凶险性前置胎盘植入侵犯膀胱32例围手术期处理及分析

Perioperative management and analysis of 32 cases of pernicious placenta previa percreta with bladder invasion

目的:探讨凶险性前置胎盘(PPP)胎盘植入侵犯膀胱的围手术期处理及妊娠结局。方法:回顾分析2014年1月至2018年10月昆明医科大学第一附属医院收治的32例PPP胎盘植入侵犯膀胱患者的临床资料。根据胎盘侵犯膀胱深度,将患者分为胎盘植入侵犯膀胱肌层或黏膜组(研究组,11例)和胎盘植入侵犯膀胱浆膜组(对照组,21例)。结果:研究组的术前腹主动脉球囊预置、术前膀胱镜检查、放置输尿管导管、难治性产后出血、子宫次全切/子宫全切及术后转入ICU等均高于对照组,差异均有统计学意义(P<0.05)。研究组的难治性产后出血、子宫次全切/子宫全切及术后转入ICU发生率分别是对照组的9.000倍(OR=9.000,95%CI为1.517~53.404)、7.438倍(OR=7.438,95%CI为1.440~38.410)及6.667倍(OR=6.667,95%CI为1.306~34.027)(P<0.05)。两组的术中膀胱损伤及输尿管损伤情况比较,差异无统计学意义(P>0.05)。研究组中经典子宫切除术4例(57.1%)、经子宫后路切除子宫1例(14.3%)及打开膀胱后切除子宫2例(28.6%),对照组则分别为4例(100%)、0例(0%)及0例(0%),两组的子宫切除方式比较,差异无统计学意义(P>0.05)。结论:胎盘植入侵犯膀胱肌层或黏膜是PPP难治性产后出血、子宫次全切/子宫全切及术后转入ICU的独立危险因素。对于侵犯膀胱的PPP,手术困难,术中出血难以控制。术前、术中均应正确评估,适时终止妊娠及根据病情术前选择行腹主动脉球囊预置及膀胱镜检查加输尿管导管放置。出血凶猛采取止血措施无效时应立即行子宫切除术,应重视个体化子宫切除方式的选择。

Objective:To explore perioperative management and pregnancy outcome for pernicious placenta previa(PPP) percreta with bladder invasion. Methods:32 patients of PPP percreta with bladder invasion from Jan.2014 to Oct.2018 delivered in Department of Obstetrics,the First Affiliated Hospital of Kunming Medical University,which were divided into2 groups according to the bladder depth of placenta invasion:the group with placenta invading the myometrium or mucosal layer of the bladder(11 cases,study group) and the group with placenta invading the serous layer of the bladder(21 cases,control group). Results:The incidence rate of accepting abdominal aorta artery balloon occlusion,preoperative cystoscopy and ureteral stents,intractable postpartum hemorrhage,hysterectomy,and postoperative transferred to ICU was higher in study group than that in control group( P <0.05).The incidence of intractable postpartum hemorrhage,hysterectomy,and postoperative transferred to ICU in study group was 9.000( OR :9.000,95% CI :1.517~53.404) times,7.438( OR :7.438,95% CI1.440~38.410 ) times and 6.667( OR :6.667,95% CI1.306~34.027) times higher than that in control group( P <0.05).There was no significant differences in the injury of the bladder or ureter between the two groups( P >0.05).There were 4(57.1%) cases of classic hysterectomy,1(14.3%) case of posterior hysterectomy,2(28.6%) cases of bladder opening before hysterectomy in the study group,and 4(100.0%) cases,0(0%) cases and 0(0%) cases,respectively,in the control group.There was no significant difference in the method of hysterectomy between the two groups ( P >0.05). Conclusions:Placenta invading the myometrium or mucosal layer of the bladder is the independent risk factor for intractable postpartum hemorrhage,hysterectomy,and postoperative transferred to ICU in PPP patients.The operation of PPP percreta with bladder invasion is difficult and the blood loss might be out of control.Therefore,a collaboration of doctors from multiple departments is needed for preoperative discussion.The perioperative condition of each patient should be evaluated correctly.The time of pregnancy termination should be choosing at an appropriate gestational week and the placement of abdominal aorta artery balloon,preoperative cystoscopy and ureteral stents before operation should be performed in appropriate cases.Once the bleeding is ferocious and hemostatic measures are ineffective,the hysterectomy should be done.Individual surgical approaches of hysterectomy should be considered.