Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA.
BMC Surg. 2021 Jan 6;21(1):10. doi: 10.1186/s12893-020-01027-9.
A diagnostic sign on magnetic resonance imaging, suggestive of posterior extrauterine adhesion (PEUA), was identified in patients with placenta previa. However, the clinical features or surgical outcomes of patients with placenta previa and PEUA are unclear. Our study aimed to investigate the clinical characteristics of placenta previa with PEUA and determine whether an altered management strategy improved surgical outcomes.
This single institution retrospective study examined patients with placenta previa who underwent cesarean delivery between 2014 and 2019. In June 2017, we recognized that PEUA was associated with increased intraoperative bleeding; thus, we altered the management of patients with placenta previa and PEUA. To assess the relationship between changes in practice and surgical outcomes, a quasi-experimental method was used to examine the difference-in-difference before (pre group) and after (post group) the changes. Surgical management was modified as follows: (i) minimization of uterine exteriorization and adhesion detachment during cesarean delivery and (ii) use of Nelaton catheters for guiding cervical passage during Bakri balloon insertion. To account for patient characteristics, propensity score matching and multivariate regression analyses were performed.
The study cohort (n = 141) comprised of 24 patients with placenta previa and PEUA (PEUA group) and 117 non-PEUA patients (control group). The PEUA patients were further categorized into the pre (n = 12) and post groups (n = 12) based on the changes in surgical management. Total placenta previa and posterior placentas were more likely in the PEUA group than in the control group (66.7% versus 42.7% [P = 0.04] and 95.8% versus 63.2% [P < 0.01], respectively). After propensity score matching (n = 72), intraoperative blood loss was significantly higher in the PEUA group (n = 24) than in the control group (n = 48) (1515 mL versus 870 mL, P < 0.01). Multivariate regression analysis revealed that PEUA was a significant risk factor for intraoperative bleeding before changes were implemented in practice (t = 2.46, P = 0.02). Intraoperative blood loss in the post group was successfully reduced, as opposed to in the pre group (1180 mL versus 1827 mL, P = 0.04).
PEUA was associated with total placenta previa, posterior placenta, and increased intraoperative bleeding in patients with placenta previa. Our altered management could reduce the intraoperative blood loss.
磁共振成像上的一种诊断征象，提示存在子宫后外侧粘连（PEUA），在前置胎盘患者中被发现。然而，PEUA 患者的临床特征或手术结局尚不清楚。我们的研究旨在探讨合并 PEUA 的前置胎盘患者的临床特征，并确定改变管理策略是否能改善手术结局。
本单中心回顾性研究纳入了 2014 年至 2019 年期间行剖宫产术的前置胎盘患者。2017 年 6 月，我们认识到 PEUA 与术中出血量增加有关，因此改变了合并 PEUA 的前置胎盘患者的管理方法。为评估实践改变与手术结局之间的关系，我们采用准实验方法，分析改变前后（预组和后组）的差异。手术管理方法的改变如下：（i）尽量减少剖宫产时子宫外展和粘连分离，（ii）在 Bakri 球囊置入时使用 Nelaton 导管引导宫颈通过。为了考虑患者特征，进行了倾向评分匹配和多变量回归分析。
研究队列（n=141）包括 24 例合并 PEUA 的前置胎盘患者（PEUA 组）和 117 例非 PEUA 患者（对照组）。PEUA 患者进一步根据手术管理的改变分为预组（n=12）和后组（n=12）。PEUA 组的完全性前置胎盘和后位胎盘的比例高于对照组（66.7%比 42.7%[P=0.04]和 95.8%比 63.2%[P<0.01]）。在倾向评分匹配（n=72）后，PEUA 组的术中出血量明显高于对照组（n=24）（1515ml 比 870ml，P<0.01）。多变量回归分析显示，在实施实践改变之前，PEUA 是术中出血的显著危险因素（t=2.46，P=0.02）。在后组中，术中出血量成功减少，而在前组中则没有（1180ml 比 1827ml，P=0.04）。
PEUA 与完全性前置胎盘、后位胎盘和前置胎盘患者术中出血增加有关。我们改变的管理方法可以减少术中出血量。
