胎盘植入是影响妊娠结局的灾难性疾病，目前我国在胎盘植入的处理已取得长足的进步。本视频讲者结合自身丰富的临床经验和相关文献，讨论了胎盘植入处理中的热点问题。首先阐述胎盘植入患者孕期管理关键问题，包括孕期严重并发症、高危因素、早期诊断、终止妊娠的时机及妊娠风险评估等；其次讨论了胎盘植入术中不同止血措施的效果评价与思考，包括动脉球囊阻断、动脉介入栓塞等；最后总结了胎盘植入处理的基本准则，有助于临床医生在临床实践中灵活运用、规范处理。
For the interventional radiology of postpartum hemorrhage in placenta accrete spectrum, the prenatal risk assessment of placental implantation should be done well, the indications should be understood, a multidisciplinary team should be established and procedures should be standardized, effective surgical hemostasis methods should be combined, and complications should be paid attention to and prevented, so as to make this technology more suitable for application.
Objective:To explore the risk and management approach of re-pregnancy and delivery after partial hysterectomy.Methods:Retrospective analysis was made on the patients who underwent partial hysterectomy to retain the uterus for PAS in the Third Affiliated Hospital of Guangzhou Medical University from January 1, 2015 to December 31, 2018.Following up the pregnancy process and outcomes of 12 re-pregnancy cases after the operation, the recurrence of placenta previa and/or PAS, intraoperative blood loss, uterine condition, delivery gestational weeks, complications, delivery mode, neonatal condition and puerperal recovery of these cases were analyzed.Results:1.Among the 12 cases, there are 1 scar pregnancy and 11 intrauterine pregnancies.Most of them had a good early embryo development(including 1 scar pregnancy) except for 1 embryo damage, and there was no embryonic dysplasia.2.Four women chose induced abortion at the first trimester(terminated at 6-8 gestational weeks, including 1 case of scar pregnancy). One woman chose induced labor in the second trimester (terminated at 13+ weeks).3.There were 7 live births (delivered at 36-38 gestational weeks, the mode of delivery was cesarean section, among which 1 case of central placenta previa combined with placenta increta underwent total hysterectomy). All the above operations were successful, the hemodynamics were stable, and no one was transferred to the ICU afterward. There was no obvious abnormality in their newborns, and the postoperative recovery was good.Conclusions:1.Women with PAS who underwent partial hysterectomy to preserve their reproductive function can have a chance of normal pregnancy afterward. 2.There are risks of scar pregnancy, placental abnormities and uterine rupture in the pregnancies after partial hysterectomy. If these pregnancies were to continue, they should undergo close observation by doctors during the entire gestation and delivery.
The role of prophylactic interventional radiology in the treatment of placenta accrete spectrum diseases has been paid more and more attention and has become one of the alternative methods to reduce severe postpartum hemorrhage in the treatment of placenta accreta. However, there is a lack of clinical operation guidelines, and there is still no uniform standard for technical indications, selection of different interventional methods, operation procedures, precautions, and prevention of complications. The Maternal and Fetal Medicine Special Committee of Obstetrics and Gynecology Branch of Chinese Medical Doctor Association and Critical Care Subgroup, Chinese Society of Perinatal Medicine, Chinese Medical Association have organized experts to discuss and refer to both domestic and international literature to formulate this consensus, which aims to provide a certain basis and guideline for the application of prophylactic interventional radiology in placenta accreta diseases.
Placenta accreta spectrum (PAS) is one of the leading causes of obstetric emergencies, characterized by abnormal invasion of trophoblasts into the uterus and adjacent organs. The incidence of PAS is increasing all around world in recent years. Histopathological examination can accurately diagnose PAS, providing a basis for subsequent treatment. Additionally, histopathological examination also contributes to understand the pathogenesis and improve the management of PAS.
