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中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2020, Vol. 16 ›› Issue (02) : 239 -244. doi: 10.3877/cma.j.issn.1673-5250.2020.02.017

所属专题： 文献；

论著

环子宫下段缝合术治疗凶险性前置胎盘伴胎盘植入性疾病的临床疗效
汤斐1, 周勇1, 赵云1,†()   
  1. 1. 华中科技大学同济医学院附属湖北妇幼保健院产科，武汉　430070
  • 收稿日期:2019-06-08 修回日期:2020-02-28 出版日期:2020-04-01
  • 通信作者: 赵云

Clinical efficacy of transverse annular compression suture of lower uterine segment for treatment of pernicious placenta previa complicated with placenta accreta spectrum disorders

Fei Tang1, Yong Zhou1, Yun Zhao1,†()   

  1. 1. Department of Obstetrics, Maternal and Child Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430070, Hubei Province, China
  • Received:2019-06-08 Revised:2020-02-28 Published:2020-04-01
  • Corresponding author: Yun Zhao
  • About author:
    Corresponding author: Zhao Yun, Email:
  • Supported by:
    Health Commission Project of Hubei Province(WJ2018H0133)
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引用本文：

汤斐, 周勇, 赵云. 环子宫下段缝合术治疗凶险性前置胎盘伴胎盘植入性疾病的临床疗效[J]. 中华妇幼临床医学杂志(电子版), 2020, 16(02): 239-244.

Fei Tang, Yong Zhou, Yun Zhao. Clinical efficacy of transverse annular compression suture of lower uterine segment for treatment of pernicious placenta previa complicated with placenta accreta spectrum disorders[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2020, 16(02): 239-244.

目的

探讨环子宫下段缝合术治疗凶险性前置胎盘(PPP)伴胎盘植入性疾病(PAS)的临床效果。

方法

选择2018年1月1日至6月1日，于华中科技大学同济医学院附属湖北妇幼保健院接受剖宫产术分娩，并于术中采用环子宫下段缝合术＋常规子宫下段-宫颈缩窄缝合术的5例PPP伴PAS孕产妇为研究对象。回顾性分析这5例患者的一般临床资料，术中出血量、生命体征、血液制品用量，娩出新生儿情况，以及患者术后恢复、随访等情况。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》。

结果

对本组5例PPP伴PAS患者的研究结果如下：①年龄为28～37岁；均有剖宫产术分娩史，此次妊娠距离上次剖宫产术时间为3～113个月；4例采取择期剖宫产术分娩，1例采取急诊剖宫产术分娩。②剖宫产术均采用腰硬联合麻醉及中心静脉插管，并且均采用腹部直切口；于子宫下段-宫颈胎盘植入部位人工剥离胎盘后，均采用环子宫下段缝合术＋Hwu缝合术，其中3例联合使用防波堤缝合术(1例还联合使用Cho缝合术)；术中生命体征均平稳，术中出血量为800～1500 mL、输血量为400～800 mL，手术时间为45～96 min，术后均转入重症监护病房(ICU)观察；分娩新生儿情况均良好。③均未发生感染；术后ICU观察4～8 d后，均痊愈出院；出院随访腹部伤口均愈合良好，术后30 d腹部超声检查均显示子宫复旧良好。

结论

环子宫下段缝合术联合其他子宫下段-宫颈缩窄缝合术，可以有效控制PPP伴PAS孕妇剖宫产术出血，并且预后良好。

关键词: 前置胎盘, 胎盘，侵入性, 产后出血, 剖宫产术, 环子宫下段缝合, 缩窄缝合, 孕产妇
Objective

To explore the clinical efficacy of transverse annular compression suture of lower uterine segment for treatment of pernicious placenta previa (PPP) complicated with placenta accreta spectrum (PAS) disorders.

Methods

A total of 5 pregnant women complicated with PPP and PAS disorders who were treated in Maternal and Child Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology from January 1 to June 1 in 2018 were chosen as research subjects. They all selected cesarean section delivery, and transverse annular compression suture plus other common compression sutures of lower uterine segment for hemostasis after placenta delivered. By retrospective method, general clinical data, volume of intraoperative bleeding, vital signs, volume of transferring blood product, status of newborns, postoperative recovery and follow-up data were analyzed. This study was in line with World Medical Association Declaration of Helsinki revised in 2013.

