剖宫产术后再次妊娠合并前置胎盘孕妇胎盘植入的风险评估及不良结局预测全国多中心回顾性研究  

Risk factor assessment and adverse outcome prediction of placenta accreta in pregnant women after cesarean section complicated with placenta previa:a national multicenter retrospective study

作　　者：白桂芹[1] 陈蔚琳[2] 黄向华[3] 赵绍杰[4] 赵淑萍[5] 陈秀娟[6] 陈素文[7] 杨华[8] 卢霞[9] 刘冠媛[10] 陈琼华[11] 张林爱[12] 金力[2] Bai Guiqin;Chen Weilin;Huang Xianghua;Zhao Shaojie;Zhao Shuping;Chen Xiujuan;Chen Suwen;Yang Hua;Lu Xia;Liu Guanyuan;Chen Qionghua;Zhang Lin′ai;Jin Li(Gene Joint Laboratory,the First Affiliated Hospital,Xi′an Jiaotong University,Xi′an 710061,China;Department of Obstetrics and Gynecology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China;Department of Obstetrics and Gynecology,the Second Hospital of Hebei Medical University,Shijiazhuang 050000,China;Department of Gynecology,Wuxi Maternal and Child Health Hospital,Wuxi 214002,China;Department of Gynecology,Qingdao Women and Children Hospital,Qingdao University,Qingdao 266034,China;Department of Gynecology,Fujian Maternity and Child Health Hospital,Fuzhou 350001,China;Department of Family Planning,Beijing Obstetrics and Gynecology Hospital,Capital Medical University,Beijing 100026,China;Department of Family Planning,Tianjin Central Hospital of Gynecology and Obstetrics,Tianjin 300011,China;Department of Obstetrics and Gynecology,the Sixth Affiliated Hospital of Xinjiang Medical University,Urumchi 830002,China;Department of Obstetrics and Gynecology,Bejing Chaoyang Hospital,Capital Medical University,Beijing 100020,China;Department of Obstetrics and Gynecology,the First Affiliated Hospital of Xiamen University,Xiamen 361003,China;Department of Family Planning,Shanxi Maternal and Child Health Hospital,Taiyuan 030013,China)

机构地区：[1]西安交通大学第一附属医院基因联合实验室,西安710061 [2]中国医学科学院北京协和医院妇产科,北京100730 [3]河北医科大学第二医院妇产科,石家庄050000 [4]江苏省无锡市妇幼保健院妇科,无锡214002 [5]青岛大学附属妇女儿童医院妇科,青岛266034 [6]福建省妇幼保健院妇科,福州350001 [7]首都医科大学附属北京妇产医院计划生育科,北京100026 [8]天津市中心妇产科医院计划生育科,天津300011 [9]新疆医科大学附属第六医院妇产科,乌鲁木齐830002 [10]首都医科大学附属北京朝阳医院妇产科,北京100020 [11]厦门大学附属第一医院妇产科,厦门361003 [12]山西省妇幼保健院计划生育科,太原030013

出　　处：《中华妇产科杂志》2023年第1期26-36,共11页Chinese Journal of Obstetrics and Gynecology

基　　金：国家自然科学基金(81771615);陕西省创新能力支撑计划(2019TD-031)。

摘　　要：目的探讨剖宫产术后再次妊娠合并前置胎盘孕妇的胎盘植入性疾病(PAS)影像学诊断及血管阻断方式对妊娠结局的影响。方法采用全国多中心回顾性研究,于2018年1月1日至12月31日选取12家三级甲等医院的剖宫产术后再次妊娠合并前置胎盘的妊娠晚期单胎妊娠孕妇共747例。采用单因素及多因素logistic回归分析,观察剖宫产术后再次妊娠合并前置胎盘孕妇严重不良结局(子宫切除、术中出血量≥1000 ml、术中诊断PAS)的危险因素;观察产前超声和磁共振成像(MRI)检查在胎盘PAS及严重不良结局预测中的作用。根据是否行血管介入(子宫动脉栓塞术或腹主动脉球囊阻断术)分为阻断组(106例)与未阻断组(641例),比较两组孕妇的母儿结局。结果(1)一般情况:747例剖宫产术后再次妊娠合并前置胎盘孕妇的子宫切除率为10.4%(78/747),术中出血量≥1000 ml者占55.8%(417/747),术中确诊PAS者占47.5%(355/747)。子宫破裂的发生率为0.8%(6/747)。(2)严重不良结局的危险因素:子宫切除的危险因素是血管阻断方式和术中出血量,子宫动脉栓塞术者子宫切除的可能性是腹主动脉球囊阻断术者的5.319倍(95%CI为1.346~21.018);术中出血量≥1000 ml的危险因素是剖宫产术次数、超声检查提示PAS及可疑PAS、术中是否诊断PAS、完全性前置胎盘;术中诊断PAS的危险因素是子宫瘢痕厚度、超声检查提示PAS及可疑PAS、MRI检查提示PAS及可疑PAS、完全性前置胎盘;(3)超声和MRI检查在预测PAS中的作用:超声检查预测PAS的敏感度为47.5%,特异度为88.4%;kappa值为0.279(P<0.001),一致性一般。MRI检查预测PAS的敏感度为79.2%,特异度为97.8%;kappa值为0.702(P<0.001),一致性较好。超声且MRI检查均提示PAS孕妇的术中出血量及子宫切除率均显著高于仅超声或仅MRI检查提示PAS的孕妇。(4)血管阻断对妊娠结局的影响:阻断组与未阻断组孕妇的术中出血量、术中出�Objective To study the risk factors of adverse pregnancy outcomes for the diagnosis and treatment of pregnancy after cesarean section complicated with placenta previa.Methods A national multicenter retrospective study was conducted to select a total of 747 pregnant women with the third trimester singleton pregnancy after cesarean section complicated with placenta previa from 12 tertiary hospitals in January 1st to December 31st,2018.The risk factors of severe adverse outcomes[hysterectomy,intraoperative blood loss≥1000 ml,intraoperative diagnosis of placenta accreta spectrum disorders(PAS)]in pregnant women with second pregnancy complicated with placenta previa after cesarean section were investigated by logistic regression analysis.The roles of prenatal ultrasonography and magnetic resonance imaging(MRI)in the prediction of PAS and severe adverse outcomes were observed.According to whether vascular intervention was performed(uterine artery embolization or abdominal aortic balloon occlusion),the pregnant women were divided into the blocked group and the unblocked group,and the maternal and infant perinatal outcomes between the two groups were compared.Results(1)General information:the hysterectomy rate of 747 pregnant women with second pregnancy complicated with placenta previa after cesarean section was 10.4%(78/747),the intraoperative blood loss≥1000 ml in 55.8%(417/747),and PAS was confirmed in 47.5%(355/747).The incidence of uterine rupture was 0.8%(6/747).(2)Analysis of risk factors for severe adverse outcomes:based on binary unconditioned logistic regression univariate and multivariate analysis,the risk factors for hysterectomy were the mode of vascular embolization and intraoperative blood loss.The probability of hysterectomy with uterine artery embolization was 5.319 times higher than that with abdominal aortic balloon occlusion(95%CI:1.346-21.018).The risk factors of intraoperative blood loss≥1000 ml were the number of cesarean section delivery,ultrasonography indicated PAS and suspected PAS,intrao

关 键 词：剖宫产术 前置胎盘 失血 手术 侵入性胎盘 子宫切除术 回顾性研究 

分 类 号：R714.2[医药卫生—妇产科学]