1212例胎盘早剥及漏误诊原因分析

Analysis of misssed diagnosis and misdiagnosis of 1 212 cases with placental abruption

目的探讨胎盘早剥发病的高危因素及临床表现，分析胎盘早剥漏诊、误诊的原因。 方法回顾性分析2005年1月至2015年12月于浙江大学医学院附属妇产科医院分娩的产妇共135 584例，其中诊断为胎盘早剥的产妇共1 212例，按照产前与产后诊断的符合性，分为3组：（1）确诊组（产前与产后诊断一致）715例（58.99%，715/1 212）；（2）漏诊组（产前未能诊断，产后诊断）312例（25.74%，312/1 212）；（3）误诊组（产前已诊断，但产后排除诊断）185例（15.26%，185/1 212）。分别对3组产妇进行胎盘早剥的疾病分级，并收集3组产妇的高危因素、临床表现、辅助检查结果、终止妊娠时机及母儿结局，对胎盘早剥的漏诊、误诊原因进行分析。 结果（1）总体胎盘早剥的发生率及漏诊、误诊率：1 212例产前或产后诊断为胎盘早剥的产妇中，产后确诊为胎盘早剥者1 027例。总体胎盘早剥的发生率为0.76%（1 027/135 584），漏诊率为30.38%（312/1 027），误诊率为0.14%（185/134 557）。（2）3组产妇不同分级胎盘早剥的发生率：3组产妇不同分级胎盘早剥的发生率比较，差异有统计学意义（P〈0.05）。（3）3组产妇发生胎盘早剥的高危因素：3组产妇中合并妊娠期高血压疾病、外伤、催引产、高龄者的比例分别比较，差异均有统计学意义（P均〈0.05）。（4）3组产妇胎盘早剥的临床表现：除子宫收缩外，3组产妇阴道出血、持续性腹痛、子宫压痛、血性羊水、子宫张力增加和死胎的发生率比较，差异均有统计学意义（P均〈0.05）。（5）3组产妇的辅助检查结果：3组产妇胎心监护异常的发生率比较，差异无统计学意义（P=0.22）。3组产妇超声结果异常、凝血功能异常的发生率比较，差异均有统计学意义（P〈0.01），其中确诊组产妇超声结果异常的发生率最高（68.1%），误诊组产妇凝血功能异常的发生率最高（24.9%）。（6）3组产妇终止妊娠的时机：3组产妇中24 h内终止妊娠者的比例比较，差异有统计学意义（P=0.01）。（7）3组产妇的母儿结局：3组产妇产后出血、DIC及其新生儿窒息及围产儿死亡者的比例分别比较，差异均有统计学意义（P均〈0.05）。确诊组产妇产后出血的发生率最高（17.9%），误诊组最低（5.4%）；确诊组DIC的发生率最高（3.9%），误诊组最低（0）；确诊组的新生儿窒息发生率最高（30.6%），误诊组最低（7.6%）；确诊组围产儿死亡的发生率最高（12.6%），误诊组最低（2.2%）。 结论仅凭合并外伤等高危因素，易造成胎盘早剥的误诊；催引产产妇中，更易出现胎盘早剥的漏诊。子宫收缩、胎心监护异常、超声结果异常和凝血功能异常为胎盘早剥漏诊、误诊的临床诊断警惕点。

ObjectiveTo investigate the risk factors and clinical manifestations of placental abruption, and to analyze the causes of missed diagnosis and misdiagnosis. MethodsA retrospective analysis was conducted in 135 584 women who delivered in Women′s Hospital, School of Medicine, Zhejiang University from January 2005 to December 2015. The diagnosis of placental abruption was made in 1 212 cases. According to the consistency of prenatal and postnatal diagnosis, they were divided into 3 groups. （1） The diagnosis was consistent prenatally and postnatally in 715 cases（58.99%, 715/1 212） as the diagnosis group. （2） In 312 cases （25.74%, 312/1 212）, the diagnosis was made after birth as the missed diagnosis group. （3） In 185 cases （15.26%, 185/1 212）, the diagnosis was made prenatally but excluded after birth as the misdiagnosis group. The disease classification was made, and the risk factors, clinical manifestations, lab results, the time of termination and perinatal outcomes were recorded in the 3 groups. The reasons of missed diagnosis and misdiagnosis were analyzed. Results（1） In the 1 212 cases, the diagnosis of placental abruption was confirmed in 1 027 cases, with the incidence of 0.76% （1 027/135 584）. The rate of missed diagnosis was 30.38% （312/1 027）, and the rate of misdiagnosis was 0.14% （185/134 557） . （2） There were significant differences in the degree of placental abruption among the 3 groups （P〈0.05）. （3）Significant differences were found among the 3 groups regarding the ratio of hypertensive disorders, trauma, induced labor and advanced maternal age （all P〈0.05）. （4） There were statistically significant differences among the 3 groups regarding the incidence of vaginal bleeding, persistent abdominal pain and uterine tenderness, bloody amniotic fluid, increased uterine tension and stillbirth （all P〈0.05）. （5） There was no significant difference in the rate of abnormal fetal heart rate mornitoring among the 3 groups （P=0.22）. The differences were statistically significant among the 3 groups when regarding the incidence of abnormal ultrasound finding and abnormal blood coagulation （P〈0.01）, with the highest incidence of abnormal ultrasound in the diagnosis group （68.1%） and the highest incidence of abnormal coagulation in the misdiagnosis group （24.9%）. （6）There was statistically significant difference among the 3 groups when comparing the ratio of termination of pregnancy within 24 hours （P=0.01）. （7） There were statistically significant differences among the 3 groups when the ratios of postpartum hemorrhage, DIC, neonatal asphyxia and perinatal death were compared （all P〈0.05）. The highest incidence of postpartum hemorrhage was in the diagnosis group （17.9%） and the lowest was in the misdiagnosis group （5.4%）. The highest incidence of DIC was in the diagnosis group （3.9%） and the lowest was in the misdiagnosis group （0）. The highest incidence of neonatal asphyxia was in the diagnosis group （30.6%） and the lowest was in the misdiagnosis group （7.6%）. And for perinatal death, the highest incidence was in the diagnosis group （12.6%）, the lowest was in the misdiagnosis group （2.2%）. ConclusionsPlacental abruption could be misdiagnosed when depending on risk factors, such as trauma. And it could be missed diagnosis during the induction of labor. Uterine contraction, abnormal fetal heart rate mornitoring, abnormal ultrasound and abnormal coagulation function are important in the diagnosis of placental abruption.