕周、住院费用、出血量、术后血红蛋白(Hb)变化情况、产后出血率、输血率、子宫切除率、新生儿窒息评分,以及晚期产后出血、产褥期感染及下肢深静脉血栓等并发症发生情况。结果:多因素分析显示,年龄、既往剖宫产术史和此次妊娠前置胎盘是影响胎盘植入严重程度的独立危险因素(P<0.05)。与未预置组比较,预置组的术后血红蛋白(Hb)下降少,产后出血率及术后输血率减少,差异均有统计学意义(P<0.05);两组的子宫切除率比较,差异无统计学意义(P>0.05)。远期随访48例重度植入患者,无晚期产后出血、产褥期感染及下肢深静脉血栓等并发症发生。结论:年龄、既往剖宫产术史和此次妊娠前置胎盘是影响胎盘植入严重程度的独立危险因素,需加强对此类孕妇的孕期监控。术前行髂内动脉球囊预置术,能明显减少重度胎盘植入患者剖宫产产后出血率,减少术后血红蛋白(Hb)下降及减少输血率,是控制出血的有效手段。

Analysis of the clinical risk factors of placental implantation and the value of internal iliac artery balloon presetting in preventing postpartum hemorrhage

Objective:To explore the clinical risk factors of placenta accrete(PA)/increta(PI)/percreta(PP).To evaluate the effect of the internal iliac artery balloon presetting technique in the control of postpartum hemorrhage in patients with PI and PP.Methods:108 pregnant women diagnosed with placental implantation after cesarean section in Shanghai Ruijin hospital from Jan.2012 to June 2019 were enrolled.According to the depth of the muscle layer of placenta implantation,60 cases in the PA and 48 cases in the severe implantation group.The clinical risk factors of placenta implantation were analyzed using univariate analysis and multivariate logistic regression.The severe implantation group included 45 PI patients and 3 PP patients.22 of whom were assigned as preset as they received balloon prepositioning of the internal iliac artery before cesarean section.Another 26 patients were assigned into non-preset group.Patients’ age,gestational age,hospital expenses,blood loss,postoperative hemoglobin(Hb),postpartum hemorrhage rate,the changes of blood transfusion rate,uterus resection rate and neonatal asphyxia score differences and late postpartum hemorrhage,puerperal infection and lower extremity deep vein thrombosis complications were compared between two groups.Results:Multivariate regression analysis showed that age,scared uterus and placenta previa were independent risk factors affecting the severity of placental implantation(P<0.05).Compared with the non-preset group,patients in the preset group had a less decrease in postoperative hemoglobin(Hb),and a lower postpartum hemorrhage rate and postoperative blood transfusion rate(P<0.05).However,there was no significant difference in the hysterectomy rate between two groups(P>0.05).No complications such as postpartum hemorrhage,puerperal infection and deep venous thrombosis occurred in 48 patients during long-term follow-up.Conclusions:Age,previous cesarean sections and placenta previa are independent risk factors affecting the severity of placenta implantation,and those patients should receive close monitoring.Preoperative balloon prepositioning of the internal iliac artery can significantly reduce the rate of postpartum hemorrhage,the decrease of postoperative Hb and the rate of blood transfusion,in patients with severe placental implantation,indicating this technique is an effective way to control bleeding.