本文選題：兇險(xiǎn)性前置胎盤 + 胎盤植入　； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：背景兇險(xiǎn)性前置胎盤(pernicious placenta previa)屬前置胎盤的一部分。為曾經(jīng)有剖宮產(chǎn)史的婦女,再次妊娠時(shí)并發(fā)前置胎盤,且此次胎盤附著于既往剖宮產(chǎn)手術(shù)瘢痕部位。兇險(xiǎn)性前置胎盤容易并發(fā)胎盤植入。胎盤植入(placenta accreta)是胎盤與子宮之間的蛻膜海綿層生理性間隙消失,一個(gè)或多個(gè)胎盤母體葉與蛻膜基底層緊密粘連或者侵入子宮肌層甚至穿透子宮肌層。兇險(xiǎn)性前置胎盤的發(fā)病率逐年升高,且由于剖宮產(chǎn)時(shí)往往會出現(xiàn)短時(shí)間內(nèi)大量失血,因此成為目前孕產(chǎn)婦產(chǎn)后出血、子宮切除甚至死亡的重要原因。胎盤植入的產(chǎn)前診斷對于術(shù)中處理至關(guān)重要。常用的產(chǎn)前影像學(xué)診斷方式為B超及MRI。其診斷準(zhǔn)確性各家報(bào)道不一。腹主動(dòng)脈球囊阻斷術(shù)(Intraoperative aorta balloon occlusion,IABO)系通過介入方法,臨時(shí)阻斷大部分供給盆腔及下肢的供血,從而達(dá)到開始阻斷時(shí)術(shù)中出血減少的目的,增加了嚴(yán)重胎盤植入患者保留子宮的可能性。近年來該介入操作在盆腔部位的手術(shù)處置中陸續(xù)開始應(yīng)用。目的本研究通過回顧性分析兇險(xiǎn)性前置胎盤及并發(fā)胎盤植入患者的影像學(xué)產(chǎn)前診斷方法的敏感性和特異性,旨在發(fā)現(xiàn)較好的產(chǎn)前診斷方法。同時(shí)分析腹主動(dòng)脈球囊阻斷術(shù)在兇險(xiǎn)性前置胎盤并胎盤植入患者剖宮產(chǎn)中的應(yīng)用價(jià)值,比較各種治療方式短期術(shù)后的并發(fā)癥,以期得到對于兇險(xiǎn)性前置胎盤及并發(fā)胎盤植入患者較好的手術(shù)治療方式,為臨床提供參考。方法選擇山東大學(xué)附屬省立醫(yī)院產(chǎn)科2013年3月至2016年3月住院并手術(shù)的兇險(xiǎn)性前置胎盤病例114例。依據(jù)剖宮產(chǎn)術(shù)中所見并結(jié)合術(shù)后病理確定是否并發(fā)胎盤植入及植入范圍和深淺,并將植入達(dá)漿膜層及穿透性植入視為深植入,其它植入均視為淺植入。分析B超和MRI兩種方法各自的產(chǎn)前診斷準(zhǔn)確性。同時(shí)比較是否并發(fā)胎盤植入兩組患者的剖宮產(chǎn)術(shù)中出血量、輸血量、平均住院時(shí)間及新生兒情況等。根據(jù)兇險(xiǎn)性前置胎盤并植入患者剖宮產(chǎn)術(shù)中是否行腹主動(dòng)脈球囊阻斷分為阻斷組和非阻斷組,比較兩組術(shù)中出血量、輸血量、平均住院時(shí)間及新生兒情況等。P0.05認(rèn)為比較差異有統(tǒng)計(jì)學(xué)意義。結(jié)果114例兇險(xiǎn)性前置胎盤病例中,術(shù)后證實(shí)合并胎盤植入者89例。其中114例病例均行B超檢查。B超產(chǎn)前診斷為胎盤植入87例,診斷敏感性為97.75%,特異性為92%;行MRI檢查85例,MRI產(chǎn)前診斷為胎盤植入70例,診斷敏感性為97.18%,特異性為92.86%。兇險(xiǎn)性前置胎盤合并胎盤植入組89例患者,平均術(shù)中出血量1867ml,輸紅細(xì)胞量7.66U,輸血漿量648ml。平均住院時(shí)間11.8天;非植入組病例25例,平均術(shù)中出血量650ml,輸紅細(xì)胞量2.5U,輸血漿量164ml,平均住院時(shí)間7.8天。兩組之間的差異具有統(tǒng)計(jì)學(xué)意義(p0.05)。114例兇險(xiǎn)性前置胎盤病例中,剖宮產(chǎn)術(shù)中同時(shí)行子宮切除29例,膀胱損傷修補(bǔ)10例,均來自胎盤植入組。兇險(xiǎn)性前置胎盤合并胎盤植入89例患者,59例行腹主動(dòng)脈球囊阻斷術(shù),阻斷組剖宮產(chǎn)術(shù)中平均出血量為1759ml,非阻斷組剖宮產(chǎn)術(shù)中平均出血量2080ml,但兩組比較差異尚無統(tǒng)計(jì)學(xué)意義(p0.05)。另外兩組間在術(shù)后并發(fā)癥的比較差異無統(tǒng)計(jì)學(xué)意義(p0.05)。但兩組在胎盤植入的程度比較中有統(tǒng)計(jì)學(xué)差異意義,阻斷組患者的胎盤深植入病例數(shù)明顯多于非阻斷組(p0.05)。胎盤植入與非植入組的新生兒轉(zhuǎn)新生兒重癥監(jiān)護(hù)病房(Neonatal Intensive Care UnitNICU)情況差異無統(tǒng)計(jì)學(xué)意義(P0.05),阻斷組與非阻斷組的新生兒NICU轉(zhuǎn)入情況差異亦無統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論本研究表明B超和MRI對兇險(xiǎn)性前置胎盤并胎盤植入的產(chǎn)前診斷中準(zhǔn)確性較高,其中B超可作為首選檢查方法,MRI可作為B超的補(bǔ)充檢查手段。兇險(xiǎn)性前置胎盤合并胎盤植入對患者的住院天數(shù)、術(shù)中出血、輸血量等有明顯影響。對產(chǎn)前診斷為胎盤植入,特別是深植入的患者剖宮產(chǎn)時(shí)行腹主動(dòng)脈球囊阻斷術(shù),可以減少術(shù)中出血,減少術(shù)中輸血量,減少住院時(shí)間,大大有利于這類患者的術(shù)后恢復(fù),因此具有較好的臨床應(yīng)用價(jià)值。同時(shí),球囊阻斷術(shù)并不會增加患者術(shù)后并發(fā)癥的可能,該治療方法安全有效。新生兒的出生情況與其胎齡有關(guān),與胎盤植入程度及是否行腹主動(dòng)脈球囊阻斷術(shù)無關(guān)。
