中晚孕期胎盘植入47例临床分析
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摘要
目的探讨和分析胎盘植入患者的临床特点、诊断和治疗。
方法总结北京协和医院自1997年5月至2007年5月收治的17例中孕期和30例晚孕期(共47例)胎盘植入病例，对胎盘植入的临床特点、诊断和治疗进行回顾性分析。
结果1997年5月～2007年5月的10年间我院胎盘植入的总发生率为2.62‰，中孕期发生率为19.32‰，晚孕期发生率为1.76‰。临床特点：有子宫手术史者占80.85％，本次妊娠合并前置胎盘者占29.79％，合并子宫肌瘤者占10.64％，有产后出血史者10.64％。临床表现：胎盘残留伴出血者占61.70％，胎盘残留不伴出血者占38.30％。诊断：中孕期17例，其中通过B超确诊12例，临床确诊5例；晚孕期30例，其中通过病理确诊8例，BUS确诊2例，临床确诊20例。治疗：中孕期刮宫术有效率41.67％，子宫动脉栓塞有效率为100％，晚孕期刮宫有效率为23.08％，宫纱填塞有效率为86.67％，子宫动脉栓塞有效率为100％。
结论胎盘植入的发生率有逐年增加趋势，在中孕期的发生率明显高于晚孕期。B超在产前诊断胎盘植入比较困难。中孕胎盘植入诊断以产后B超诊断为主，治疗上子宫动脉栓塞效果好，可以保留子宫，无严重并发症；晚孕期胎盘植入诊断以临床为主，治疗采用手术清除和止血相结合的方法，大多可以保留子宫。
Objective To discuss the clinical characters, diagnosis and treatment methods ofplacenta accreta.
Methods Retrospective analysis was made in 47cases of placenta accreta from May1997 to May 2007 in Peking Union Medical College Hospital.These cases include 17cases in the second stage of pregnancy and 30 cases in the third trimester.
Results During May 1997 to May 2007, the incidence of placenta accreta in ourhospital was 2.62‰.Most of these cases had received one or more dilatation andcurettage, previous cesarean delivery, or myomectomy. Some cases were found withplacenta previa or myoma in the current pregnancy. There were 61.70％of all thecases with hemorrhage. In the 17 cases in the second stage of pregnancy there are 12cases were diagnosed by B-ultrasound and 5 by clinical evidence.While in the 30cases in the third trimester there are 8 cases ware diagnosed by pathology,2 byB-ultrasound and 20 by clinical evidence.45 cases had been cured by conservativetreatment.These methods include dilatation and curettage, uterine arteryembolism(UAE) with or without MTX, package and B-lynch suture, singly withMTX, RU-486. Only 2 cases received cesarean hysterectomy.
Conclusion The incidence of placenta accreta is rising.The incidence in the secondstage of pregnancy was higher than that in the third. No cases can be diagnosed byB-ultrasound before birth.In the second stage most cases can be diagnosed byB-ultrasound after labor, and now UAE is the best satisfactory conservativemanagement. While in the third trimester few cases can be diagnosed byB-ultrasound, and clinical evidence is the most frequent diagnostic methods, tampingis one of the best satisfactory conservative management. In our hospital a majority ofthe cases had been cured by conservative therapy which could in turn avoid hysterectomy.
方法总结北京协和医院自1997年5月至2007年5月收治的17例中孕期和30例晚孕期(共47例)胎盘植入病例，对胎盘植入的临床特点、诊断和治疗进行回顾性分析。
结果1997年5月～2007年5月的10年间我院胎盘植入的总发生率为2.62‰，中孕期发生率为19.32‰，晚孕期发生率为1.76‰。临床特点：有子宫手术史者占80.85％，本次妊娠合并前置胎盘者占29.79％，合并子宫肌瘤者占10.64％，有产后出血史者10.64％。临床表现：胎盘残留伴出血者占61.70％，胎盘残留不伴出血者占38.30％。诊断：中孕期17例，其中通过B超确诊12例，临床确诊5例；晚孕期30例，其中通过病理确诊8例，BUS确诊2例，临床确诊20例。治疗：中孕期刮宫术有效率41.67％，子宫动脉栓塞有效率为100％，晚孕期刮宫有效率为23.08％，宫纱填塞有效率为86.67％，子宫动脉栓塞有效率为100％。
结论胎盘植入的发生率有逐年增加趋势，在中孕期的发生率明显高于晚孕期。B超在产前诊断胎盘植入比较困难。中孕胎盘植入诊断以产后B超诊断为主，治疗上子宫动脉栓塞效果好，可以保留子宫，无严重并发症；晚孕期胎盘植入诊断以临床为主，治疗采用手术清除和止血相结合的方法，大多可以保留子宫。
Objective To discuss the clinical characters, diagnosis and treatment methods ofplacenta accreta.
