Sparić Radmila, Mirković Ljiljana, Ravilić Uroš, Janjić Tijana
Vojnosanit Pregl. 2014 Dec;71(12):1163-6. doi: 10.2298/vsp1412163s.
Placenta previa is related to severe maternal and fetal morbidity. The increasing incidence of cesarean delivery rate causes a marked increase in abnormally invasive placenta over the past decades. The abnormally invasive placenta is becoming the foremost cause of obstetric hemorrhage and postpartum hysterectomy, causing a significant maternal and fetal morbidity and even mortality. Maternal morbidity in such cases also comprise politransfusion, development of disseminated intravascular coagulation, uterine rupture, cystostomy, fistula formation, ureteral stricture, intensive care unit admission, infection, and prolonged hos- pitalization, adult respiratory distress syndrome, renal failure, septicemia and even death.
A 38-year-old gravida 3, para 2, was admitted to our hospital at 27 weeks of gestation as an emergency due to vaginal bleeding, previously diagnosed with an anterior placenta previa. Following tocolytic therapy, bleeding stopped. The patient was informed on the diagnosis and the possibility of life-threatening hemorrhage necessitating preterm delivery. She was given corticosteroids to enhance fetal lung maturity. At 28 weeks of gestation, she experienced massive vaginal bleeding, and a decision was made to perform emergency cesarean section. We made a corporeal transverse uterine incision well above the uterovesical fold and tortuous vessels, at the same time avoiding the superior edge of the placenta. The placenta was found to be densely adherent to the lower uterine segment, penetrating through it and infiltrating the posterior wall of the urinary bladder. An attempt to remove the placenta resulted in injury to the bladder wall and the uterine rupture at a previous cesarean scar. The decision was made to perform total abdominal hysterectomy with placenta left in situ. At present, both mother and the baby are well.
Anticipation and the surgeon's judgment are leading factors for surgery, from the choice of uterine incision type to the decision to proceeding to hysterectomy in order to reduce maternal morbidity.
前置胎盘与严重的母婴发病率相关。在过去几十年中，剖宫产率的不断上升导致异常侵入性胎盘的发生率显著增加。异常侵入性胎盘正成为产科出血和产后子宫切除术的首要原因，导致严重的母婴发病率甚至死亡率。此类病例中的产妇发病率还包括多次输血、弥散性血管内凝血、子宫破裂、膀胱造口术、瘘管形成、输尿管狭窄、入住重症监护病房、感染、住院时间延长、成人呼吸窘迫综合征、肾衰竭、败血症甚至死亡。
一名38岁经产妇，孕3产2，因阴道出血于妊娠27周时急诊入院，此前诊断为前置胎盘。经宫缩抑制剂治疗后，出血停止。患者被告知诊断结果以及可能因危及生命的出血而需要早产。给予她糖皮质激素以促进胎儿肺成熟。妊娠28周时，她再次出现大量阴道出血，决定行急诊剖宫产。我们在子宫膀胱反折和迂曲血管上方做了一个子宫体部横切口，同时避开胎盘上缘。发现胎盘与子宫下段紧密粘连，穿透子宫下段并浸润膀胱后壁。试图取出胎盘导致膀胱壁损伤和既往剖宫产瘢痕处子宫破裂。决定行全腹子宫切除术，胎盘原位保留。目前，母婴均状况良好。
从子宫切口类型的选择到决定是否进行子宫切除术，预判和外科医生的判断是手术的主导因素，以降低产妇发病率。
