Lional Karuna M, Tagore S, Wright A M
Department of Maternal and Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore.
Department of Maternal and Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore.
Eur J Obstet Gynecol Reprod Biol. 2020 Nov;254:212-217. doi: 10.1016/j.ejogrb.2020.09.029. Epub 2020 Sep 24.
To examine whether expectant management confers any benefit on operative morbidity for the management of placenta accrete spectrum (PAS) disorders.
This was a single center retrospective cohort study at a tertiary referral center In Singapore. Women with PAS disorder between January 2006 and December 2017 were identified from the hospital register. Antenatal features, surgical factors and post-operative morbidity were compared between women having caesarean hysterectomy, those having caesarean section with placental removal and women having expectant management, defined as caesarean section with retention of placenta using the student's t and Chi square tests. The natural course, complications and preservation of fertility were examined for women having expectant management.
Ninety women with PAS were included. The incidence of PAS was 0.064 %. Mean gestational age (GA) at diagnosis was 26.4 weeks. Elective and emergency deliveries were performed at 36.7 and 32.4 weeks respectively (p = <0.0001). Caesarean hysterectomy, Caesarean section with placenta removal and expectant management (EM) were performed in 51(56.7 %),16(17.8 %) and 23(25.6 %) women respectively. The mean blood loss (MBL) and surgical time for EM were significantly lower than those for caesarean hysterectomy 0.52 L vs 3.17 L (p < 0.0001) and 70.8 min vs 171.6 min (p < 0.0001). The advantage of lower blood loss with expectant management persisted even after blood loss at delayed hysterectomy was considered (1284.09 mL vs 3168.72 mL (p-value <0.0001)). Uterine preservation with EM was successful in 61 % (14/23) women. Although nine women (39 %) in this group needed hysterectomy most complications were minor and presented within three months. The mean follow up overall was 13 months.
Traditionally caesarean hysterectomy has been the main surgical approach for PAS. Our study consolidates existing evidence for expectant management being an option for a select group of patients to avoid complications associated with hysterectomy and allow uterine preservation.
探讨期待治疗对胎盘植入谱系疾病（PAS）手术并发症是否有任何益处。
这是一项在新加坡一家三级转诊中心进行的单中心回顾性队列研究。从医院登记册中识别出2006年1月至2017年12月期间患有PAS疾病的女性。采用学生t检验和卡方检验，比较行剖宫产子宫切除术、行胎盘去除剖宫产术和接受期待治疗（定义为保留胎盘的剖宫产术）的女性的产前特征、手术因素和术后并发症。对接受期待治疗的女性的自然病程、并发症和生育功能保留情况进行了研究。
纳入90例患有PAS的女性。PAS的发病率为0.064%。诊断时的平均孕周（GA）为26.4周。择期和急诊分娩分别在36.7周和32.4周进行（p = <0.0001）。分别有51例（56.7%）、16例（17.8%）和23例（25.6%）女性接受了剖宫产子宫切除术、胎盘去除剖宫产术和期待治疗（EM）。EM组的平均失血量（MBL）和手术时间显著低于剖宫产子宫切除术组，分别为0.52 L对3.17 L（p < 0.0001）和70.8分钟对171.6分钟（p < 0.0001）。即使考虑延迟子宫切除术后的失血量，期待治疗组失血量较低的优势依然存在（1284.09 mL对3168.72 mL（p值<0.0001））。EM组61%（14/23）的女性子宫保留成功。虽然该组中有9名女性（39%）需要子宫切除术，但大多数并发症较轻，且在三个月内出现。总体平均随访时间为13个月。
传统上，剖宫产子宫切除术一直是PAS的主要手术方式。我们的研究巩固了现有证据，即期待治疗是部分患者的一种选择，可避免与子宫切除术相关的并发症并保留子宫。