Methods Retrospective analysis was made in 47cases of placenta accreta from May1997 to May 2007 in Peking Union Medical College Hospital.These cases include 17cases in the second stage of pregnancy and 30 cases in the third trimester.
Results During May 1997 to May 2007, the incidence of placenta accreta in ourhospital was 2.62‰.Most of these cases had received one or more dilatation andcurettage, previous cesarean delivery, or myomectomy. Some cases were found withplacenta previa or myoma in the current pregnancy. There were 61.70％of all thecases with hemorrhage. In the 17 cases in the second stage of pregnancy there are 12cases were diagnosed by B-ultrasound and 5 by clinical evidence.While in the 30cases in the third trimester there are 8 cases ware diagnosed by pathology,2 byB-ultrasound and 20 by clinical evidence.45 cases had been cured by conservativetreatment.These methods include dilatation and curettage, uterine arteryembolism(UAE) with or without MTX, package and B-lynch suture, singly withMTX, RU-486. Only 2 cases received cesarean hysterectomy.
Conclusion The incidence of placenta accreta is rising.The incidence in the secondstage of pregnancy was higher than that in the third. No cases can be diagnosed byB-ultrasound before birth.In the second stage most cases can be diagnosed byB-ultrasound after labor, and now UAE is the best satisfactory conservativemanagement. While in the third trimester few cases can be diagnosed byB-ultrasound, and clinical evidence is the most frequent diagnostic methods, tampingis one of the best satisfactory conservative management. In our hospital a majority ofthe cases had been cured by conservative therapy which could in turn avoid hysterectomy.
引文
1. Hollander D I, Pupkin M J, Crenshaw MC et al. Conservative management of placenta accretal Reprod Med, 1988, 33(1): 74.
2. Adair SR, Elamin D, Tharmaratnam S. Placenta increta; conservative management--a successful outcome 1Case report and literature review. Matern Fetal Neonatal Med, 2004, 15(4): 275.
3. 3 Bennett M J, Sen RC. Conservative' management of p lacenta p raevia percreta: report of two cases and discussion of current management options Aust N ZlObstet Gynaecol, 2003,43(3): 249.
4. Kayem G, Davy C, Goffinet F et all. Conservative versus extirpative management in cases of placenta accretal Obstet Gynecol, 2004, 104(3): 531.
5. Liu X, Fan G, J in Zl. Lower uterine segment pregnancy with placenta increta complicating first trimester induced abortion: diagnosis and conservative m anagementl Chin Med(Engl), 2003, 116(5): 695
6. Williams Obstetrics, 21thedlMj. McGrawH. New York, 2001. 641～643.
7．曹泽毅主编．中华妇产科学．第2版．北京：人民卫生出版社，479．
8. Mussalli G M, Shah J, Berck DJ et al. Placenta accreta and methotrexate therapy: three case reportslPerinatol, 2000, 20(5): 331.
9. Riggs JC, Jahshan A, Schiavello H J. Alternative conservative management of placenta accreta～A case reportl Rep rod Med, 2000, 45(7): 595.
10. Wu S, Kocherginsky M, Hibbard J U. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecl 2005; 192: 1458-1461.
11. Miller D A, Choller J A, Goodwin T M. Clinical risk factors for placenta previa-placenta accrete. Am J Obstet Gynecol 1997; 177: 210-214.
12．吴燕，王秀云．胎盘植入11例临床分析．实用妇产科杂志，1997，13(2)：94-95．
13．周莉，吴连芳．40例植入性胎盘的回顾性分析．首都医科大学学报，2005，26(1)：90-92．
14. Kwee A, Bots M L, Visser G H, Bruinse H W. Emergency peripartum hysterectomy: A prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 2006; 124: 187-192.
15. Miller D A, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accrete. Am J Obstet Gynecol 1997; 177:210-214.
16. Clarke S L, Koonings P P, Phelan J P. Placenta previa/accrete and prior cesarean section. Obstet Gynecol 1985;66: 89～92.
17. Comstock C H, Love J J Jr, Bronsteen R A, Lee W, Vettraino I M, Huang R R, et al. Sonographic detection of placenta accrete in the second and third trimesters of pregnancy .Am J Obstet Gynecol 2004;190: 1135～1140.