Adverse outcomes of placenta accreta spectrum disorders include uterine rupture, postpartum hemorrhage, blood transfusion, hysterectomy, multiple organ damage, maternal death, etc. Long-term effects include intrauterine adhesions, amenorrhea, recurrent placenta accreta spectrum disorders, psychological disorders and infertility. For high-risk groups, prenatal assessment, early diagnosis and individualized treatment plan should be strengthened, and MDT team management and intervention should be actively carried out to effectively reduce the incidence of adverse outcomes and improve the long-term prognosis of patients.
Placenta accreta spectrum (PAS) disorders are severe maternal complications that can lead to life-threatening outcomes. The incidence of PAS has been increasing year by year, making it a substantial challenge for obstetricians. Improving the quality of obstetric care to enhance maternal outcomes in an evidence-based approach stands as a shared objective on a global scale. This article focuses on the key issues surrounding PAS, including the risk factors for PAS, preoperative risk stratification for PAS, and optimizing surgical strategies to improve clinical outcomes.
胎盘植入性疾病(placenta accrete spectrum disorders, PAS)是指胎盘绒毛异常侵入子宫肌层的一组疾病，依据绒毛侵入程度分成粘连性胎盘植入(placenta creta，PC)、植入性胎盘植入(placenta increta，PI)和穿透性胎盘植入(placenta percreta，PP)。PAS发生率为1/350~1/500，近年来呈上升趋势，是导致妊娠期子宫破裂、严重产科出血、子宫切除、脏器损伤，甚至孕产妇死亡的重要原因[1,2]。PAS已经成为影响妊娠结局的灾难性疾病，产科医师需要在"区域性PAS处置中心"联合影像科、病理科、新生儿科、妇科、泌尿外科、血管介入科、检验科等多学科共同处置[3,4]。
胎盘植入的根本原因是子宫蜕膜发育不良，目前的诊断方法有生化诊断、影像学诊断、临床及病理诊断。本视频主要介绍了胎盘植入的影像学诊断，分别介绍超声(二维超声、彩色多普勒、三维超声)和MRI检查在胎盘植入诊断中的应用价值、图像特征及对胎盘植入类型和凶险程度的预测作用，还特别介绍了MRI技术新进展在胎盘植入研究中的应用，并对各项检查的特异度、敏感性和优点进行了比较、总结，有助于临床医生在实践中灵活应用。
Objective:To investigate the application value of magnetic resonance imaging in predicting massive hemorrhage in patients with placenta accreta spectrum disorders during cesarean section.Methods:A total of 161 patients with placenta previa were selected who received prenatal examination and delivered in our hospital from January 2015 to December 2020. According to the amount of intraoperative blood loss, they were divided into the study group (79 cases) (intraoperative bleeding ≥2000 ml) and the control group (82 cases) (intraoperative bleeding <2000 ml). The general situation and MRI characteristics of the subjects were analyzed to explore the predictive value of MRI in the severe intraoperative hemorrhage of placenta previa.Results:There were no significant differences in age, body mass index, hysterectomy rate and bladder injury rate between the two groups (P>0.05). The number of pregnancies, number of births and operation time in the study group were higher than those in the control group, and the difference was statistically significant (P<0.05). The gestational age and neonatal weight of the study group were lower than those of the control group, and the differences were statistically significant (P<0.05). The amount of intraoperative blood loss in the study group was higher than that in the control group [(2491.68±504.48)ml vs (997.46±421.81)ml], and the difference was statistically significant (P<0.05). The amount of intraoperative blood transfusion in the study group was higher than that in the control group [(1987.58±596.94)ml vs (681.23±445.64)ml], and the difference was statistically significant (P<0.05). In the study group, the percentage of the placental anterior wall (79.75% vs 30.49%), placental thickness[(5.23±1.28)cm vs (4.32±1.27)cm], cervical length[(2.76±0.51)cm vs (3.20±0.51)cm], placental hyposignal area[(7.02±1.89)cm2vs (4.69±1.70)cm2], cervical placental signal(21.52% vs 6.10%), the low signal in the cervix(26.58% vs 10.98%), and inner bladder roughness(18.99% vs 7.32%) were higher than those in the control group, the difference was statistically significant (P<0.05). The placenta signal in the cervical canal was the most high-risk sign of intraoperative massive hemorrhage (OR=6.76, 95%CI: 2.44-9.27, P<0.05). Combined with seven MRI features, it is an effective method in the prediction of massive hemorrhage during cesarean section in placenta previa patients with placenta accreta (AUC=0.90).Conclusions:MRI can effectively evaluate the severity of placenta previa and predict the risk of massive bleeding during cesarean section, which is beneficial to obstetricians to make full preoperative preparations, reduce intraoperative bleeding and save the lives of pregnant women.
