穿透入膀胱的凶险型前置胎盘处理决策

Clinical strategies for pernicious placenta accreta with invasion of the bladder

随着孕妇妊娠年龄的增加,以及剖宫产后再次妊娠数量的增加,凶险型前置胎盘合并胎盘植入已经成为相对常见的严重并发症之一。其中临床处理最困难的情况往往是前置胎盘合并胎盘植入并穿透子宫浆膜层侵及膀胱后壁,一般称为"穿透入膀胱的凶险型前置胎盘"。文章基于近期相关病例报道和综述性文献的收集,就穿透入膀胱的凶险型前置胎盘的孕期处理、术前诊断、围手术期的准备以及不同手术方式的介绍、保守性治疗方案等关键问题进行了阐述,提出目前该种病例的诊治尚没有统一的临床指南或规范,往往强调个体化的诊治思路。即以保证孕妇生命安全和生活质量为底线,兼顾胎儿生存,减少术中出血,最大可能保护再生育能力为原则。诊治工作重在预防和早期识别,充分的产前评估及术前准备以及正确的手术策略选择是诊治成功与否的关键。

With the increase of the advanced age of pregnancy, and the increase in the number of pregnancy with prior cesarean section, pernicious placenta previa complicated with placenta implantation has become one of the relatively common serious complications. Among them, the most difficult situation is the clinical treatments for placenta previa complicated with placenta accreta which penetrates into the bladder wall, commonly known as ＂placenta accreta penetration into the bladder＂. In this paper, based on the collection of recent related cases report and literature review, we summarized key points of the preoperative diagnosis of placenta previa with penetration into the bladder, preparation of the surgery, different operation methods and conservative treatment. So far, there have been no agreed clinical guidelines or standard of diagnosis and treatment for such cases;instead the individualized strategy of clinical treatment is often emphasized. The bottom line is to ensure the safety and life quality of pregnant woman,and the principle is to focus on fetal survival, decrease bleeding during the operation, and protect the fertility as muchas possible. Prevention and early identification are the main aspect of clinical process. Correct surgery strategies with full evaluation and preparations before the surgery is the key to the success of the treatment.