Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA.
Keck School of Medicine, University of Southern California, Los Angeles, CA.
Am J Obstet Gynecol. 2021 Nov;225(5):534.e1-534.e38. doi: 10.1016/j.ajog.2021.04.233. Epub 2021 Apr 21.
Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed.
This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States.
This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation.
Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1).
Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.
尽管胎盘粘连异常的情况较为少见，但在剖宫产分娩时，仍会显著增加产妇的发病率和死亡率。目前需要了解与胎盘黏连密切相关的病态胎盘，即胎盘植入谱系疾病的国家统计数据。
本研究旨在探讨美国胎盘植入谱系疾病患者的剖宫产手术的全国性趋势、特征和围手术期结局。
这是一项基于人群的回顾性观察性研究，对全国住院患者样本进行了查询。研究队列包括 2015 年 10 月至 2017 年 12 月期间行剖宫产术且诊断为胎盘植入谱系疾病的女性。主要观察指标是多变量分析中广义估计方程评估的与胎盘植入谱系疾病相关的患者特征和手术结果。胎盘植入谱系疾病的时间趋势也通过对数转换的线性分段回归进行评估。
在研究期间，2727477 例剖宫产术中，8030 例（0.29%）诊断为胎盘植入谱系疾病。胎盘黏连是最常见的诊断（n=6205，0.23%），其次是胎盘穿透（n=1060，0.04%）和胎盘植入（n=765，0.03%）。胎盘植入谱系疾病的病例数每季度增加 2.1%，从 0.27%增加到 0.32%（P=0.004）。多变量分析显示，（1）患者特征（年龄较大、吸烟、近期诊断、较高的合并症和辅助生殖技术的使用）、（2）妊娠特征（前置胎盘、既往剖宫产、臀位和巨大多胎妊娠）和（3）医院因素（城市教学中心和大床位容量医院）是与胎盘植入谱系疾病相关的独立特征（均 P<0.05）。胎盘黏连的剖宫产中位孕龄为 36 周，胎盘植入和胎盘穿透分别为 34 周和 39 周（非胎盘植入谱系疾病病例为 39 周；P<0.001）。多变量分析显示，胎盘植入谱系疾病的剖宫产与任何手术并发症（78.3%比 10.6%）、疾病控制与预防中心定义的严重产妇发病率（60.3%比 3.1%）、出血（54.1%比 3.9%）、凝血障碍（5.3%比 0.3%）、休克（5.0%比 0.1%）、尿路上皮损伤（8.3%比 0.2%）和死亡（0.25%比 0.01%）的风险增加相关。当进一步按亚型分析时，胎盘植入和胎盘穿透的剖宫产与更高的子宫切除术可能性相关（非胎盘植入谱系疾病为 0.4%，植入为 45.8%，穿透为 82.4%，穿透为 78.3%；P<0.001）和尿路上皮损伤（非胎盘植入谱系疾病为 0.2%，植入为 5.2%，穿透为 11.8%，穿透为 24.5%；P<0.001）。此外，胎盘植入和胎盘穿透组的女性手术死亡率明显高于无胎盘植入谱系疾病的女性（植入组，比值比 19.9；穿透组，比值比 32.1）。
胎盘植入谱系疾病的患者特征和结局存在差异，胎盘植入和胎盘穿透的女性具有较高的手术发病率和死亡率风险。值得注意的是，到 2017 年底，每 313 名行剖宫产术的女性中就有 1 名被诊断为胎盘植入谱系疾病，这一发病率似乎高于以往研究报道。