Objective:To investigate the effect of transfusion protocol on maternal outcomes in patients with placenta accreta spectrum (PAS) and severe postpartum hemorrhage (sPPH).Methods:Make a retrospective analysis of the clinical data of 262 puerpera who were diagnosed with PAS, underwent cesarean delivery, developed sPPH, and received a blood transfusion from January 1, 2018 to October 31, 2021, in the Third Affiliated Hospital of Guangzhou Medical University. The patients were divided into groups according to the total amount of bleeding in 24 hours after the operation and the infusion ratio of red blood cell (RBC) to fresh frozen plasma (FFB): 151 cases of moderate sPPH (the total amount of bleeding 24 hours >1000~2000 ml) were divided into four groups: 1A (RBC∶FFB<1∶1, 17 cases), 1B (RBC∶FFB=1∶1, 45 cases), 1C(RBC∶FFB>1∶1, 17 cases) and 1D (RBC only, 72 cases); Severe SPPH (the total amount of bleeding 24 hours >2000 ml, 111 cases) were divided into three groups: 2A(RBC∶FFB<1∶1, 19 cases), 2B(RBC∶FFB=1∶1, 43 cases) and 2C (RBC∶FFB>1∶1, 49 cases). The general clinical data, intraoperative conditions, blood consumption in 24 hours and postoperative complications of puerpera in each group under different bleeding conditions were analyzed.Results:(1) The total blood loss at 24 h after operation of the four groups 1A-1D were 1510.91±285.72, 1440.22±244.87, 1563.41±167.13, and 1340.93±293.16, respectively, the 1C was the most and the 1D was the least, and there was a statistical difference between the 1C and 1D (P<0.05). The infusion of RBC (U) were 2.91±1.27, 3.28±1.21, 4.88±0.99, and 2.61±1.12, respectively. The 1C was the most and the 1D was the least, and there was statistical difference between 1C and 1A, 1B, and 1D respectively (P<0.05); the infusion of FFB (ml) were 452.94±141.94, 327.78±121.34, 308.02±93.93, 0, respectively, 1A was the most which had statistical differences with 1B and 1C (P<0.05). According to the transfusion of blood products in the 24 hours after the operation(RBC and FFB), 1D used the least blood in the four groups. The total blood loss at 24 h after operation of the three groups 2A-2C were not statistically significant (P>0.05); infusion of RBC (U) were 5.76±2.48, 5.30±1.63, 8.20±4.16, 2C was the most, and there were statistical differences with 2A and 2B (P<0.05); FFB infusion (ml) were 760.53±292.77, 530.23±162.62, and 548.98±326.04, respectively, 2A was the most which had statistically significant differences with 2B and 2C (P<0.05). According to the transfusion of blood products in the 24 hours after the operation(RBC and FFB), 2B used the least blood in the three groups. (2) There was no significant difference in the length of hospital stay, transfer rate to ICU, and postoperation complications (except the ratio of PLT decrease) among the four groups 1A-1D and the three groups 2A-2C (P>0.05). All puerpera survived with no deaths.Conclusions:For patients with placenta accreta spectrum undergoing cesarean section, the blood transfusion strategy of a single infusion of RBC can be considered in moderate sPPH patients while RBC∶FFB=1∶1 can be considered firstly in serve sPPH patients, and then perform individualized blood transfusion according to subsequent bleeding and blood test indicators.
