Khong T Y, Khong T K
Department of Pathology, Queen Victoria Hospital, Rose Park, Australia.
Obstet Gynecol. 1993 Jul;82(1):17-22.
To ascertain the various causes of delayed postpartum hemorrhage and to test whether subinvolution of the placental bed is associated with other pregnancy disorders for which defective maternal-fetal interaction has been implicated pathogenetically.
In a group of women presenting with postpartum hemorrhage following singleton pregnancies, tissue that had been submitted for histopathologic examination was reviewed morphologically to delineate the various causes of delayed postpartum hemorrhage. The stratified groups were analyzed for relationship to preeclampsia, fetal growth retardation (FGR), spontaneous abortion, placenta accreta, and retained placental fragments in previous pregnancies. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated for each association.
One hundred sixty-nine cases were identified. Tissue obtained at curettage or, rarely, at hysterectomy could be categorized into seven pathologic groups: involution of the placental bed, subinvolution of the placental bed, retained placental fragments, endometritis, normal endometrium, normal decidua, or nondiagnostic tissue. Hyalinized fragments of uteroplacental (spiral) arteries that were either collapsed or completely thrombosed were seen in involution of the placental bed. Subinvolution of the placental bed was characterized by widely distended and patent residua of uteroplacental arteries with only partial occlusion by thrombosis. Women with retained placental fragments (OR 3.93, 95% CI 1.51-10.47), but not women with an involuted placental bed (OR 2.40, 95% CI 0.68-8.54) or subinvolution of the placental bed (OR 1.52, 95% CI 0.51-4.57), had increased incidences of preeclampsia, FGR, spontaneous abortion, or retained placenta in previous pregnancies when compared to women with endometritis, endometrium only, decidua only, or nondiagnostic tissue.
Retained placental fragments, reflecting placenta accreta, and subinvolution of the placental bed are important causes of delayed postpartum hemorrhage. The former is associated with an increased incidence, in prior pregnancies, of pregnancy complications that probably reflect aberrant maternal-trophoblastic interaction.
确定产后出血延迟的各种原因，并检验胎盘床复旧不全是否与其他妊娠疾病相关，而这些妊娠疾病在发病机制上涉及母婴相互作用缺陷。
在一组单胎妊娠后出现产后出血的女性中，对提交进行组织病理学检查的组织进行形态学复查，以确定产后出血延迟的各种原因。分析分层组与子痫前期、胎儿生长受限（FGR）、自然流产、胎盘植入和既往妊娠中胎盘碎片残留的关系。计算每种关联的比值比（OR）及其95%置信区间（CI）。
共识别出169例病例。刮宫时获得的组织，或很少情况下子宫切除时获得的组织，可分为七个病理组：胎盘床复旧、胎盘床复旧不全、胎盘碎片残留、子宫内膜炎、正常子宫内膜、正常蜕膜或无法诊断的组织。在胎盘床复旧中可见子宫胎盘（螺旋）动脉的透明变性碎片，这些碎片要么塌陷要么完全血栓形成。胎盘床复旧不全的特征是子宫胎盘动脉的残余部分广泛扩张且通畅，仅有部分被血栓阻塞。与患有子宫内膜炎、仅子宫内膜、仅蜕膜或无法诊断的组织的女性相比，有胎盘碎片残留的女性（OR 3.93，95% CI 1.51 - 10.47），而非胎盘床复旧的女性（OR 2.40，95% CI 0.68 - 8.54）或胎盘床复旧不全的女性（OR 1.52，95% CI 0.51 - 4.57），既往妊娠中子痫前期、FGR、自然流产或胎盘残留的发生率增加。
反映胎盘植入的胎盘碎片残留和胎盘床复旧不全是产后出血延迟的重要原因。前者与既往妊娠中妊娠并发症发生率增加相关，这些并发症可能反映了异常的母体 - 滋养层相互作用。