Results

The findings of 5 pregnant women complicated with PPP and PAS disorders were as follows. ① Their age was 28-37 years old and all had previous cesarean section histories, and this pregnancy was 3 -113 months from last cesarean section. 4 cases among them took elective cesarean section and 1 case took emergency cesarean section. ② Anesthesia for all were epidural combined with spinal anesthesia and placed central venous intubation preventively, cesarean sections used abdominal vertical incision. After manual stripping of placenta from the lower segment of uterine and cervix in which the placenta implanted, suture strategies adopted for all of them were transverse annular compression suture and Hwu suture, suture strategies for 3 cases were also with breakwater-like suture (1 case also combined with Cho suture). They all had stable vital signs, volume of blood bleeding was 800-1500 mL, volume of blood transfusion was 400-800 mL, duration of operation time was 45 -96 min. After operation, they were transferred to intensive care unit (ICU). Five of their newborns had good conditions after birth. ③ No infection was observed after operation and duration of stay in ICU was 4-8 d, then healed and discharged from hospital. During follow-up period, their abdominal incisions healed well, and abdominal ultrasound examination result showed their uterus recovered well after 30 d of cesarean section.

Conclusions

Suture strategies of transverse annular compression suture plus others compression sutures of lower uterine segment were effective hemostasis for cesarean section of pregnant women complicated with PPP and PAS disorders, and their prognosis were good.

