低位腹主动脉外阻断术在胎盘植入性疾病剖宫产术中的效果及对MDA、SOD表达的影响

Efficacy of low extra-abdominal aortic block in cesarean section for placenta accreta spectrum disorders and its effect on the expression of MDA and SOD

目的:胎盘植入性疾病(placenta accreta spectrum disorders,PAS)指胎盘黏附和侵入异常的一类疾病,可能导致难治性产后大出血等严重并发症,在剖宫产术中采用低位腹主动脉外阻断术可以减少PAS患者术中出血量,但同时也可能造成缺血再灌注损伤。本研究拟探讨低位腹主动脉外阻断术在PAS剖宫产术中的效果及对丙二醛(malondialdehyde,MDA)、超氧化物歧化酶(superoxide dismutase,SOD)表达的影响,分析其引起缺血再灌注损伤的严重程度。方法:选取2017年7月至2021年7月在中南大学湘雅三医院妇产科住院分娩的侵入性PAS孕妇,剖宫产术中行低位腹主动脉外阻断术者为A组(n=15),未行腹主动脉外阻断术者为B组(n=15)。比较2组术中出血量、输血量、子宫切除及并发症发生率、术后住院时间、住院费用等,分析低位腹主动脉外阻断术在PAS中的治疗效果。测定2组相对应时间点缺血再灌注损伤相关生化指标MDA水平和总超氧化物歧化酶(total superoxide dismutase,T-SOD)活力。各检测时间点:A组为胎儿娩出后行低位腹主动脉外阻断术前(A0),开放阻断后0 h(A1,即开始缝合子宫肌层时)、0.5 h(A2)、2 h(A3)、4 h(A4),B组为胎儿娩出后(B0),开始缝合子宫肌层0 h(B1)、0.5 h(B2)、2 h(B3)、4 h(B4);记录A组腹主动脉阻断总时长,并观察2组患者术后肢体有无水肿、缺血、坏死、感染等情况,通过检测再灌注不同时间点相关生化指标变化,了解低位腹主动脉外阻断术引起缺血再灌注损伤的严重程度。结果:A组术中出血量、输血量均少于B组,差异均有统计学意义(均P<0.05);2组术后住院时间、住院费用差异均无统计学意义(均P>0.05);手术并发症:A组均保留子宫,1例膀胱损伤,2例盆腔感染;B组1例切除子宫、3例膀胱损伤、3例盆腔感染。T-SOD、MDA水平变化:与阻断前A0时间点比较,A1、A2、A3时间点血中MDA水平明显升高,而SOD活力明显降低(P<0.05),开放阻断后4 h(A4)两指标基本恢复到A1(缺血期)水平;B组各时间点T-SOD、MDA值变化差异均无统计学意义(均P>0.05)。A组和B组T-SOD及MDA结果比较:A0和B0时间点比较差异无统计学意义(P>0.05),A1和B1时间点MDA差异无统计学意义(P>0.05),A1时间点T-SOD活力低于B1时间点,差异有统计学意义(P<0.05),其余同一时间点A组MDA表达均高于B组,A组T-SOD活力均低于B组,差异均有统计学意义(均P<0.05)。2组患者术后肢体均无水肿、缺血、坏死、感染等情况。结论:低位腹主动脉外阻断术能有效减少PAS剖宫产术中的出血及输血量,导致一过性MDA水平升高、SOD活力下降,即出现一过性缺血再灌注损伤,但不会引起肢体水肿、缺血、坏死、感染等并发症。

Objective:Placenta accreta spectrum disorders(PAS)refers to a group of abnormalities in placental adhesion and invasion,which may lead to serious complications such as intractable postpartum hemorrhage.The use of low-level extra-abdominal aortic temporary block during cesarean section may reduce intraoperative bleeding in patients with PAS,but it may also cause ischemia-reperfusion injury.In this study,we intend to investigate the efficacy of low extra-abdominal aortic block in cesarean section for placental implantation disease and its effect on malondialdehyde(MDA)level and superoxide dismutase(SOD)activity,and analyze the severity of ischemia-reperfusion injury caused by them.Methods:Pregnant women with invasive placenta accreta spectrum disorders who delivered in the Department of Obstetrics and Gynecology of the Third Xiangya Hospital of Central South University from July 2017 to July 2021,were selected,and they were divided into 2 groups.Group A consisted of those who underwent low extra-abdominal aortic block during cesarean section(n=15)and group B consisted of those who did not undergo extra-abdominal aortic block(n=15).The intraoperative bleeding,blood transfusion,hysterectomy and complication rate,postoperative hospital stay and hospitalization expenses were compared between the 2 groups to analyze the efficacy of abdominal aortic block.The biochemical indexes related to ischemia-reperfusion,MDA content and total superoxide dismutase(T-SOD)activity,were measured at the corresponding time points in both groups.The time points of each test were:in group A,before the block of the low extra-abdominal aorta after delivery(A0),0 h(A1,when the myometrium was started to be sutured),0.5 h(A2),2 h(A3),and 4 h(A4)after the open block;in group B,after delivery of the fetus(B0),0 h(B1),0.5 h(B2),2 h(B3),and 4 h(B4)after the myometrium was started to be sutured.Total duration of abdominal aortic block in group A was also recorded.Both groups were observed for sings of edema,ischemia,necrosis and infection in the limbs after surgery.The severity of ischemiareperfusion injury caused by abdominal aortic block were determined by detecting the relevant biochemical indexes at different moments of reperfusion.Results:The intraoperative bleeding and blood transfusion in group A were less than those in group B,and the difference was statistically significant(P<0.05).There was no significant difference in postoperative hospital stay and hospitalization expenses between the 2 groups(P>0.05).Surgical complications:in group A,the uterus was preserved in all cases,there was 1 bladder injury and 2 pelvic infections;while in group B,there was 1hysterectomy,3 bladder injuries,and 3 pelvic infections.Changes in T-SOD and MDA values:compared with A0 before block,the MDA level was significantly elevated in blood at time points A1,A2,and A3,while SOD activity was significantly decreased(P<0.05),and the 2 observed indexes basically returned to A1 level(ischemic period)at 4 h after open block(A4).There was no significant difference in the changes of T-SOD and MDA in group B(P>0.05).Comparison of T-SOD and MDA levels between group A and B:the difference of the 2 indexes was not statistically significant between A0 and B0(P>0.05),MDA level was not statistically significant between A1 and B1,T-SOD activity at A1 was lower than B1,the difference was statistically significant,at the rest of the same time point,MDA level in group A were higher than that in group B,T-SOD activity in group A were lower than that in group B,the difference was statistically significant(P<0.05).No postoperative limb edema,ischemia,necrosis,or infection occurred in both groups.Conclusion:Low-level extra-abdominal aortic block effectively reduces bleeding and transfusion during cesarean section for placenta accreta spectrum disorders,resulting in a transient MDA elevation and a decrease of SOD activity,which means causing transient ischemia-reperfusion injury without complications such as limb edema,ischemia,necrosis,and infection.