18. Comstock C H. Antenatal diagnosis of placenta accrete :a review. Ultrasound Obstet Gynecol 2005; 26: 89～96.
19. Chestnut D H, Dewan D M, Redick L F, Caton D, Spielman F J. Anesthetic management for obstetric hysterectomy: a multi-institutional study. Anesthesiology 1989; 70: 607～610.
20. Kidney D D, Nguyen A M, Ahdoot D, Bickrnore D, Deutsch L S, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. A JR Am J Roent-genol 2001; 176: 1521～1524.
21．欧阳为相，沙慧兰，吴超英．米非司酮治疗产后胎盘残留23例．医药导报2001；20(12)：765～766．
22．严云．天花粉治疗胎盘植入40例疗效观察．青海医药杂志2002；32(6)：3．
23．周莉，吴连芳．40例植入性胎盘的回顾性分析．首都医科大学学报2005；26(1)：90～92．
24．杨利亚，李力，胡珊．胎盘植入18例临床分析．四川医学2006；27(1)：86～87．
25. Levine A B, Kuhlman K, Bonn J. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters. J Matern Fetal Med 1999; 8: 173～176.
26. Yinka O, John C S. Placenta previa, placenta accreta, and vasa previa. Obstet and Gynecol 2006; 107: 927-941.
1. Placenta accrete. ACOG Committee Opinion No.266.American College of Obstetricians and Gynecologists .Obstet Gynecol 2002; 99: 169～170.
2. O'Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative atretegies .Am J Obstet Gynecol 1996;175:1632-1638.
3. Hudon L,Belfort MA,Broome DR .Diagnosis and management of placenta percreta:a review.Obstet Gynecol Surv1998;53:509-517.
4. Kastner ES ,Figueroa R,Garry D, Maulik D. Emergency peripartum hysterectomy :experience at a commynity teaching hospital. Obstet Gynecol 2002;99:971-975.
5. DeRoux SJ, Prendergast NC, Adsay NV. Spontaneous uterine rupture with fatal hemoperitoneum due to placenta accrete percreta :a case report and review of the literature. Int J Gynecol Pathol 1999;18:82-86.
6. Williams Obstetrics, 21thedlMj. McGrawH. NewYork, 2001. 641-643.
7．曹泽毅主编．中华妇产科学,第2版．北京：人民卫生出版社,196-197,479．
8. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accrete. Am J Obetet Gynecol 1997; 177:210-214.
9. Wu S, Kocherginsky M, Hibbard JU. Abnorma placentation :twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-1461.
10. Clarke SL, Koonings PP, Phelan JP. Placenta previa/accrete and prior cesarean section. Obstet Gynecol 1985;66:89-92.
11. Zelop C,Nadel A,Frigoletto FD Jr,Pauker S,MacMillan M,Benacerraf BR.Placenta accrete/percreta/increta:a cause of elevated maternal serum alpha-fetoprotein.Obstet Gynecol 1992;80:693-694.
12. Kupferminc MJ,Tamura RK,Wigton TR,Glassenberg R,Socol ML.Placenta accerta is associated with elevated maternal serum alpha-fetoprotein.Obstet Gynecol 1993;82:266-269.
13. Benirschke K,Kaufmann P.Pathology of the human placenta.4~(th) ed.New York(NY):Spring;2000.
14. Comstock CH.Antenatal dagnosis of placenta accrete :a review. Ultrasound Obstet Gynecol 2005;26:89-96.
15. Comstock CH,Love JJ Jr, Bronsteen RA, Lee W, Vettraino IM, Huang RR, et al. Sonographic detection of placenta accrete in the second and third trimesters of pregnancy. Am J Obstet Gynecol 2004; 190:1135- 1140.
16. Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accrete by transabdominal color Doppler ultrasound. Ultrasound Obstret Gynecol 2000; 15: 28～35.
17. Comstock CH, Lee W, Vettaino IM, Bronsteen RA. The early sonographic appearance of placenta accrete.J Ultrasound Med 2003;22:19～23; quiz 24～26.
18. Thorp JM Jr, Wells SR, Wiest HH, Jeffries L, Lyles E. First-trimester disgnosis of placenta previa percreta by magnetic resonance imaging. Am J Obstet Gynecol 1998;178: 616～618.
19. Palacios Jaraquemada JM, Bruno CH. Magnetic resonance imaging in 300 cases of placenta accrete: surgical correlation of new findings. Acta Obstet Gynecol Scand 2005; 84: 716～724.
