Weiniger Carolyn F, Kabiri Doron, Ginosar Yehuda, Ezra Yossef, Shachar BatZion, Lyell Deirdre J
Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA; Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel.
Eur J Obstet Gynecol Reprod Biol. 2016 Mar;198:56-61. doi: 10.1016/j.ejogrb.2015.12.020. Epub 2016 Jan 8.
Planned cesarean hysterectomy (CH) is recommended to minimize morbidity for suspected placenta accreta (PA), yet this ends fertility. We examined CH frequency and post-operative morbidities for suspected PA cases when an intra-operative decision strategy to perform CH was used.
Suspected PA cases were pre-operatively identified in one tertiary care center. Women were assessed intra-operatively, prior to uterine incision, for immediate CH or for attempted placental separation. We compared outcomes among women with versus without PA (surgical and/or pathologic diagnosis), and examined outcomes following immediate CH versus attempted placental separation.
Our cohort, from 2002 to 2012, comprised 99 women with suspected PA; 54 (54.5%) had PA diagnosed by surgery/pathology, and 45 (45.5%) did not. Among women diagnoses surgically or pathologically with PA, CH was performed for 46/54 (85%); 8 women with suspected PA had successful placental separation. 27 of the 46 CH were performed immediately following uterine wall examination and 19 were performed following attempted placental separation. We received histological confirmation of the clinical placenta accreta diagnosis for 24/46 (52.2%) cases, and in 22/46 (47.8%) cases the histology did not confirm the clinical diagnosis. Surgery duration, packed cell transfusion requirement and postoperative outcomes were similar among women with PA regardless of immediate CH versus attempted placental separation, except for a higher cystotomy rates following attempted placental separation. Emergency deliveries were performed at significantly earlier gestational ages.
Among women with suspected PA, an intra-operative CH decision allows some women to avoid CH. Consideration of attempted placental separation did not increase blood transfusion or post-operative complications, but was associated with a higher rate of cystotomy.
对于疑似胎盘植入（PA）的情况，建议计划性剖宫产子宫切除术（CH）以尽量降低发病率，但这会导致生育能力丧失。我们研究了在采用术中决定是否进行CH的策略时，疑似PA病例的CH频率和术后发病率。
在一家三级医疗中心术前识别疑似PA病例。在子宫切开术前对女性进行术中评估，以确定是立即进行CH还是尝试胎盘剥离。我们比较了有PA（手术和/或病理诊断）和无PA的女性的结局，并检查了立即进行CH与尝试胎盘剥离后的结局。
我们2002年至2012年的队列包括99例疑似PA的女性；54例（54.5%）经手术/病理诊断为PA，45例（45.5%）未诊断为PA。在经手术或病理诊断为PA的女性中，46/54例（85%）进行了CH；8例疑似PA的女性成功进行了胎盘剥离。46例CH中有27例在子宫壁检查后立即进行，另外19例在尝试胎盘剥离后进行。我们对24/46例（52.2%）病例的临床胎盘植入诊断获得了组织学证实，22/46例（47.8%）病例的组织学未证实临床诊断。无论立即进行CH还是尝试胎盘剥离术，PA女性的手术时间、红细胞输注需求和术后结局相似，但尝试胎盘剥离术后膀胱切开术发生率更高。急诊分娩的孕周明显更早。
在疑似PA的女性中，可以在术中决定是否进行CH来避免一些女性接受CH。尝试胎盘剥离术虽未增加输血或术后并发症，但与膀胱切开术发生率较高有关。
