凶险性前置胎盘并植入的产前诊断及腹主动脉球囊阻断术的应用研究

发布时间：2018-06-17 01:28

本文选题：凶险性前置胎盘 + 胎盘植入　；参考：《山东大学》2017年硕士论文

【摘要】：背景凶险性前置胎盘(pernicious placenta previa)属前置胎盘的一部分。为曾经有剖宫产史的妇女,再次妊娠时并发前置胎盘,且此次胎盘附着于既往剖宫产手术瘢痕部位。凶险性前置胎盘容易并发胎盘植入。胎盘植入(placenta accreta)是胎盘与子宫之间的蜕膜海绵层生理性间隙消失,一个或多个胎盘母体叶与蜕膜基底层紧密粘连或者侵入子宫肌层甚至穿透子宫肌层。凶险性前置胎盘的发病率逐年升高,且由于剖宫产时往往会出现短时间内大量失血,因此成为目前孕产妇产后出血、子宫切除甚至死亡的重要原因。胎盘植入的产前诊断对于术中处理至关重要。常用的产前影像学诊断方式为B超及MRI。其诊断准确性各家报道不一。腹主动脉球囊阻断术(Intraoperative aorta balloon occlusion,IABO)系通过介入方法,临时阻断大部分供给盆腔及下肢的供血,从而达到开始阻断时术中出血减少的目的,增加了严重胎盘植入患者保留子宫的可能性。近年来该介入操作在盆腔部位的手术处置中陆续开始应用。目的本研究通过回顾性分析凶险性前置胎盘及并发胎盘植入患者的影像学产前诊断方法的敏感性和特异性,旨在发现较好的产前诊断方法。同时分析腹主动脉球囊阻断术在凶险性前置胎盘并胎盘植入患者剖宫产中的应用价值,比较各种治疗方式短期术后的并发症,以期得到对于凶险性前置胎盘及并发胎盘植入患者较好的手术治疗方式,为临床提供参考。方法选择山东大学附属省立医院产科2013年3月至2016年3月住院并手术的凶险性前置胎盘病例114例。依据剖宫产术中所见并结合术后病理确定是否并发胎盘植入及植入范围和深浅,并将植入达浆膜层及穿透性植入视为深植入,其它植入均视为浅植入。分析B超和MRI两种方法各自的产前诊断准确性。同时比较是否并发胎盘植入两组患者的剖宫产术中出血量、输血量、平均住院时间及新生儿情况等。根据凶险性前置胎盘并植入患者剖宫产术中是否行腹主动脉球囊阻断分为阻断组和非阻断组,比较两组术中出血量、输血量、平均住院时间及新生儿情况等。P0.05认为比较差异有统计学意义。结果114例凶险性前置胎盘病例中,术后证实合并胎盘植入者89例。其中114例病例均行B超检查。B超产前诊断为胎盘植入87例,诊断敏感性为97.75%,特异性为92%;行MRI检查85例,MRI产前诊断为胎盘植入70例,诊断敏感性为97.18%,特异性为92.86%。凶险性前置胎盘合并胎盘植入组89例患者,平均术中出血量1867ml,输红细胞量7.66U,输血浆量648ml。平均住院时间11.8天;非植入组病例25例,平均术中出血量650ml,输红细胞量2.5U,输血浆量164ml,平均住院时间7.8天。两组之间的差异具有统计学意义(p0.05)。114例凶险性前置胎盘病例中,剖宫产术中同时行子宫切除29例,膀胱损伤修补10例,均来自胎盘植入组。凶险性前置胎盘合并胎盘植入89例患者,59例行腹主动脉球囊阻断术,阻断组剖宫产术中平均出血量为1759ml,非阻断组剖宫产术中平均出血量2080ml,但两组比较差异尚无统计学意义(p0.05)。另外两组间在术后并发症的比较差异无统计学意义(p0.05)。但两组在胎盘植入的程度比较中有统计学差异意义,阻断组患者的胎盘深植入病例数明显多于非阻断组(p0.05)。胎盘植入与非植入组的新生儿转新生儿重症监护病房(Neonatal Intensive Care UnitNICU)情况差异无统计学意义(P0.05),阻断组与非阻断组的新生儿NICU转入情况差异亦无统计学意义(P0.05)。结论本研究表明B超和MRI对凶险性前置胎盘并胎盘植入的产前诊断中准确性较高,其中B超可作为首选检查方法,MRI可作为B超的补充检查手段。凶险性前置胎盘合并胎盘植入对患者的住院天数、术中出血、输血量等有明显影响。对产前诊断为胎盘植入,特别是深植入的患者剖宫产时行腹主动脉球囊阻断术,可以减少术中出血,减少术中输血量,减少住院时间,大大有利于这类患者的术后恢复,因此具有较好的临床应用价值。同时,球囊阻断术并不会增加患者术后并发症的可能,该治疗方法安全有效。新生儿的出生情况与其胎龄有关,与胎盘植入程度及是否行腹主动脉球囊阻断术无关。
[Abstract]:Background perilous placenta previa (pernicious placenta previa) is part of the placenta previa. For women who have had a history of cesarean section, the placenta previa is complicated by the placenta previa, and the placenta is attached to the scar site of the previous cesarean section. The perilous placenta previa is easily implantable with fetal disc implantation. Placental implantation (placenta accreta) is the placenta and the placenta. The physiological gap between the cavernous cavernous layer of the uterus disappears, and one or more placental mother leaves are closely connected with the decidua basal layer or intruded into the uterine myometrium and even through the myometrium. The incidence of perilous placenta previa increases year by year, and as a result of cesarean section, a large amount of blood loss often occurs in the short time, thus becoming the present maternity and obstetrics and gynecology. Postpartum diagnosis of placenta implantation is very important for intraoperative treatment. The common prenatal imaging diagnosis is the B ultrasonic and MRI. diagnostic accuracy in different reports. Abdominal aorta balloon occlusion (Intraoperative aorta balloon occlusion, IABO) through interventional methods, temporary obstruction Most of the supply of blood supply to the pelvic and lower extremities can achieve the purpose of reducing the bleeding during the beginning of the interruption, and increase the possibility of retaining the uterus in patients with serious placenta implantation. The sensitivity and specificity of the prenatal diagnosis of placental implantation is aimed at finding a better prenatal diagnosis. At the same time, the application value of abdominal aorta balloon occlusion in the caesarean section of patients with perilous placenta previa and placenta implantation is analyzed, and the complications of various treatments in the short term are compared in order to obtain the risk of the perilous risk. A good surgical treatment for the patients with placenta previa and placenta implants was provided for clinical reference. Methods 114 cases of perilous placenta previa from the affiliated Provincial Hospital of Shandong University from March 2013 to March 2016 were