Objective:To investigate the anesthetic choices and the maternal and neonatal prognosis for patients undergoing cesarean section complicated with different degrees of placenta accreta.Methods:A retrospective case review of 562 patients complicated with placenta accreta from 2018 to 2021 in The Third Affiliated Hospital of Guangzhou Medical University was conducted. Patients with abortion and missing data were excluded, and the total of 353 cases were enrolled in this study. According to the degree of placenta accreta reported by MRI, they were divided into the accreta group (n=63), increta group (n=249) and percreta group (n=41). We analyzed the perioperative management, and maternal and neonatal prognosis.Results:There was statistical significance in the selection of anesthesia methods in three groups (P<0.05), 27 cases (47.9%) in the accreta group, 46 cases (18.5%) in the increta group and 2 cases (4.9%) in the percreta group underwent spinal anesthesia, 36 cases (57.1%) in accreta group, 203 cases (81.5%) in increta group, 39 cases (95.1%) in percreta group underwent general anesthesia, 3 cases (11.1%), 12 cases (26.1%) in increta group and 1 case (50.0%) in percreta group underwent spinal anesthesia were eventually switched to general anesthesia from initial spinal anesthesia during the operation. In the percreta group, 36 cases (87.8%) of patients underwent hysterectomy, which were significantly higher than accreta group and increta group (P<0.05). There were no statistically significant differences in the postoperative complications in three groups (P>0.05). There were no statistically significant differences in the total length of hospitalization and postoperative length of hospitalization (P>0.05). The 1 min Apgar score in percreta group was significantly lower than the accreta group and increta group (P<0.05) while there was no statistically significants in the 5 min and 10 min Apgar scores in three Group (P>0.05).Conclusions:Anesthesiologists choose anesthesia according to the degrees of placenta accrete reported by MRI preoperatively and general anesthesia should be considered in placenta percreta. With the cooperation of obstetricians, anesthesiologists and neonatologists, the prognosis of mother and infant is good. However, patients complicated with placenta percreta have a high rate of hysterectomy.
Objective:To analyze the research content, hotspot and development trend of placenta accreta research from 2011-2021 by CiteSpace literature metrology tool, in order to provide useful reference and enlightenment for the future research direction.Methods:Literature on placental accreta from 2011 to 2021 was retrieved from three core journals of Chinese database, namely China National Knowledge Network, Wanfang and VIP. CiteSpace software was used to analyze and draw the visual knowledge map of authors, research institutions and keyword clustering, and the research achievements in this field were sorted out.Results:A total of 1314 valid literatures were included.The visualization knowledge graph analysis showed that experts and scholars such as Yang Huixia, Chen Dunjin and Zhao Yangyu were the main research forces in this field. The First Hospital of Peking University, the Third Hospital of Peking University and the Second Hospital of West China of Sichuan University are the main medical institutions for the study of placenta accreta. In recent ten years, the research of placental accreta has focused on subjects such as placenta accreta, placenta previa, prenatal diagnosis, hemostasis, hysterectomy and pregnancy outcome.Conclusions:Chinese scholars attach great importance to the imaging diagnosis of placental accreta disease, improvement of cesarean section surgical methods, and the prevention of severe postpartum hemorrhage. However, how to improve pregnancy management, improve maternal and infant prognosis, strengthen inter-hospital cooperation, and reduce the geographical gap are still urgent issues to be solved in the study of placenta accreta disease.
