穿透性胎盘植入合并完全子宫破裂临床分析及文献复习

Placenta Percreta Combined with Complete Uterine Rupture: A Clinical Analysis and Literature Review

目的探讨穿透性胎盘植入合并完全子宫破裂的高危因素、临床特点、诊疗方法及诊断时机。方法回顾性分析2011年1月至2017年12月首都医科大学附属北京妇产医院围产医学部收治的28例完全子宫破裂孕妇中4例由穿透性胎盘植入导致的病例资料。结果穿透性胎盘植入合并完全子宫破裂的发生率约为0. 003%(4/128 242),占子宫破裂的14. 3%(4/28)。其中,3例瘢痕子宫(2例有剖宫产史,1例有腹腔镜子宫肌瘤剔除术+宫腔镜宫腔赘生物切除术史),2例凶险性前置胎盘,3例有人工流产史(1~3次),2例胎盘附着于宫角,2例高龄。2例胎盘植入于剖宫产切口,2例植入于宫角; 2例行全子宫切除,2例保留子宫,出血量2 000~5 000 m L; 4例孕产妇均存活,3例死胎/新生儿重度窒息。结论穿透性胎盘植入合并完全子宫破裂起病急,进展快,易误诊,出血严重,对孕产妇和胎儿影响巨大。因此,快速诊断、及时手术是减少不良结局的关键。

Objective To investigate the high risk factors,clinical features,diagnosis and treatment,and the diagnostic timing of placenta percreta combined with complete uterine rupture.Methods Retrospective analysis of 4 cases of penetrating placenta implantation in 28 pregnant women with complete uterine rupture admitted to Beijing Obstetrics and Gynecology Hospital affiliated to Capital Medical University from Jan.2011 to Dec.2017 was done.Results The incidence of placenta percreta combined with complete uterine rupture was about 0.003%(4/128 242),accounting for 14.3%of all the uterine rupture cases(4/28),among which 3 cases were scarred uterine(2 cases with previous cesarean section,1 case with previous history of laparoscopic myomectomy and transcervical resection of uterine cavity neoplasm),2 cases were dangerous placenta praevia,3 cases had previous vacuum aspiration(1-3 times),2 cases with placenta attached to the cornual area,2 cases were advanced age pregnancy.2 placenta were implanting in previous caesarean section scar,2 cases were penetrating into the cornual area,2 cases ended with hysterectomy,while the other 2 with uterine preserved,and the blood loss was between 2 000-5 000 mL,all of the 4 patients survived,3 cases ended up with stillbirth or severe asphyxia of newborn.Conclusion The penetrating placenta implantation combined with complete uterine rupture has the characteristics of acute onset,rapid progress,easy misdiagnosis,severe bleeding,and great influence on pregnant women and fetuses.Therefore,rapid diagnosis and timely operation are the keys to reduce adverse outcomes.