前置胎盘对胎盘植入性疾病致子宫全/次全切除及胎盘植入部位子宫局部切除患者手术情况及妊娠结局的影响

Effects of placenta previa on surgical and pregnancy outcomes in patients with total/subtotal or segmental hysterectomy attributed to placenta accreta spectrum disorders

目的探讨前置胎盘对胎盘植入性疾病(placenta accreta spectrum disorders,PAS)致子宫全/次全切除及胎盘植入部位子宫局部切除(简称植入部位切除)患者手术情况和妊娠结局的影响。方法回顾性纳入2017年1月1日至2022年12月31日于广州医科大学附属第三医院分娩、因PAS行子宫全/次全切除或者植入部位切除的患者510例。根据是否合并前置胎盘分为合并前置胎盘组(427例)和无前置胎盘组(83例)。根据子宫切除方式(子宫全/次全切除或植入部位切除)分层,子宫全/次全切除者根据是否合并前置胎盘分为合并前置胎盘组(221例)和无前置胎盘组(23例),植入部位切除者根据是否合并前置胎盘分为合并前置胎盘组(206例)和无前置胎盘组(60例)。采用非参数检验或χ^(2)检验比较组间临床特征、手术情况和妊娠结局的差异。利用二分类logistic回归分析前置胎盘对需要额外手术操作和发生不良妊娠结局的影响。结果(1)合并前置胎盘组与无前置胎盘组比较:与无前置胎盘组比较,合并前置胎盘组产后24 h出血量[1541 ml(1036~2368 ml)与1111 ml(695~2000 ml),Z=-3.91],以及需要额外手术操作[84.8%(362/427)与69.9%(58/83),χ^(2)=10.61]、子宫全/次全切除[51.8%(221/427)与27.7%(23/83),χ^(2)=16.10]、膀胱镜检查术和/或输尿管支架置入术[60.7%(259/427)与31.3%(26/83),χ^(2)=24.25]、总体不良妊娠结局[86.9%(371/427)与65.1%(54/83),χ^(2)=17.75]、产后24 h出血量>1500 ml[54.1%(231/427)与33.7%(28/83),χ^(2)=29.94]和输注血制品的比例较高[75.9%(324/427)与47.0%(39/83),χ^(2)=28.27](P值均<0.05)。采用二分类logistics回归分析,校正年龄、既往剖宫产次数、产次、孕期增重、双胎、是否辅助生殖技术受孕等混杂因素,发现前置胎盘是PAS子宫切除(全/次全切除和植入部位切除)患者需要额外手术操作(aOR=3.26,95%CI:1.85~5.72)及发生不良妊娠结局(aOR=5.59,95%CI:2.01~6.42)的危险因素。(2)按子宫全/次全切除和植入部位切除分层,合并前置胎盘组与无前置胎盘组比较:①在全/次全子宫切除患者中:合并前置胎盘组发生额外手术操作[82.8%(183/221)与56.5%(13/23),χ^(2)=9.11],尤其是膀胱镜检查术和/或输尿管支架置入术的比例高于无前置胎盘组[67.9%(150/221)与34.8%(8/23),χ^(2)=9.99](P值均<0.05),但不良妊娠结局的比例2组差异无统计学意义[89.6%(198/221)与87.0%(20/23),χ^(2)<0.01,P=0.972]。②在子宫植入部位切除患者中:合并前置胎盘组需要额外手术操作[86.9%(179/206)与75.0%(45/60),χ^(2)=4.94]及发生不良妊娠结局的比例高于无前置胎盘组[84.0%(173/206)与56.7%(34/60),χ^(2)=25.31](P值均<0.05)。与无前置胎盘组比较,合并前置胎盘组中需要膀胱镜检查术和/或输尿管支架置入术[52.9%(109/206)与30.0%(18/60),χ^(2)=9.78]和血管阻断术的比例高[94.2%(194/206)与71.7%(43/60),χ^(2)=24.23],产后24 h出血量多[1368 ml(970~2026 ml)与995 ml(654~1352 ml),Z=-3.66],产后24 h出血>1500 ml[46.6%(96/206)与23.3%(14/60),χ^(2)=10.37]及输注血制品的比例高[68.9%(142/206)与33.3%(20/60),χ^(2)=24.73](P值均<0.05)。采用二分类logistics回归分析,校正年龄、既往剖宫产次数、产次、孕期增重、双胎、是否辅助生殖技术受孕等混杂因素,发现前置胎盘在子宫全/次全切除患者中并未增加需要额外手术操作(aOR=2.71,95%CI:0.99~7.42)及发生不良妊娠结局的风险(aOR=2.14,95%CI:0.54~8.42),前置胎盘在子宫植入部位切除患者中是需要额外手术操作(aOR=4.67,95%CI:2.15~10.10)及发生不良妊娠结局的危险因素(aOR=3.80,95%CI:1.86~7.77)。结论前置胎盘增加PAS致子宫全/次全切除及植入部位切除患者的额外手术操作和孕产妇不良妊娠结局的风险,临床诊断PAS合并前置胎盘,需做好相应的准备。