复发性流产(recurrent spontaneous abortion, RSA)，也叫反复妊娠丢失，是指与同一性伴侣，妊娠28周内3次或3次以上的妊娠丢失[1]。但目前大多数专家认为，连续发生2次流产的患者，其发生再次流产的风险与3次相近，应予以重视，该观点与欧洲人类生殖与胚胎学会和美国生殖医学学会一致[2,3]。临床上，发生2次或2次以上流产的患者约占生育期妇女的5%，而3次或3次以上者约占1%[3]。RSA的复发风险随着流产次数的增加而上升，研究表明，曾有3次以上连续自然流产史的患者再次妊娠后胚胎丢失率接近40%[1]。
Thrombophilia in pregnancy includes both inherited and acquired. Hereditary thrombophilia involves changes in the factors involved in coagulation and fibrinolysis due to genetic alterations, and their relationship with adverse pregnancy outcomes is still unclear. The acquired thrombophilias are mainly associated with antiphospholipid syndrome, in which the spectrum of antiphospholipid antibodies play a key role in the pathogenesis of the disease, inducing activation of various cells, inflammation and the complement system, leading to the occurrence of thrombosis and adverse pregnancy outcomes. This article reviews the pathogenesis of thrombophilia in pregnancy.
Objective:To analyze and compare the adverse outcomes of women and infants with Preeclampsia (PE) combined with fetal growth restriction (FGR) and the pathological changes of maternal placenta, and explore whether the adverse outcomes of women and infants with PE combined with FGR are worse. In the case of PE pregnant women with FGR, whether the maternal placenta has more serious lesions, and explore the correlation between the severity of maternal placenta lesions and adverse maternal and infant outcomes.Methods:The pregnancy outcomes and maternal placenta pathology data of 148 women with PE who were hospitalized and gave birth in the Obstetrics Department of The Third Affiliated Hospital of Guangzhou Medical University from January 2019 to June 2022 were retrospectively analyzed, and 148 women were divided into two groups according to whether the pregnant women were combined with FGR: The FGR group (44 cases, 29.7%) was the observation group, and the non-FGR group (104 cases, 70.3%) was the control group.Results:(1) There was no significant difference in age and basic body mass index between the two groups. However, the proportion of first-time mothers and previous history of hypertension or FGR in the FGR group were higher than those in the non-FGR group [61.36% (27/44) vs 37.50% (39/104), 11.36% (5/44) vs 2.88% (3/104), 4.55% (2/44) vs 0% (0/104)], (all P<0.05), the difference was statistically significant. (2) The birth weight of newborns in the FGR group was lower than that in the non-FGR group [(1434.6±536.4) g vs (2288.7±976.7) g, t= 5.456, P<0.001], and the difference was statistically significant. The incidence of preterm birth and admission to neonatal department after birth in the FGR group was higher than that in the non-FGR group [79.5% (35/44) vs 50.0% (52/104) and 86.4% (38/44) vs 46.2% (48/104), P<0.001], the difference was statistically significant. (3) The incidence of related maternal complications in the FGR group was higher than that in the non-FGR group, especially the incidence of hypoproteinemia, which was significantly higher in the FGR group than in the non-FGR group [29.6% (13/44) vs10.6% (11/104)] (χ2=8.188, P=0.004). The difference was statistically significant. The incidence of liver and kidney dysfunction and thoracoabdominal effusion in patients with FGR was higher than that in patients without FGR [11.4% (5/44) vs. 3.9% (4/104), 13.6% (6/44) vs. 6.7% (7/104) and 9.1% (4/44) vs. 5.8% (6/104)]. There was no significant difference (P>0.05). (4) The placental weight in the FGR group was significantly lower than that in the non-FGR group [(345.93±101.06) g vs (436.78±125.70) g, t=4.246, P<0.001], and the placental coefficient was higher than that in the non-FGR group. [(0.26±0.09) vs (0.21±0.08), t=3.181, P=0.002], the differences were statistically significant, indicating that the placental hypoplasia of pregnant women with FGR was more significant. (5) The incidence of various placental lesions in the FGR group was higher than that in the non-FGR group, especially the incidence of decidua vascular disease and villus hypoplasia was about 2 times higher than that in the non-FGR group, and the placental lesions in the FGR group were mostly severe or diffuse.Conclusions:The overall incidence of maternal complications in the FGR group was higher than that in the non-FGR group, and the perinatal preterm birth and low birth weight were more serious. The placental lesions in the FGR group were more serious, that is, the incidence of related placental lesions was higher, and the lesions were mainly diffuse or severe. Severe placental pathology is likely to be associated with worse perinatal adverse outcomes.
