Bai G Q, Chen W L, Huang X H, Zhao S J, Zhao S P, Chen X J, Chen S W, Yang H, Lu X, Liu G Y, Chen Q H, Zhang L A, Jin L
Gene Joint Laboratory, the First Affiliated Hospital, Xi'an Jiaotong University, Xi'an 710061, China.
Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.
Zhonghua Fu Chan Ke Za Zhi. 2023 Jan 25;58(1):26-36. doi: 10.3760/cma.j.cn112141-20221009-00615.
To study the risk factors of adverse pregnancy outcomes for the diagnosis and treatment of pregnancy after cesarean section complicated with placenta previa. A national multicenter retrospective study was conducted to select a total of 747 pregnant women with the third trimester singleton pregnancy after cesarean section complicated with placenta previa from 12 tertiary hospitals in January 1st to December 31st, 2018. The risk factors of severe adverse outcomes [hysterectomy, intraoperative blood loss ≥1 000 ml, intraoperative diagnosis of placenta accreta spectrum disorders (PAS)] in pregnant women with second pregnancy complicated with placenta previa after cesarean section were investigated by logistic regression analysis. The roles of prenatal ultrasonography and magnetic resonance imaging (MRI) in the prediction of PAS and severe adverse outcomes were observed. According to whether vascular intervention was performed (uterine artery embolization or abdominal aortic balloon occlusion), the pregnant women were divided into the blocked group and the unblocked group, and the maternal and infant perinatal outcomes between the two groups were compared. (1) General information: the hysterectomy rate of 747 pregnant women with second pregnancy complicated with placenta previa after cesarean section was 10.4% (78/747), the intraoperative blood loss ≥1 000 ml in 55.8% (417/747), and PAS was confirmed in 47.5% (355/747). The incidence of uterine rupture was 0.8% (6/747). (2) Analysis of risk factors for severe adverse outcomes: based on binary unconditioned logistic regression univariate and multivariate analysis, the risk factors for hysterectomy were the mode of vascular embolization and intraoperative blood loss. The probability of hysterectomy with uterine artery embolization was 5.319 times higher than that with abdominal aortic balloon occlusion (95%: 1.346-21.018). The risk factors of intraoperative blood loss ≥1 000 ml were the number of cesarean section delivery, ultrasonography indicated PAS and suspected PAS, intraoperative PAS and complete placenta previa. The risk factors for intraoperative PAS were uterine scar thickness, ultrasonography indicated PAS and suspected PAS, MRI indicated PAS and suspected PAS, and complete placenta previa. (3) The roles of ultrasonography and MRI in predicting PAS: the sensitivity and specificity of ultrasonography in predicting PAS were 47.5% and 88.4%; the kappa value was 0.279 (<0.001), with fair agreement. The sensitivity and specificity of MRI to predict PAS were 79.2% and 97.8%, respectively. The kappa value was 0.702 (<0.001), indicating a good agreement. The intraoperative blood loss and hysterectomy rate of pregnant women with PAS indicated by ultrasonography and MRI were significantly higher than those with PAS only by ultrasonography or MRI. (4) Influence of vascular occlusion on pregnancy outcome: there were no significant differences in intraoperative blood loss and incidence of intraoperative bleeding ≥1 000 ml between the blocked group and the unblocked group (all >0.05). There was no significant difference in intraoperative blood loss between the pregnant women with abdominal aortic balloon occlusion, uterine artery embolization and those without occlusion (=0.409). The hysterectomy rate of pregnant women with uterine artery embolization was significantly higher than those with abdominal aortic balloon occlusion [39.3% (22/56) vs 10.0% (5/50), =0.001]. In the third trimester of pregnancy with placenta previa after cesarean section, MRI examination has better consistency in predicting PAS than ultrasonography examination. Ultrasonography examination combined with MRI examination could effectively predict the hysterectomy rate and intraoperative blood loss. Vascular occlusion could not reduce the amount of intraoperative blood loss. The hysterectomy rate of pregnant women with uterine artery embolization is higher than those with abdominal aortic balloon occlusion.
研究剖宫产术后合并前置胎盘妊娠不良妊娠结局的危险因素，为其诊断和治疗提供依据。选取2018年1月1日至12月31日期间，全国12家三级医院剖宫产术后合并前置胎盘的单胎妊娠晚期孕妇747例，进行多中心回顾性研究。采用logistic回归分析剖宫产术后再次妊娠合并前置胎盘孕妇严重不良结局（子宫切除、术中出血量≥1000ml、术中诊断为胎盘植入谱系疾病）的危险因素。观察产前超声和磁共振成像（MRI）在预测胎盘植入谱系疾病和严重不良结局中的作用。根据是否进行血管介入（子宫动脉栓塞或腹主动脉球囊阻断），将孕妇分为阻断组和未阻断组，比较两组母婴围产结局。（1）一般资料：747例剖宫产术后再次妊娠合并前置胎盘孕妇子宫切除率为10.4%（78/747），术中出血量≥1000ml者占55.8%（417/747），确诊胎盘植入谱系疾病者占47.5%（355/747）。子宫破裂发生率为0.8%（6/747）。（2）严重不良结局危险因素分析：基于二元非条件logistic回归单因素和多因素分析，子宫切除的危险因素为血管栓塞方式和术中出血量。子宫动脉栓塞组子宫切除概率比腹主动脉球囊阻断组高5.319倍（95%：1.346-21.018）。术中出血量≥1000ml的危险因素为剖宫产次数、超声提示胎盘植入谱系疾病和可疑胎盘植入谱系疾病、术中胎盘植入谱系疾病和完全性前置胎盘。术中胎盘植入谱系疾病的危险因素为子宫瘢痕厚度、超声提示胎盘植入谱系疾病和可疑胎盘植入谱系疾病、MRI提示胎盘植入谱系疾病和可疑胎盘植入谱系疾病、完全性前置胎盘。（3）超声和MRI在预测胎盘植入谱系疾病中的作用：超声预测胎盘植入谱系疾病的敏感度和特异度分别为47.5%和88.4%；kappa值为0.279（<0.001），一致性一般。MRI预测胎盘植入谱系疾病的敏感度和特异度分别为79.2%和97.8%。kappa值为0.702（<0.001），一致性良好。超声和MRI提示胎盘植入谱系疾病孕妇的术中出血量和子宫切除率显著高于仅超声或MRI提示胎盘植入谱系疾病者。（4）血管阻断对妊娠结局的影响：阻断组与未阻断组术中出血量及术中出血≥1000ml发生率比较，差异均无统计学意义（均>0.05）。腹主动脉球囊阻断、子宫动脉栓塞孕妇与未阻断孕妇术中出血量比较，差异无统计学意义（=0.409）。子宫动脉栓塞孕妇子宫切除率显著高于腹主动脉球囊阻断孕妇[39.3%（22/56）比10.0%（5/50），=0.001]。剖宫产术后前置胎盘妊娠晚期，MRI检查预测胎盘植入谱系疾病的一致性优于超声检查。超声检查联合MRI检查可有效预测子宫切除率和术中出血量。血管阻断不能减少术中出血量。子宫动脉栓塞孕妇子宫切除率高于腹主动脉球囊阻断孕妇。