Objective To investigate the effects of placenta previa on the surgical and pregnancy outcomes in patients with total/subtotal or segmental hysterectomy attributed to placenta accreta spectrum disorders(PAS).Methods This study retrospectively enrolled 510 patients who gave birth and underwent total/subtotal hysterectomy or segmental hysterectomy(local implantation site)due to PAS at the third Affiliated Hospital of Guangzhou Medical University from January 1,2017,to December 31,2022.These subjects were divided into the placenta previa group(427 cases)and non-placenta previa group(83 cases).According to the type of hysterectomy,they were further divided into the total/subtotal hysterectomy and placenta previa subgroup(221 cases),total/subtotal hysterectomy and non-placenta previa subgroup(23 cases),segmental hysterectomy and placenta previa subgroup(206 cases),and segmental hysterectomy and non-placenta previa subgroup(60 cases).Nonparametric test or Chi-square test were used to compare the differences in the clinical features,surgical and pregnancy outcomes between different groups.Binary logistic regression was used to analyze the effects of placenta previa on the risk of additional surgical procedures and adverse maternal outcomes.Results(1)Compared with the non-placenta previa group,the hemorrhage volume within 24 h postpartum[1541 ml(1036-2368 ml)vs 1111 ml(695-2000 ml),Z=-3.91]and the proportion of women requiring additional surgical procedures[84.8%(362/427)vs 69.9%(58/83),χ^(2)=10.61],with total/subtotal hysterectomy[51.8%(221/427)vs 27.7%(23/83),χ^(2)=16.10],cystoscopy and/or ureteral stenting[60.7%(259/427)vs 31.3%(26/83),χ^(2)=24.25],total adverse pregnancy outcomes[86.9%(371/427)vs 65.1%(54/83),χ^(2)=17.75],hemorrhage volume>1500 ml within 24 h postpartum[54.1%(231/427)vs 33.7%(28/83),χ^(2)=29.94],transfusion of blood products[75.9%(324/427)vs 47.0%(39/83),χ^(2)=28.27]were all higher in the placenta previa group(all P<0.05).Binary logistic regression analysis found that for PAS patients with hysterectomy,regardless of the hysterectomy type(total/subtotal/segmental),placenta previa was risk factor for requiring additional surgical procedures(aOR=3.26,95%CI:1.85-5.72)and adverse pregnancy outcomes(aOR=5.59,95%CI:2.01-6.42),even if adjusting for the confounding factors such as maternal age,number of previous cesarean sections,parity,gestational weight gain,twin pregnancy,and the use of assisted reproductive technology.(2)In patients with total/subtotal hysterectomy,the proportion of women requiring additional surgical procedures was higher in those with placenta previa[82.8%(183/221)vs 56.5%(13/23),χ^(2)=9.11]than those without placenta previa,especially the proportion of cystoscopy and/or ureteral stenting[67.9%(150/221)vs 34.8%(8/23),χ^(2)=9.99](both P<0.05).However,no significant difference was found in adverse pregnancy outcomes[89.6%(198/221)vs 87.0%(20/23),χ^(2)<0.01,P=0.972]between the two groups.In patients with segmental hysterectomy,higher proportions of women requiring additional surgery[86.9%(179/206)vs 75.0%(45/60),χ^(2)=4.94],with adverse pregnancy outcomes[84.0%(173/206)vs 56.7%(34/60),χ^(2)=25.31],cystoscopy and/or ureteral stenting[52.9%(109/206)vs 30.0%(18/60),χ^(2)=9.78],vascular occlusion[94.2%(194/206)vs 71.7%(43/60),χ^(2)=24.23],hemorrhage volume>1500 ml within 24 h postpartum[46.6%(96/206)vs 23.3%(14/60),χ^(2)=10.37],and transfusion of blood products[68.9%(142/206)vs 33.3%(20/60),χ^(2)=24.73]were found in the placenta previa group(all P<0.05).Furthermore,patients with placenta previa had more hemorrhage volume within 24 h postpartum[1368 ml(970-2026 ml)vs 995 ml(654-1352 ml),Z=-3.66,P<0.001]in the segmental hysterectomy subgroup.After adjusting for the confounding factors such as age,number of previous cesarean sections,parity,gestational weight gain,twin pregnancy,and the use of assisted reproductive technology,binary logistic regression analysis found that placenta previa did not increase the risk of additional surgical operations(aOR=2.71,95%CI:0.99-7.42)and adverse pregnancy outcomes(aOR=2.14,95%CI:0.54-8.42)in patients with total/subtotal hysterectomy but were risk factors of the two outcomes for those with segmental hysterectomy(aOR=4.67,95%CI:2.15-10.10;aOR=3.80,95%CI:1.86-7.77).Conclusions Placenta previa increases the risk of additional surgical procedures and adverse pregnancy outcomes in patients with total/subtotal or segmental hysterectomy caused by PAS.Appropriate preparation is required after the clinical diagnosis of PAS with placenta previa.