穿透性胎盘植入致自发性子宫破裂12例临床分析

Clinical analysis of 12 cases of spontaneous uterine rupture caused by placenta percreta

目的探讨穿透性胎盘植入致自发性子宫破裂的临床特点及早期识别要点。方法收集2014年6月至2019年12月郑州大学第一附属医院收治的12例穿透性胎盘植入致自发性子宫破裂孕妇的临床资料,对其年龄、发生孕周、孕产史、临床表现、诊断方法、子宫手术史、破裂发生部位、手术方式、治疗及转归进行分析。结果(1)一般情况:孕妇中位年龄为37岁(范围:30~43岁),发生子宫破裂的中位孕周为29周+6(范围:18周+3~36周+3)。(2)临床表现:12例孕妇中,临床表现为不同程度腹痛者9例;胸闷伴腰酸、腹部坠胀者2例;1例无症状,为择期剖宫产术时发现子宫破裂口。术前彩超提示12例孕妇中9例有腹腔积液,其中6例行诊断性腹腔穿刺或阴道后穹隆穿刺抽出不凝血。(3)子宫手术史及破裂发生部位:12例穿透性胎盘植入致自发性子宫破裂孕妇中,10例有剖宫产术史,其中,原剖宫产术子宫切口处破裂4例、子宫下段前壁胎盘穿透性植入处破裂3例、穿透性胎盘植入达子宫底部致子宫底部破裂2例、穿透性胎盘植入发生于右侧宫角部肌瘤剔除部位致右侧宫角破裂1例;2例无剖宫产术史的穿透性胎盘植入致自发性子宫破裂孕妇中,1例多次流产、刮宫术史,子宫破裂发生于宫底部,1例宫腔镜子宫内膜息肉电切除术后胎盘穿透性植入破裂,子宫破裂口在子宫下段前壁。(4)母儿结局:11例孕妇输注悬浮RBC,1例未输注血制品;行子宫修补术9例,子宫次全切除术3例;孕产妇存活11例,死亡1例;围产儿存活7例,死亡6例。结论穿透性胎盘植入致子宫破裂对母儿危害极大,临床表现的异质性易导致误诊。对存在胎盘植入高危因素的孕妇,孕期应尽早明确诊断;对已诊断为胎盘植入者,当出现子宫破裂典型或不典型表现时,都应警惕子宫破裂的发生。

Objective To investigate the clinical characteristics and early identification of spontaneous rupture of uterus caused by placenta percreta.Methods The clinical data of 12 patients with spontaneous uterine rupture caused by placenta percreta and admitted to the First Affiliated Hospital of Zhengzhou University from June 2014 to December 2019 were collected.The age,gestational age,gestational history,clinical manifestations,diagnostic methods,uterine operation history,rupture location,surgical method,treatment and outcome were analyzed.Results(1)General condition:the median age of pregnant women was 37 years(range:30-43 years),and the median gestational week of uterine rupture was 29+6 weeks(range:18+3-36+3 weeks).(2)Clinical manifestation:among the 12 pregnant women,9 showed different degrees of abdominal pain;chest distress accompanied by waist soreness,abdominal distension in 2 cases;one asymptomatic pregnant women was found with uterine rupture during elective cesarean section.Preoperative color Doppler ultrasonography indicated that 9 of the 12 pregnant women had peritoneal effusion,and 6 of them underwent diagnostic peritoneal puncture or posterior vault puncture for non-clotting blood extraction.(3)Uterine operation history and rupture location:among the 12 cases of spontaneous rupture of uterus caused by placenta percreta pregnant women,10 had placenta previa after cesarean section,including 4 cases of rupture at the incision of the original cesarean section,3 cases of rupture at the penetrating placental implantation of the lower segment of the anterior wall of the uterus,and 1 case of placenta percreta occurred at the myomectomy site of the right angle of the uterus.Among the 2 pregnant women with spontaneous uterine rupture caused by penetrating placental implantation without a history of cesarean section,1 case with history of multiple abortions,and uterine rupture occurred at the bottom of the palace,1 had rupture of placental penetrating implantation after hysteroscopic electroresection of endometrial polyps,and the uterine rupture occurred at the anterior wall of the lower segment of the uterus.(4)Maternal and fetal outcomes:11 pregnant women were injected with suspension RBC and 1 pregnant woman was not injected with blood products.Nine cases underwent hysteroplasty and 3 cases underwent subtotal hysterectomy.There were 11 maternal survivors and 1 maternal death;7 neonates survived and 6 stillbirths.Conclusions Uterine rupture caused by placenta percreta is of great harm to mother and infant,due to its heterogeneity in clinical manifestations,which increases the possibility of misdiagnosis.For pregnant women with risk factors of placenta percreta,early diagnosis should be made during pregnancy.For those who have been diagnosed with placenta percreta,when there is typical or atypical uterine rupture,doctors should be alert to the occurrence of uterine rupture.