患者39岁，孕3产0，因"停经35+4周，甲亢病史19+年"于2022年2月17日收入广州医科大学第三附属医院妇产科。2011年患者孕1个多月因甲亢行人工流产1次，2021年2月生化妊娠1次；此次妊娠为自然受孕，末次月经2021年6月13日，预产期2022年3月20日。患者2021年8月6日于外院行超声诊断："宫内早孕，胎儿如孕7+周，子宫左侧壁见大小64 mm×33 mm低回声结节"。孕期定期产检，行胎儿超声提示胎儿颈项透明层厚度正常，行母体外周血胎儿染色体非整倍体基因检测、口服葡萄糖耐量试验均正常，行产科Ⅲ级超声检查提示胎儿结构未见明显异常。孕期一般情况好，孕前体重56 kg，现体重68 kg，孕期增重12 kg，孕前体重指数：23 kg/m2。患者孕前心率85~95次/min，随孕周增加孕期心率逐渐增快，由90次/min增加至128次/min，孕34周后自行口服中药(具体不详)，心率波动于97~115次/min。确诊早孕后建议其改用"丙硫氧嘧啶(propylthiouracil，PTU)"治疗甲亢，但患者口服"PTU"2周后复查肝功能异常(正常值2倍)，自行改为"甲巯咪唑(methimazole，MMI)"控制甲亢症状(患者为中医研究生毕业)。为进一步诊治至我院就诊。
患者30岁，妊2产0，因"停经26周，宫颈环扎术后15 d"于2021年1月10日由南通大学附属妇幼保健院妇科病房转入产科病房继续治疗。患者平素月经欠规则，周期30~60 d，婚后5年未孕，胚胎移植4次，生化妊娠2次。此次妊娠系外院行体外受精胚胎移植(in vitro fertilization and embryo transfer，IVF-ET)术后妊娠，早孕期曾因阴道少量流血在我院妇科住院保胎，半个月后无特殊情况出院。患者孕期定期产检，胎儿超声系统排畸检查未见明显异常，无创DNA检测为低风险。2020年12月23日(孕25周)，因"阴道分泌物增多、宫口开大2 cm"再次入住我院妇科病房，行宫颈环扎术后继续使用盐酸利托君保胎、地塞米松促胎儿肺成熟及抗炎治疗。孕妇入院后检查血常规、输血四项、肝肾功能及甲状腺功能均正常。1月10日(孕26周)转入产科病房，产科检查情况：宫高26 cm，腹围103 cm，胎儿超声检查(1月8日)：双顶径63 mm，腹围208 mm，股骨长约51 mm，估计胎儿体重1200 g，胎儿存活，胎心率145次/min。孕妇身高155 cm，孕前体重73 kg。入住产科后初步诊断：(1)妊2产0，孕26周待产，左枕前位；(2)妊娠合并子宫颈环扎术后；(3)妊娠合并肥胖症；(4)IVF-ET妊娠状态。
患者34岁，孕6产2，因"停经25+4周，恶心、呕吐伴下腹痛8+ h"于2021年8月10日04：32收入深圳市龙岗区妇幼保健院妇科。入院前1周曾在外院行口服葡萄糖糖耐量试验(oral glucose tolerance test, OGTT)示：空腹血糖5.09 mmol/L，餐后1 h血糖11.11 mmol/L，餐后2 h血糖9.15 mmol/L，诊断妊娠期糖尿病，予以饮食运动指导，未规律检测血糖。入院前1天(8月9日)早餐进食糯米团等碳水化合物，出现口渴、多饮、多尿，8月9日夜间上述症状加重，19：00时进食牛奶后出现恶心，呕吐4次为胃内容物，伴下腹隐痛、腰部酸痛、坠胀感，有头痛、心慌、胸闷，无抽搐、昏迷。
