Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.
Int J Gynecol Cancer. 2023 Oct 2;33(10):1633-1644. doi: 10.1136/ijgc-2023-004615.
Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.
胎盘植入谱系包括胎盘病态附着于子宫肌层的病例。胎盘穿透性植入（胎盘植入谱系的最严重形式，3E 级）是指胎盘穿透子宫肌层并可能侵入子宫旁的邻近结构。胎盘穿透性植入的产妇发病率较高，全美近期统计数据显示严重产妇发病率为 82.1%，死亡率为 1.4%。尽管对于胎盘植入谱系患者通常采用剖宫产子宫切除术，但由于某些情况下发病率降低，保守治疗越来越受欢迎。由于侵入性胎盘位于母体骨盆深部，涉及膀胱、子宫颈或子宫旁组织的 3E 级疾病的治疗较为复杂。在这种情况下，行剖宫产子宫切除术可能会发生灾难性出血，并对周围器官造成严重损伤。我们提出了一个逐步评估 3E 级疾病病例的方案，并确定立即行子宫切除术还是保守治疗（包括计划延迟性子宫切除术）是最合适的治疗选择。该方法包括在产前通过超声和磁共振成像进行评估，以确定是否存在胎盘前置穿透性伴周围器官受累的可疑情况，计划由多学科团队进行剖宫产，包括有经验的骨盆外科医生（如妇科肿瘤学家），术中评估包括大体手术野暴露和检查、膀胱镜检查，并考虑仔细的术中经阴道超声检查以确定胎盘侵入周围器官的程度。这种评估有助于确定原发性剖宫产子宫切除术的安全性。如果可以安全切除，还需要考虑术中使用子宫动脉栓塞术联合氨甲环酸注射，以降低盆腔出血和输尿管支架置入的风险。如果可以获得主动脉球囊阻断复苏术，则更为理想。如果担心可以安全切除，则建议在剖宫产 4 周左右稳定的患者中进行保守治疗，包括计划延迟性子宫切除术。