[Abstract]:Background perilous placenta previa (pernicious placenta previa) is part of the placenta previa. For women who have had a history of cesarean section, the placenta previa is complicated by the placenta previa, and the placenta is attached to the scar site of the previous cesarean section. The perilous placenta previa is easily implantable with fetal disc implantation. Placental implantation (placenta accreta) is the placenta and the placenta. The physiological gap between the cavernous cavernous layer of the uterus disappears, and one or more placental mother leaves are closely connected with the decidua basal layer or intruded into the uterine myometrium and even through the myometrium. The incidence of perilous placenta previa increases year by year, and as a result of cesarean section, a large amount of blood loss often occurs in the short time, thus becoming the present maternity and obstetrics and gynecology. Postpartum diagnosis of placenta implantation is very important for intraoperative treatment. The common prenatal imaging diagnosis is the B ultrasonic and MRI. diagnostic accuracy in different reports. Abdominal aorta balloon occlusion (Intraoperative aorta balloon occlusion, IABO) through interventional methods, temporary obstruction Most of the supply of blood supply to the pelvic and lower extremities can achieve the purpose of reducing the bleeding during the beginning of the interruption, and increase the possibility of retaining the uterus in patients with serious placenta implantation. The sensitivity and specificity of the prenatal diagnosis of placental implantation is aimed at finding a better prenatal diagnosis. At the same time, the application value of abdominal aorta balloon occlusion in the caesarean section of patients with perilous placenta previa and placenta implantation is analyzed, and the complications of various treatments in the short term are compared in order to obtain the risk of the perilous risk. A good surgical treatment for the patients with placenta previa and placenta implants was provided for clinical reference. Methods 114 cases of perilous placenta previa from the affiliated Provincial Hospital of Shandong University from March 2013 to March 2016 were selected. Implantation scope and depth, and the implantation of the serosa and penetrating implantation as deep implantation, and the other implants are regarded as shallow implants. The accuracy of the prenatal diagnosis of the two methods of B-ultrasound and MRI is analyzed. At the same time, the amount of bleeding, blood transfusion, the average time of hospitalization, and the condition of the newborns in the caesarean section of the two groups of patients with placenta accreta are compared. According to the perilous placenta previa and whether the abdominal aorta balloon was blocked in the caesarean section, it was divided into blockage group and non blockage group. Compared the two groups of intraoperative bleeding, blood transfusion, average hospitalization time and newborns, there were statistically significant differences between the two groups. Results in 114 cases of perilous placenta previa, the postoperative complication was confirmed. There were 89 cases of placenta implants, of which 114 cases were examined by B-ultrasound. Prenatal diagnosis was 87 cases of placenta implantation, the diagnostic