胎盘植入性疾病管理流程改进对母儿结局的影响

Effect of improved management of placenta accreta spectrum disorders on maternal and infant outcomes

目的评价管理流程的改进在胎盘植入性疾病(placenta accreta spectrum disorders,PAS)中的作用和对母儿结局的影响。方法回顾性收集2019年1月到2022年12月在南京大学医学院附属鼓楼医院分娩并最终诊断为PAS伴前置胎盘的164例孕妇资料,根据改进时间分为改进前组(2019年1月至2020年12月,n=96,包括双胎妊娠1例)和改进后组(2021年1月至2022年12月,n=68,均为单胎妊娠)。改进措施包括:将计划终止妊娠孕周由改进前的34~36周,推迟至37周;改进前以妊娠期贮存式自体备血为主,改进后增加了自体血回收技术的使用;腹壁切口改进前为下腹正中纵切口,改进后为原手术切口;子宫切口改进前为避开胎盘位置,改进后为根据术前超声PAS分级和术中情况,可选用子宫下段切口穿过胎盘;子宫下段和膀胱界面的分离时机改进前是在完成胎儿娩出和止血带或沙氏钳临时阻断血流后,改进后是在胎儿娩出前。采用t检验、χ^(2)检验或Fisher精确概率法等统计学方法,比较2组母儿结局。结果与改进前组比较,改进后<37周的分娩率显著下降[83.3%(80/96)与69.1%(47/68),χ^(2)=4.60,P=0.038],择期、亚急诊和急诊手术构成比差异无统计学意义(χ^(2)=0.36,P=0.834),术中采用前次手术腹壁切口的比例显著增加[74.0%(71/96)与91.1%(64/68),χ^(2)=11.11,P=0.001],采用下腹纵切口和子宫体部切口的比例显著减少[84.3%((81/96)与57.3%(39/68),χ^(2)=14.81,P<0.001;83.3%(80/96)与61.8%(42/68),χ^(2)=9.72,P=0.003]。总的异体红细胞、血小板等其他成分输血率、出院前血红蛋白水平、子宫次全切除率、膀胱损伤、血栓事件、产妇重症监护病房入住率、非计划二次手术率在2组间差异均无统计学意义(P值均>0.05)。新生儿重症监护病房入住率和坏死性小肠结肠炎发生率改进后均下降[24.7%(24/97)与11.8%(8/68),χ^(2)=4.31,P=0.038;4.1%(4/97)与0.0%(0/68),χ^(2)=58.06,P<0.001],新生儿呼吸窘迫综合征、机械通气以及新生儿败血症的发生率均有减少,但差异无统计学意义(P值均>0.05)。结论PAS孕妇采用延迟计划分娩孕周至37周后、结合个体化剖宫产手术、改变自体血获取方法等一系列改进措施后,新生儿早产或入住新生儿重症监护病房的比例明显减少,但没有增加母体并发症和急诊手术风险,母体脏器损伤、非计划二次手术、再次入院等不良事件发生率处于低水平,因此此改进具有可行性。

Objective To evaluate the role of improved management procedures in placenta accreta spectrum disorders(PAS)and its impact on maternal and infant outcomes.Methods This retrospective study involved 164 pregnant women who were diagnosed with PAS complicated with placenta previa and delivered at Nanjing Drum Tower Hospital,Nanjing University Medical School from January 2019 to December 2022.All subjects were allocated to pre-improvement group(January 2019 to December 2020,n=96)and post-improvement group(January 2021 to December 2022,n=68).The management was improved in the following five aspects:(1)The time for scheduled delivery was postponed to 37 weeks from 34-36 weeks;(2)Intraoperative cell salvage was encouraged despite autologous blood donation during pregnancy;(3)Original surgical incision was utilized instead of mid-longitudinal incision in the lower abdomen to reduce operative trauma;(4)A lower segment incision of the uterus was not prohibited based on pre-operative PAS classification and intra-operative situation to enter the uterine cavity,even through the placenta instead of pass-by;(5)The interface between lower uterine segment and bladder was dissected before instead of after the baby was born and uterine blood supply was stopped by tourniquet or Scharr forceps.Statistical methods such as t-test,Chi-square test or Fisher exact probability method were used to compare the difference in maternal and infant outcomes between the two groups.Results After the improvement,the delivery rate beyond 37 weeks decreased significantly[83.3%(80/96)vs 69.1%(47/68),χ^(2)=4.60,P=0.038].There was no significant difference in the distribution of elective,subemergency and emergency surgeries before and after the improvement(χ^(2)=0.36,P=0.834).Compared to the pre-improvement group,the proportion of women who underwent cesarean section through previous abdominal incisions increased significantly[74.0%(71/96)vs 91.1%(64/68),χ^(2)=11.11,P=0.001]in the post-improvement group,while the proportion of application of abdominal longitudinal incision and classical cesarean section decreased significantly[84.3%(81/96)vs 57.3%(39/68),χ^(2)=14.81,P<0.001;83.3%(80/96)vs 61.8%(42/68),χ^(2)=9.72,P=0.003].No significant difference was found between the two groups in terms of the transfusion rate of allogeneic red blood cell,platelet and other blood components,pre-discharge hemoglobin level,subtotal hysterectomy rate,bladder injury,thrombus event,the admission rate of intensive care unit and unplanned reoperation rate(all P>0.05).The incidence of admission in neonatal intensive care unit(NICU)and necrotizing enterocolitis decreased significantly after improvement[24.7%(24/97)vs 11.8%(8/68),χ^(2)=4.31,P=0.038;4.1%(4/97)vs 0.0%(0/68),χ^(2)=58.06,P<0.001].The incidence of respiratory distress syndrome,mechanical ventilation,and neonatal septicemia also decreased,but without statistical difference.Conclusions After adopting a series of improvement measures,such as delaying planned delivery to 37 weeks of gestation,individualized cesarean section plan,and changing the method of obtaining autoblood,the number of premature infants and the NICU admission rate decreased significantly without increasing the risk of maternal complications and emergency operation.Furthermore,the incidence of adverse events such as maternal organ injury,unplanned reoperation,and re-admission remains at a low level.Therefore,this improved management is feasible.