胎盘植入谱系疾病，不伴有前置胎盘。
Placenta Accreta Spectrum Without Placenta Previa.
机构信息
Harvard Medical School, Boston, Massachusetts; Baylor College of Medicine, Houston, Texas; Stanford University, Stanford, California; University of Utah, Salt Lake City, Utah; and the Pan-American Society for Placenta Accreta Spectrum, Houston, Texas.
出版信息
Obstet Gynecol. 2020 Sep;136(3):458-465. doi: 10.1097/AOG.0000000000003970.
OBJECTIVE
To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity.
METHODS
We conducted a retrospective cohort study of pathology-confirmed placenta accreta spectrum deliveries with hysterectomy from two U.S. referral centers from January 2010-June 2019. Maternal, pregnancy, and delivery characteristics were compared among placenta accreta spectrum cases with (previa PAS group) and without (nonprevia PAS group) placenta previa. Surgical outcomes and a composite of severe maternal morbidities were evaluated, including eight or more blood cell units transfused, reoperation, pulmonary edema, acute kidney injury, thromboembolism, or death. Logistic regression was used with all analyses controlled for delivery location.
RESULTS
Of 351 deliveries, 106 (30%) had no placenta previa at delivery. When compared with the previa group, nonprevia placenta accreta spectrum was less likely to be identified antepartum (38%, 95% CI 28-48% vs 87%, 82-91%), less likely to receive care from a multidisciplinary team (41%, 31-51% vs 86%, 81-90%), and less likely to have invasive placenta increta or percreta (51% 41-61% vs 80%, 74-84%). The nonprevia group had more operative hysteroscopy (24%, 16-33% vs 6%, 3-9%) or in vitro fertilization (31%, 22-41% vs 9%, 6-13%) and was less likely to have had a prior cesarean delivery (64%, 54-73% vs 93%, 89-96%) compared with the previa group, though the majority in each group had a prior cesarean delivery. Rates of severe maternal morbidity were similar in the two groups, at 19% (nonprevia) and 20% (previa), even after controlling for confounders (adjusted odds ratio for the nonprevia group 0.59, 95% CI 0.30-1.17).
CONCLUSION
Placenta accreta spectrum without previa is less likely to be diagnosed antepartum, potentially missing the opportunity for multidisciplinary team management. Despite the absence of placenta previa and less placental invasion, severe maternal morbidity at delivery was not lower. Broader recognition of patients at risk for placenta accreta spectrum may improve early clinical diagnosis and patient outcomes.
目的
评估有无前置胎盘的胎盘植入谱系疾病（placenta accreta spectrum，PAS）病例与危险因素、产前诊断和产妇发病率的关系。
方法
我们对 2010 年 1 月至 2019 年 6 月期间，美国两家转诊中心因胎盘植入谱系疾病而行子宫切除术的病理确诊病例进行了回顾性队列研究。比较了胎盘植入谱系疾病病例（有前置胎盘 PAS 组）和无前置胎盘 PAS 病例（无前置胎盘 PAS 组）的产妇、妊娠和分娩特征。评估了手术结果和严重产妇合并症的综合情况，包括输 8 个或更多单位的血、再次手术、肺水肿、急性肾损伤、血栓栓塞或死亡。所有分析均控制了分娩地点，采用 logistic 回归。
结果
在 351 例分娩中，有 106 例（30%）在分娩时无前置胎盘。与前置胎盘组相比，无前置胎盘 PAS 组更不可能在产前被识别（38%，95%CI 28-48% vs 87%，82-91%），更不可能接受多学科团队的治疗（41%，31-51% vs 86%，81-90%），也更不可能患有侵袭性胎盘植入或胎盘穿透（51%，41-61% vs 80%，74-84%）。无前置胎盘 PAS 组更倾向于进行手术性宫腔镜检查（24%，16-33% vs 6%，3-9%）或体外受精（31%，22-41% vs 9%，6-13%），且剖宫产史较少（64%，54-73% vs 93%，89-96%），但两组的大多数患者都有剖宫产史。两组严重产妇合并症的发生率相似，分别为 19%（无前置胎盘）和 20%（前置胎盘），即使在控制了混杂因素后也是如此（无前置胎盘组调整后的优势比为 0.59，95%CI 0.30-1.17）。
结论
无前置胎盘的 PAS 不太可能在产前被诊断，可能会错过多学科团队管理的机会。尽管没有前置胎盘和更少的胎盘侵袭，分娩时的严重产妇发病率并不低。更广泛地认识到胎盘植入谱系疾病的高危患者，可能会改善早期临床诊断和患者结局。
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