Panigrahi Anil K, Yeaton-Massey Amanda, Bakhtary Sara, Andrews Jennifer, Lyell Deirdre J, Butwick Alexander J, Goodnough Lawrence Tim
From the Departments of *Anesthesiology, Perioperative, and Pain Medicine and Department of Pathology and †Obstetrics and Gynecology, Stanford University Medical Center, Palo Alto, California; ‡Department of Laboratory Medicine, University of California, San Francisco, San Francisco, California; Departments of §Pathology and Pediatrics and ‖Pathology and Medicine, Stanford University Medical Center, Palo Alto, California.
Anesth Analg. 2017 Aug;125(2):603-608. doi: 10.1213/ANE.0000000000002050.
The incidence of placenta accreta (PA) has increased from 0.8 to 3.0 in 1000 pregnancies, driven by increased rates of cesarean deliveries (32.2% in 2014) of births in the United States. The average blood loss for a delivery complicated by PA ranges from 2000 to 5000 mL, frequently requiring substantial transfusion medicine support. We report our own institutional multidisciplinary approach for managing such patients, along with transfusion medicine outcomes, in this setting over a 5-year period.
We reviewed records for patients referred to our program in placental disorders from July 1, 2009, to July 1, 2014. A placental disorders preoperative checklist was implemented to ensure optimal management of patients with peripartum hemorrhage.
Of 136 patients whose placentas were reviewed postpartum, 21 had PA, 39 had microscopic PA, 17 had increta, 17 had percreta, and 42 had no accreta (of which 11 had placenta previa). For each subtype, the percentage of patients receiving blood products were 71% (PA), 28% (microscopic PA), 82% (increta), 82% (percreta), and 19% (no accreta). Among patients with PA or variants, 89% of patients with PA or variants underwent postpartum hysterectomy, compared to only 5% of patients with no or microscopic PA.
Based on our experience and on the findings of our retrospective analysis, patients presenting with either antepartum radiological evidence or clinical suspicion of morbidly adherent placenta will benefit from a standardized protocol for clinical management, including transfusion medicine support. We found that massive hemorrhage is predictable when abnormal placentation is identified predelivery and that blood product support is substantial regardless of the degree of placental invasiveness. The protocol at our institution provides immediate access to sufficient volumes and types of blood products at delivery for patients at highest risk for life-threatening obstetric hemorrhage. Therefore, for patients with a diagnosis of morbidly adherent placenta scheduled for planned cesarean delivery with possible hysterectomy, a programmatic checklist that mobilizes a multidisciplinary team, including proactive transfusion medicine support, represents best practices.
在美国，由于剖宫产率上升（2014年为32.2%），胎盘植入（PA）的发生率已从每1000例妊娠中的0.8例增至3.0例。PA所致分娩的平均失血量在2000至5000毫升之间，常常需要大量输血医学支持。我们报告了我们机构在5年期间针对此类患者的多学科管理方法以及输血医学结果。
我们回顾了2009年7月1日至2014年7月1日转诊至我们项目的胎盘疾病患者的记录。实施了一份胎盘疾病术前检查表，以确保对产后出血患者进行最佳管理。
在136例产后胎盘接受检查的患者中，21例有PA，39例有微小PA，17例有植入性胎盘，17例有穿透性胎盘，42例无胎盘植入（其中11例有前置胎盘）。对于每种亚型，接受血液制品的患者百分比分别为71%（PA）、28%（微小PA）、82%（植入性胎盘）、82%（穿透性胎盘）和19%（无胎盘植入）。在有PA或其变异型的患者中，89%的PA或其变异型患者接受了产后子宫切除术，而无或有微小PA的患者中只有5%接受了该手术。
基于我们的经验和回顾性分析结果，产前有影像学证据或临床怀疑胎盘粘连严重的患者将受益于标准化的临床管理方案，包括输血医学支持。我们发现，在分娩前识别出异常胎盘植入时，大量出血是可预测的，并且无论胎盘侵入程度如何，血液制品支持量都很大。我们机构的方案为面临危及生命的产科出血风险最高的患者在分娩时立即提供了足够数量和类型的血液制品。因此，对于计划行剖宫产并可能行子宫切除术的诊断为胎盘粘连严重的患者，一份调动多学科团队的程序性检查表，包括积极的输血医学支持，代表了最佳实践。