sensitivity was 97.75%, specificity was 92%; MRI examination 85 cases, MRI prenatal diagnosis of placenta implantation 70 cases, diagnostic sensitivity 97.18%, 92.86%. perilous placenta previa combined placenta implantation group 89 patients, average operation The amount of bleeding was 1867ml, the amount of erythrocyte transfusion was 7.66U, the average hospitalization time of blood transfusion 648ml. was 11.8 days, 25 cases in non implanting group, mean intraoperative bleeding volume, 2.5U, blood transfusion 164ml, average length of hospital stay 7.8 days. The difference between the two groups was statistically significant (P0.05) in the caesarean section of.114 case pernicious placenta previa At the same time, 29 cases of hysterectomy and 10 cases of bladder injury repair were from placental implantation group. 89 patients with perilous placenta previa combined with placenta implantation, 59 cases of abdominal aorta balloon occlusion, the average bleeding amount in caesarean section was 1759ml, and the average bleeding amount of the caesarean section was 2080ml in the non blocking group, but there was no statistical difference between the two groups. Significance (P0.05). There was no significant difference in postoperative complications between the other two groups (P0.05). However, there were significant differences in the degree of placental implantation in the two groups, and the number of deep placenta implanted cases in the blockage group was significantly more than that in the non blocking group (P0.05). The difference of Neonatal Intensive Care UnitNICU) was not statistically significant (P0.05). There was no significant difference in NICU transfer between the blockage group and the non blocking group (P0.05). Conclusion this study showed that B ultrasound and MRI have high accuracy in prenatal diagnosis of perilous placenta previa and placenta implantation, and B ultrasound can be used as the first choice examination method. MRI can be used as a supplementary examination for B-ultrasound. The perilous placenta previa combined with placenta implantation has a significant influence on the patient's days of hospitalization, intraoperative bleeding, and the amount of blood transfusion. The abdominal aorta balloon occlusion for the prenatal diagnosis of placenta implantation, especially in the patients with deep implantation, can reduce intraoperative bleeding, reduce intraoperative blood transfusion, and reduce the amount of blood transfusion. The time of hospitalization is of great benefit to the postoperative recovery of this type of patients and therefore has a good clinical value. At the same time, balloon occlusion does not increase the possibility of postoperative complications. The treatment is safe and effective. The birth of the newborn is related to the gestational age, the degree of placenta implantation and the operation of abdominal aorta balloon occlusion. Close.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R714.2

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