Melber Dora J, Berman Zachary T, Jacobs Marni B, Picel Andrew C, Conturie Charlotte L, Zhang-Rutledge Kathy, Binder Pratibha S, Eskander Ramez N, Roberts Anne C, McHale Michael T, Ramos Gladys A, Ballas Jerasimos, Kelly Thomas F
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, CA.
Division of Interventional Radiology, Department of Radiology, University of California San Diego, San Diego, CA.
Am J Obstet Gynecol. 2021 Oct;225(4):442.e1-442.e10. doi: 10.1016/j.ajog.2021.07.001. Epub 2021 Jul 7.
Multidisciplinary care of placenta accreta spectrum cases improves pregnancy outcomes, but the specific components of such a multidisciplinary collaboration varies between institutions. As experience with placenta accreta spectrum increases, it is crucial to assess new surgical techniques and protocols to help improve maternal outcomes and to advocate for hospital resources.
This study aimed to assess a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that comprises cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite.
This was a matched prepost study of placenta accreta spectrum cases managed before (2010-2017) and after implementation of the Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol (2018-2021) at a tertiary medical center. Historical cases were managed with internal iliac artery balloon placement in selected cases with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. Intraoperative Embolization cases were compared with historical cases in a 1:2 ratio matched on the basis of placenta accreta spectrum severity and surgical urgency. The primary outcome was a requirement for transfusion with packed red blood cells. Secondary outcomes included estimated surgical blood loss, operative and postoperative complications, procedural time, length of stay, and neonatal outcomes.
A total of 15 Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization cases and 30 matched historical cases were included in the analysis. There were no demographic differences noted between the groups. A median (interquartile range) of 0 units (0-2 units) of packed red blood cells were transfused in the Intraoperative Embolization group compared with 2 units (0-4.5 units) in the historical group (P=.045); 5 of 15 (33.3%) Intraoperative Embolization cases required blood transfusions compared with 19 of 30 (63.3%) cases in the historical group (P=.11). The estimated blood loss was significantly less in the Intraoperative Embolization group with a median (interquartile range) of 750 mL (450-1050 mL) compared with 1750 mL (1050-2500 mL) in the historical group (P=.003). There were no cases requiring massive transfusion (≥10 red blood cell units in 24 hours) in the Intraoperative Embolization group compared with 5 of 30 (16.7%) cases in the historical group (P=.15). There were no intraoperative deaths from hemorrhagic shock using the Intraoperative Embolization protocol, whereas this occurred in 2 of the historical cases. The mean duration of the interventional radiology procedure was longer in the Intraoperative Embolization group (67.8 vs 34.1 minutes; P=.002). Intensive care unit admission and postpartum length of stay were similar, and surgical and postoperative complications were not significantly different between the groups. The gestational age and neonatal birthweights were similar; however, the neonatal length of stay was longer in the Intraoperative Embolization group (median duration, 32 days vs 15 days; P=.02) with a trend toward low Apgar scores. Incidence of arterial umbilical cord blood pH <7.2 and respiratory distress syndrome and intubation rates were not statistically different between the groups.
A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and estimated blood loss with no increase in operative complications. The Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol provides a definitive surgical method that warrants consideration by other centers specializing in placenta accreta spectrum treatment.
胎盘植入谱系病例的多学科护理可改善妊娠结局，但这种多学科协作的具体组成部分在不同机构之间有所不同。随着胎盘植入谱系经验的增加，评估新的手术技术和方案以帮助改善孕产妇结局并争取医院资源至关重要。
本研究旨在评估一种新型的多学科方案，用于治疗胎盘植入谱系，该方案包括在杂交手术室中一次手术完成剖宫产、多支子宫动脉栓塞和子宫切除术。
这是一项配对前后对照研究，研究对象为一家三级医疗中心在实施胎盘植入谱系术中多支血管栓塞治疗方案（2018 - 2021年）之前（2010 - 2017年）和之后管理的胎盘植入谱系病例。部分历史病例采用髂内动脉球囊置入术，由主刀医生酌情决定术中是否充气。术中栓塞组病例与历史病例按1:2的比例进行匹配，匹配因素为胎盘植入谱系严重程度和手术紧迫性。主要结局是是否需要输注浓缩红细胞。次要结局包括估计手术失血量、手术及术后并发症、手术时间、住院时间和新生儿结局。
分析共纳入15例胎盘植入谱系术中多支血管栓塞治疗病例和30例匹配的历史病例。两组之间在人口统计学特征上未发现差异。术中栓塞组输注浓缩红细胞量的中位数（四分位间距）为0单位（0 - 2单位），而历史组为2单位（0 - 4.5单位）（P = 0.045）；术中栓塞组15例中有5例（33.3%）需要输血，历史组30例中有19例（63.3%）需要输血（P = 0.11）。术中栓塞组的估计失血量显著更少，中位数（四分位间距）为750 mL（450 - 1050 mL），而历史组为1750 mL（1050 - 2500 mL）（P = 0.003）。术中栓塞组没有病例需要大量输血（24小时内≥10个红细胞单位），而历史组30例中有5例（16.7%）需要大量输血（P = 0.15）。采用术中栓塞方案未发生因失血性休克导致的术中死亡，而历史病例中有2例发生。术中栓塞组介入放射学操作的平均持续时间更长（67.8分钟对34.1分钟；P = 0.002）。重症监护病房入住率和产后住院时间相似，两组之间手术及术后并发症无显著差异。孕周和新生儿出生体重相似；然而，术中栓塞组新生儿住院时间更长（中位数持续时间，32天对15天；P = 0.02），且有阿氏评分低的趋势。两组之间动脉脐血pH <7.2、呼吸窘迫综合征的发生率和插管率无统计学差异。
包括多支子宫动脉栓塞的单手术方案的多学科途径与输血需求和估计失血量的减少相关，且手术并发症未增加。胎盘植入谱系术中多支血管栓塞治疗方案提供了一种确定性的手术方法值得其他专门治疗胎盘植入谱系的中心考虑。
