Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.
Eur J Obstet Gynecol Reprod Biol. 2019 Jun;237:126-130. doi: 10.1016/j.ejogrb.2019.04.026. Epub 2019 Apr 19.
One of the major complications of the placenta accreta spectrum (PAS) is the development of coagulopathy. The detection, prevention and prompt treatment of coagulopathy may be lifesaving.
Our objective was to study selected factors associated with coagulopathy in the management of PAS by a well-established multidisciplinary team.
This is a retrospective review of all patients with pathologically proven PAS (including placenta accreta, increta or percreta) who underwent surgery by our multidisciplinary team between January 2011 and February 2017. Coagulopathy in this setting was defined as a platelet count of <100,000/mm, international normalized ratio >1.5, and/or fibrinogen <300 mg/dL based on institutional protocols developed by our Division of Transfusion Medicine & Coagulation. The outcomes of those patients with and without coagulopathy were compared with appropriate adjustments. Receiver operating characteristics curves (ROCs) were constructed to assess the ability of select variables to discriminate between women with and without coagulopathy, and the area under the curves (AUCs) were calculated.
Of 123 singleton patients with PAS, 37 (30.1%; 95%CI 22.1-39.0) developed coagulopathy and 86 (69.9%; 95%CI 61.0-77.9) did not. Baseline patient demographic characteristics did not differ significantly between these groups. Estimated blood loss (median and Inter-quartile range) was 2100cc (1800, 400) and 1400 (1000, 2500) in the presence and absence of coagulopathy, respectively (P < 0.01). The overall number of units of red blood cells (RBC) transfused was greatest in the coagulopathy group [3 (2, 9) vs. 1 (0, 4); P < 0.01]. Univariate regression analysis confirmed the association between coagulopathy and (i) the number of units of RBC's transfused, and (ii) the estimated blood loss. ROC curves showed that an estimated blood loss ≥ 1500 mL had the best discriminating power. Depth and/or severity of placental invasion were not associated with coagulopathy in patients with PAS.
Coagulopathy in patients with PAS undergoing hysterectomy is strongly associated with blood loss and replacement. It may be prudent to establish protocols that aggressively monitor for, and treat, coagulopathy when EBL exceeds 1500 mL in such surgeries, prior to the development of clinical coagulopathy which if uncorrected may lead to massive blood loss.
胎盘植入谱系疾病（PAS）的主要并发症之一是凝血功能障碍。凝血功能障碍的检测、预防和及时治疗可能是救命的。
我们的目的是通过一个成熟的多学科团队研究 PAS 管理中与凝血功能障碍相关的选定因素。
这是对我们的多学科团队在 2011 年 1 月至 2017 年 2 月期间治疗的所有经病理证实的 PAS（包括胎盘植入、胎盘侵入或胎盘穿透）患者的回顾性分析。根据我们的输血医学和凝血科制定的机构方案，将这种情况下的凝血功能障碍定义为血小板计数<100,000/mm³、国际标准化比值>1.5 和/或纤维蛋白原<300mg/dL。比较了有和无凝血功能障碍患者的结局，并进行了适当的调整。构建了受试者工作特征曲线（ROC）来评估选择变量区分有和无凝血功能障碍患者的能力，并计算了曲线下面积（AUCs）。
在 123 例 PAS 单胎患者中，37 例（30.1%；95%CI 22.1-39.0）发生凝血功能障碍，86 例（69.9%；95%CI 61.0-77.9）未发生凝血功能障碍。这些组之间的基线患者人口统计学特征没有显著差异。估计失血量（中位数和四分位距）分别为 2100cc（1800、400）和 1400（1000、2500）在凝血功能障碍存在和不存在的情况下（P<0.01）。凝血功能障碍组输注红细胞（RBC）的单位数最多[3（2、9）比 1（0、4）；P<0.01]。单变量回归分析证实了凝血功能障碍与（i）输注 RBC 单位数和（ii）估计失血量之间的关联。ROC 曲线显示，估计失血量≥1500mL 具有最佳鉴别力。在 PAS 患者中，胎盘植入的深度和/或严重程度与凝血功能障碍无关。
行子宫切除术的 PAS 患者的凝血功能障碍与失血和输血密切相关。在这种手术中，当估计失血量超过 1500mL 时，可能需要制定积极监测和治疗凝血功能障碍的方案，而不是在出现未经纠正的临床凝血功能障碍导致大量失血之前。
