术前可疑穿透性胎盘植入的手术方案选择——附三例病历分析及文献回顾

Surgical choices of placenta percreta suspected preoperatively:three case study and literature review

目的探讨穿透性胎盘植入手术方式,以提高母儿救治水平。方法回顾分析我院近6个月术前可疑穿透性胎盘植入的患者共3例,结合文献探讨如何选择制定术前可疑穿透性胎盘植入的手术方案。结果近6个月在我院住院分娩的孕妇共1 118例,经过B超或/及MRI检查可疑穿透性胎盘植入的共3例,手术及病理检查明确诊断的有2例。其孕周分别为32+6、32及35周,其中2例有剖宫产史及2次以上宫腔手术操作史,此2例均为中央型前置胎盘,均为胎盘植入在原剖宫产切口瘢痕部位,其中1例穿透性胎盘植入并浸润至膀胱,另1例胎盘植入已达子宫浆膜层,但尚未穿透,与泌尿外科等多科室协作完成子宫切除术。另1例为第1次宫内妊娠,突发腹腔内出血伴失血性休克及胎死宫内。术中见胎盘附着并全部植入于子宫右角,突破宫底后壁浆膜层,直径3 cm破口,有活动性出血,尽量保留子宫肌层组织并切除植入胎盘。结论可疑穿透性胎盘植入在原剖宫产术后瘢痕部位者术中出血难以控制,术前应多科室协作共同讨论,充分术前准备并制订手术预案;出血凶猛采取止血措施无效时应果断行子宫切除术;重视个体化手术方式的选择。

Objective To explore surgical approaches to placenta percreta so as to enhance the prognosis of the pregnancy women and their babies.Methods Medical records were reviewed and analyzed of three women with placenta percreta suspected preoperatively in our hospital in the past six months.Literature was reviewed to investigate how to decide on the surgical plan for placenta percreta preoperatively.Results A total of 1 118 pregnancy women were admitted to deliver in our hospital in the past six months.With B-ultrasound and MRI,3 were suspected with placenta percreta,and 2 of them were confirmed pathologically.The gestational age of the 3 patients were 32^＋6,32,and 35 weeks respectively.Two of them had history of Caesarean section and more than 2 uterine cavity operations,and both of them presented central placenta previa.Preoperative B-ultrasound and MRI showed that the suspected placenta percreta was located at the scar of previous Caesarean section.During the operation,placenta percreta was found to have invaded the bladder in one case and reached the uterine serous without penetrating in another case.Complete hysterectomy was performed with urologist assisting.The third one was a primipara,who presented sudden abdominal hemorrhage accompanied by hemorrhagic shock and intrauterine fetal death.During the operation,the placenta was found to have accreted into the right corner of the uterus.The placenta penetrated the rear serous of uterus with a 3-cm-diameter crevasse and active bleeding.The placenta percreta was excised and the uterine myometrium was reserved as much as possible.Conclusions If the placenta percreta is suspected at the scar of previous caesarean section,the blood loss might be out of control during the operation.Therefore,acollaboration of doctors from multi-departments is needed for preoperative discussion,sufficient preparation,surgical plans.Once the bleeding is ferocious and hemostatic measures are ineffective,hysterectomy should be performed timely.Individualized surgical approaches should be considered.