不同位置胎盘发生胎盘植入产前诊断情况及围产结局分析

Prenatal diagnosis of placenta accreta spectrum in different positions and analysis of their perinatal outcomes

摘要:

目的： 探讨不同位置胎盘发生胎盘植入（placenta accreta spectrum，PAS）的产前诊断情况、临床特点及围产结局。方法： 回顾性纳入2012年1月至2021年12月于重庆医科大学附属第一医院分娩孕周≥28周且最终被诊断为PAS的孕妇，按照胎盘位置不同分为3组（前壁组、后壁组、两侧壁及宫底部组），比较3组PAS的产前诊断情况、临床特点及围产结局上是否存在差异。结果： 共纳入2 070名孕妇。一般资料比较上，前壁组在孕次、产次、前置胎盘率、剖宫产次数≥2和既往前置胎盘病史上明显高于后壁组（P<0.05）；而后壁组在胎盘粘连、多胎妊娠、人工辅助生殖、阴道分娩率和分娩孕周上均高于前壁组（P<0.05）。胎盘植入程度和产前诊断方面，前壁胎盘中胎盘植入和穿透性胎盘植入发生率明显高于后壁组，总的PAS产前识别率前壁组明显高于另外2组（P<0.05）；进一步比较胎盘粘连中的产前诊断率，前壁明显高于另外2组（P<0.05），胎盘植入中产前诊断也是前壁高于后壁（P<0.05），穿透性胎盘植入方面，3组没有明显统计学差异。围产期处理方式上，前壁组在术前腹主动脉球囊、使用宫腔填塞、子宫捆绑、子宫切除、术后子宫动脉栓塞上高于后壁组（P<0.05）。围产结局方面，前壁组在24 h出血量、输注血液制品情况、其他器官损伤、孕妇转重症监护病房（intensive care unit，ICU）、术后住院天数上均高于后壁组（P<0.05），而后壁组新生儿平均出生体质量高于前壁组（P<0.05）。结论： 非前壁胎盘发生PAS的产前诊断率低，但是前壁胎盘发生严重胎盘植入的比例更高，其最终围产结局比后壁组更差。临床工作中一方面需对后壁胎盘发生PAS有更高的警惕性，必要时可通过磁共振成像（magnetic resonance imaging，MRI）进一步确诊，另一方面有必要对产前诊断PAS孕妇进行积极的多学科管理，以改善这些孕妇的围产结局。

Abstract:

Objective: To investigate the prenatal diagnosis, clinical features and perinatal outcomes of placenta accreta spectrum (PAS) in different positions of the placenta. Methods: All pregnant women who delivered at Ｔhe First Affiliated Hospital of Chongqing Medical University from January 2012 to December 2021 and were finally diagnosed with PAS were included. They were divided into three groups depending on the placenta location (anterior, posterior, lateral/uterine fundus). Prenatal diagnosis rate, clinical features and perinatal outcomes among the three groups were compared. Results: A total of 2 070 pregnant women were included. In terms of basic characteristics, gravidity, parity, placenta previa rate, cesarean section times≥2 and previous history of placenta previa was significantly higher in the anterior placenta group (P<0.05). The placental accreta rate, multiple pregnancy, in vitro fertilization, vaginal delivery rate and delivery gestational age in the posterior group were higher than those in the anterior placenta group (P<0.05). In terms of grade of PAS and prenatal diagnosis rate, the incidence of placental increta and percreta in anterior wall was significantly higher than that in posterior wall, and the overall prenatal diagnosis rate of PAS was significantly higher than the other two groups (P<0.05) ; further comparison showed that the prenatal diagnosis rate of placental accreta in anterior wall was significantly higher than the other two groups (P<0.05) , and the diagnosis rate of placental increta in anterior wall was also higher than posterior wall (P<0.05) , and there was no statistically significant difference among the three groups in comparison of placenta percreta. Compared with the preoperative procedure, the abdominal aortic balloon, uterine packing, uterine binding, hysterectomy, and postoperative uterine artery embolization were higher in anterior placenta group (P<0.05). In terms of perinatal outcomes, 24 hours blood loss, transfusion of blood products, other organ damage, transfer to intensive care unit (ICU) and postoperative hospital stay were significantly higher in the anterior placenta group (P<0.05). The mean birth weight of neonates in the posterior placenta group was higher than that in the anterior placenta group (P<0.05). Conclusion: The prenatal diagnosis rate of PAS in non-anterior placenta is low, but the rate of severe placenta accreta is higher in anterior placenta, and perinatal outcomes is much worse in anterior placenta. On the one hand, it is necessary to be more vigilant about the occurrence of PAS in posterior placenta, and if necessary, further diagnosis can be made by magnetic resonance imaging (MRI). On the other hand, active multidisciplinary management of pregnant women with prenatal diagnosis of PAS is necessary to improve the perinatal outcomes of these women.