Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX.
Am J Obstet Gynecol. 2023 Jul;229(1):61.e1-61.e7. doi: 10.1016/j.ajog.2023.03.028. Epub 2023 Mar 23.
Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage.
This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management.
This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records.
A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent.
The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
胎盘植入谱系疾病是一系列胎盘病理，具有显著的母体发病率和死亡率。发病率与胎盘附着的整体程度有关，因此，胎盘植入或胎盘穿透的患者属于高危类别。出血和输血制品占胎盘植入谱系疾病发病率的 90%。氨甲环酸和子宫动脉栓塞术均可独立减少产科出血。
本研究旨在为胎盘植入谱系疾病的管理提供循证的术中方案。
本研究为在 5 年内（2018-2022 年）对产前疑似胎盘植入和穿透的患者同时进行子宫动脉栓塞术和氨甲环酸治疗的病例进行了实施前后的分析。为了比较，使用了 5 年（2013-2017 年）的实施前组来评估子宫动脉栓塞术和氨甲环酸治疗胎盘植入谱系的方案对胎盘植入谱系的影响。从电子病历中获得患者的人口统计学和临床相关结局。
共有 126 例患者由胎盘植入谱系团队管理，其中 10 年间有 66 例疑似胎盘植入/穿透。由于 2 例患者未同时接受两种干预，因此有 2 例患者被排除在实施后队列之外。因此，有 30 例（30/64；47%）在实施胎盘植入谱系的子宫动脉栓塞术和氨甲环酸方案后接受治疗，34 例（34/64；53%）未接受子宫动脉栓塞术或氨甲环酸输注的患者为实施前组。采用子宫动脉栓塞术和氨甲环酸方案，手术时间延长（416 分钟 vs 187 分钟；P<.01），更有可能接受全身麻醉（80% vs 47%；P<.01）。然而，出血量减少了 33%（2000 毫升 vs 3000 毫升；P=.03），总输血率下降了 51%（比值比，0.05[95%置信区间，0.001-0.20]；P<.01），大量输血（>10 个单位）减少了 5 倍（比值比，0.17[95%置信区间，0.02-0.17]；P=.02）。术后并发症发生率保持不变（4 例 vs 10 例事件；P=.14）。新生儿结局相当。
胎盘植入谱系的子宫动脉栓塞术和氨甲环酸方案是一种有效的方法，可对复杂的胎盘植入谱系病例进行标准化处理，从而获得最佳围手术期结局并降低母体发病率。