Key words: Placenta previa, Placenta accreta, Postpartum hemorrhage, Cesarean section, Transverse annular compression suture, Compression sutures, Gravida and puerperant
图1 环子宫下段缝合术示意图(图1A：手术方法示意图；图1B：缝合后示意图)
表1 本组凶险性前置胎盘伴胎盘植入性疾病患者一般临床资料
病例编号(No.) 年龄(岁) 分娩时孕龄(周) 人工终止妊娠史(次) 剖宫产术分娩史(次) 分娩时人体质量指数(kg/m2) 此次妊娠距上次剖宫产术时间(月) 术前阴道流血情况
1 28 37＋1 3 1 25.4 101 无
2 36 36＋4 3 1 24.0 60 无
3 28 40＋1 3 1 29.7 21 无
4 37 32＋6 2 2 33.5 3 少量
5 33 37＋1 1 1 25.5 113 无
图2 凶险性前置胎盘伴胎盘植入性疾病患者剖宫产术中(1为环子宫下段缝合，2为Hwu缝合)
表2 本组凶险性前置胎盘伴胎盘植入性疾病患者剖宫产术分娩及其新生儿情况
病例编号(No.) 胎盘植入部位 术中子宫下段缝合方式 术中出血量(mL) 术后出血量(mL)
环子宫下段缝合术 Hwu缝合术 Cho缝合术 防波堤缝合术
1 子宫下段肌层 是 是 否 否 820 50
2 子宫下段肌层 是 是 否 是 850 60
3 子宫下段肌层 是 是 否 是 1 000 60
4 膀胱表面 是 是 是 是 1 500 150
5 子宫下段肌层 是 是 否 否 800 50
病例编号(No.) 总输血量(mL) 术中生命体征 双侧髂内动脉介入术 剖宫产术时间(min) 新生儿情况
体重(g) 1 min Apgar评分(分) 5 min Apgar评分(分) 转入新生儿重症监护病房
1 400 平稳 否 51 2 700 9 10 否
2 400 平稳 否 62 2 500 9 10 否
3 400 平稳 否 75 3 100 9 10 否
4 800 平稳 是 96 1 710 8 9 是
5 400 平稳 否 45 2 850 9 10 否
[1]
Chattopadhyay SK, Kharif H, Sherbeeni MM. Placenta praevia and accreta after previous caesarean section[J]. Eur J Obstet Gynecol Reprod Biol, 1993, 52(3): 151-156. DOI: 10.1016/0028-2243(93)90064-j.
[2]
Allen L, Jauniaux E, Hobson S, et al. FIGO consensus guidelines on placenta accreta spectrum disorders: nonconservative surgical management[J]. Int J Gynaecol Obstet, 2018, 140(3): 281-290. DOI: 10.1002/ijgo.12409.
[3]
朱方玉，漆洪波. 2018 FIGO胎盘植入性疾病指南解读[J]. 中国实用妇科与产科杂志，2018, 34(12): 1353-1359. DOI: 10.19538/j.fk2018120114.
[4]
Ying H, Duan T, Bao YR, et al. Transverse annular compression sutures in the lower uterine segment to control postpartum hemorrhage at cesarean delivery for complete placenta previa[J]. Int J Gynaecol Obstet, 2010, 108(3): 247-248. DOI: 10.1016/j.ijgo.2009.10.006.
[5]
杨慧霞，余琳，时春艳，等. 止血带捆绑下子宫下段环形蝶式缝扎术治疗凶险性前置胎盘伴胎盘植入的效果[J]. 中华围产医学杂志，2015, 18(7): 497-501. DOI: 10.3760/cma.j.issn.1007-9408.2015.07.005.
[6]
Hwu YM, Chen CP, Chen HS, et al. Parallel vertical compression sutures: a technique to control bleeding from placenta praevia or accreta during caesarean section[J]. BJOG, 2005, 112(10): 1420-1423. DOI: 10.1111/j.1471-0528.2005.00666.x.
[7]
Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery[J]. Obstet Gynecol, 2000, 96(1): 129-131. DOI: 10.1016/s0029-7844(00)00852-8.
[8]
赵茵，朱剑文，吴迪，等. 子宫下段防波堤样缝合术在前置胎盘手术止血中的应用[J]. 中华妇产科杂志，2018, 53(4): 234-238. DOI: 10.3760/cma.j.issn.0529-567x.2018.04.005.
[9]
种轶文，张爱青，王妍，等. 超声评分系统预测胎盘植入凶险程度的价值[J]. 中华围产医学杂志，2016, 19(9): 705-709. DOI: 10.3760/cma.j.issn.1007-9408.2016.09.014.
[10]
邓喜青，李一辉，彭晚祥，等. 胎盘植入的MRI征象[J]. 实用放射学杂志，2018, 34(4): 635-637. DOI: 10.3969/j.issn.1002-1671.2018.04.041.
[11]
梁娜，田伟. 胎盘植入的MRI间接征象分析[J]. 实用放射学杂志，2016, 32(1): 68-71. DOI: 10.3969/j.issn.1002-1671.2016.01.018.
[12]
Dai MJ, Jin GX, Lin JH, et al. Pre-cesarean prophylactic balloon placement in the internal iliac artery to prevent postpartum hemorrhage among women with pernicious placenta previa[J]. Int J Gynaecol Obstet, 2018, 142(3): 315-320. DOI: 10.1002/ijgo.12559.
[13]
Zhu B, Yang K, Cai L. Discussion on the timing of balloon occlusion of the abdominal aorta during a caesarean section in patients with pernicious placenta previa complicated with placenta accreta[J]. Biomed Res Int, 2017, 2017: 8604849. DOI: 10.1155/2017/8604849.
[14]
周勇，汤斐，赵云. 子宫下段-宫颈压迫缝合在前置胎盘术中止血的应用[J]. 现代妇产科进展，2018, 27(11): 869-872. DOI: 10.13283/j.cnki.xdfckjz.2018.11.017.
[15]
汤斐，赵云，孙国强，等. Bakri球囊宫腔填塞治疗难治性产后出血的效果[J]. 中华围产医学杂志，2017, 20(12): 891-894. DOI: 10.3760/cma.j.issn.1007-9408.2017.12.010.
[16]
罗方媛，陈锰，张力，等. 难治性产后出血的五种止血手术疗效的比较及止血失败原因分析[J]. 中华妇产科杂志，2012, 47(9): 641-645. DOI: 10.3760/cma.j.issn.0529-567x.2012.09.001.
[17]
Sumigama S, Itakura A, Ota T, et al. Placenta previa increta/percreta in Japan: a retrospective study of ultrasound findings, management and clinical course[J]. J Obstet Gynaecol Res, 2007, 33(5): 606-611. DOI：10.1111/j.1447-0756.2007.00619.x.
[18]
Dedes I, Ziogas V. Circular isthmic-cervical sutures can be an alternative method to control peripartum haemorrhage during caesarean section for placenta praevia accreta[J]. Arch Gynecol Obstet, 2008, 278(6): 555-557. DOI: 10.1007/s00404-008-0646-z.
[19]
侯燕燕，林婧，顾玮. 前置胎盘合并胎盘植入的临床特点和产前诊断[J/CD]. 中华妇幼临床医学杂志(电子版), 2017, 13(5): 524-531. DOI: 10.3877/cma.j.issn.1673-5250.2017.05.005.
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