selected. Implantation scope and depth, and the implantation of the serosa and penetrating implantation as deep implantation, and the other implants are regarded as shallow implants. The accuracy of the prenatal diagnosis of the two methods of B-ultrasound and MRI is analyzed. At the same time, the amount of bleeding, blood transfusion, the average time of hospitalization, and the condition of the newborns in the caesarean section of the two groups of patients with placenta accreta are compared. According to the perilous placenta previa and whether the abdominal aorta balloon was blocked in the caesarean section, it was divided into blockage group and non blockage group. Compared the two groups of intraoperative bleeding, blood transfusion, average hospitalization time and newborns, there were statistically significant differences between the two groups. Results in 114 cases of perilous placenta previa, the postoperative complication was confirmed. There were 89 cases of placenta implants, of which 114 cases were examined by B-ultrasound. Prenatal diagnosis was 87 cases of placenta implantation, the diagnostic sensitivity was 97.75%, specificity was 92%; MRI examination 85 cases, MRI prenatal diagnosis of placenta implantation 70 cases, diagnostic sensitivity 97.18%, 92.86%. perilous placenta previa combined placenta implantation group 89 patients, average operation The amount of bleeding was 1867ml, the amount of erythrocyte transfusion was 7.66U, the average hospitalization time of blood transfusion 648ml. was 11.8 days, 25 cases in non implanting group, mean intraoperative bleeding volume, 2.5U, blood transfusion 164ml, average length of hospital stay 7.8 days. The difference between the two groups was statistically significant (P0.05) in the caesarean section of.114 case pernicious placenta previa At the same time, 29 cases of hysterectomy and 10 cases of bladder injury repair were from placental implantation group. 89 patients with perilous placenta previa combined with placenta implantation, 59 cases of abdominal aorta balloon occlusion, the average bleeding amount in caesarean section was 1759ml, and the average bleeding amount of the caesarean section was 2080ml in the non blocking group, but there was no statistical difference between the two groups. Significance (P0.05). There was no significant difference in postoperative complications between the other two groups (P0.05). However, there were significant differences in the degree of placental implantation in the two groups, and the number of deep placenta implanted cases in the blockage group was significantly more than that in the non blocking group (P0.05). The difference of Neonatal Intensive Care UnitNICU) was not statistically significant (P0.05). There was no significant difference in NICU transfer between the blockage group and the non blocking group (P0.05). Conclusion this study showed that B ultrasound and MRI have high accuracy in prenatal diagnosis of perilous placenta previa and placenta implantation, and B ultrasound can be used as the first choice examination method. MRI can be used as a supplementary examination for B-ultrasound. The perilous placenta previa combined with placenta implantation has a significant influence on the patient's days of hospitalization, intraoperative bleeding, and the amount of blood transfusion. The abdominal aorta balloon occlusion for the prenatal diagnosis of placenta implantation, especially in the patients with deep implantation, can reduce intraoperative bleeding, reduce intraoperative blood transfusion, and reduce the amount of blood transfusion. The time of hospitalization is of great benefit to the postoperative recovery of this type of patients and therefore has a good clinical value. At the same time, balloon occlusion does not increase the possibility of postoperative complications. The treatment is safe and effective. The birth of the newborn is related to the gestational age, the degree of placenta implantation and the operation of abdominal aorta balloon occlusion. Close.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.2

【参考文献】