前置胎盘患者再次剖宫产术中发生产后出血的15例临床病例分析

Clinical analysis of fifteen cases with placenta previa and postpartum hemorrhage during repeated cesarean section

目的:总结既往处理经验,结合文献复习,摸索针对前置胎盘患者施行再次剖宫产术的更好的临床路径。方法:回顾分析1999年1月至2011年12月在我院产科行再次剖宫产术中合并前置胎盘和产后出血的15例患者的临床资料。患者年龄26～43岁;既往有2次剖宫产史者2例,1次者13例;终止妊娠孕周为30～40周。15例患者中产前B超提示前置胎盘者12例,其中孕期或产前有阴道出血症状者9例。手术按常规步骤进行。结果:(1)15例患者中13例为完全性前置胎盘,胎盘主体位于前壁者8例、后壁者7例;2例为边缘性前置胎盘。胎盘完全或部分粘连者13例,其中9例存在不同程度的胎盘植入,1例胎盘部分直接侵入膀胱;(2)术中平均出血量2564ml(400～12500ml),中位出血量1100ml。11例患者术中发生休克,3例患者继发弥漫性血管内凝血(DIC)。出血后采取促宫缩剂治疗及手术方法,包括局部缝合开放的血窦,缝扎子宫动脉下行支,填塞宫纱,Blynch缝合及子宫次全切除术。2例术中同时行膀胱修补术;(3)13例患者术中止血成功,2例术后加行双侧子宫动脉栓塞术。患者预后均良好。结论:前次剖宫产史的患者如合并前置胎盘、胎盘粘连或植入,术前、术中和术后都极易并发大出血,应引起临床医生的重视。

Objective：To find a better protocal for patients who was undergoing a repeated cesarean section and complicates with placenta previa.Methods：15 women who had placenta previa and postpartum hemorrhage at the second or third cesarean section were enrolled from Jan.1999 to Dec.2011.The median age was 35 years.Two patients underwent the third cesarean section and the others underwent the second cesarean section.Placenta previa was diagnosed in 12 patients by ultrasound before the operation.9 of them had vaginal bleeding.Surgery was done by routine strategy.Results：（1）Among thoses 15 patients,13 had complete placenta previa.Placenta located in the anterior wall in 8 patients and 7 in posterior wall.13 patients had complete or partial placenta adhesion,and placenta accrete was found in 9 cases.The placenta implanted to the bladder in 1 case.（2）The mean volume of blood loss during the operation was 2546ml（400~12500ml）,the median volume was 1100ml.11 patients had a shock during operation and 3 patients had secondary diffuse intravascular coagulation（DIC）.Several kind of medicine and some surgical methods including suturing,ligating the descending branches of uterine artery,intrauterine packing,and subtotal hysterectomy were used.Bladder repairing were performed on 2 patients.（3）The amount of bleeding was significantly reduced at the end of operation in 13 cases while 2 patients underwent bilateral uterine artery embolization.All patients had good prognosis.Conclusions：Pregnant women who have previous cesarean section with placenta preiva,placenta accreta and placenta increta have high risks of massive bleeding.Obstetricians should pay more attention to these patients.