20. Levine D, Hulka CA, Ludmir J, Li W, Edelman RR. Placenta accrete: evaluation with color Doppler US. power Doppler US,and MR imaging.Radiology 1997; 205: 773～776.
21. Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ. Anesthetic management for obstetric hysterectomy: a mutli-institutional study. Anesthesiology 1989; 70: 607～610.
22. Alvarez M, Lockwood CJ, Ghidini A, Dottino P, Mitty HA, Berkowitz RL. Prophylactic and emergent arterial catheterization for selective embolization in obstetric hemorrhage. Am J Perinatol 1992;9: 441～444.
23. Kidney DD, Nguyen AM, Ahdoot D, Bickmore D, Deutsch LS, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. AJR Am J Roent-genol 2001; 176: 1521～1524.
24. Levine AB, Kuhlman K, Bonn J. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters. J Matern Fetal Med 1999; 8: 173～176.
25. Arulkumaran S, Ng CS, Ingemarsson I, Ratnam SS. Medical treatment of placenta accrete with methotrexate. Acta Obstet Gynecol Scand 1986; 65: 285～286.
26. Mussalli GM, Shah J, Berck DJ, Elimian A, Tejani N, Manning FA. Placenta accrete and methotrexate therapy: three case reports. J Perinatol 2000; 20: 331～334.
27．茅云霞．米非司酮保守治疗植入性胎盘10例分析．中国优生与遗传杂志，2002，10(6)：85．
28．杨利亚，李力，胡珊等．胎盘植入18例临床分析．四川医学2006；27(1)：86～87．
29．严云．天花粉治疗胎盘植入40例疗效观察．青海医药杂志2002；32(6)：3．
30. Kayem G, Davy C, Goffinet F, Thomas C, Clement D, Cabrol D. Conservative versus extirpative management in cases of placenta accrete. Obstet Gynecol 2004; 104z; 531～536.
31. Caliskan E, Tan O, Kurtaran V, Dilbaz B, Haveral A. Placenta previa percreta with urinary bladder and ureter invasion. Arch Gyynecol Obstet 2003; 268: 343～344.
32. Washecka R, Behling A. Urologic complications of placenta percreta invading the urinary bladder: a case report and review of the literature. Hawaii Med J 2002; 61: 66～69.
2. Adair SR, Elamin D, Tharmaratnam S. Placenta increta; conservative management--a successful outcome 1Case report and literature review. Matern Fetal Neonatal Med, 2004, 15(4): 275.
3. 3 Bennett M J, Sen RC. Conservative' management of p lacenta p raevia percreta: report of two cases and discussion of current management options Aust N ZlObstet Gynaecol, 2003,43(3): 249.
4. Kayem G, Davy C, Goffinet F et all. Conservative versus extirpative management in cases of placenta accretal Obstet Gynecol, 2004, 104(3): 531.
5. Liu X, Fan G, J in Zl. Lower uterine segment pregnancy with placenta increta complicating first trimester induced abortion: diagnosis and conservative m anagementl Chin Med(Engl), 2003, 116(5): 695
6. Williams Obstetrics, 21thedlMj. McGrawH. New York, 2001. 641～643.
7．曹泽毅主编．中华妇产科学．第2版．北京：人民卫生出版社，479．
8. Mussalli G M, Shah J, Berck DJ et al. Placenta accreta and methotrexate therapy: three case reportslPerinatol, 2000, 20(5): 331.
9. Riggs JC, Jahshan A, Schiavello H J. Alternative conservative management of placenta accreta～A case reportl Rep rod Med, 2000, 45(7): 595.
10. Wu S, Kocherginsky M, Hibbard J U. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecl 2005; 192: 1458-1461.
11. Miller D A, Choller J A, Goodwin T M. Clinical risk factors for placenta previa-placenta accrete. Am J Obstet Gynecol 1997; 177: 210-214.
12．吴燕，王秀云．胎盘植入11例临床分析．实用妇产科杂志，1997，13(2)：94-95．
13．周莉，吴连芳．40例植入性胎盘的回顾性分析．首都医科大学学报，2005，26(1)：90-92．
14. Kwee A, Bots M L, Visser G H, Bruinse H W. Emergency peripartum hysterectomy: A prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 2006; 124: 187-192.
15. Miller D A, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accrete. Am J Obstet Gynecol 1997; 177:210-214.
16. Clarke S L, Koonings P P, Phelan J P. Placenta previa/accrete and prior cesarean section. Obstet Gynecol 1985;66: 89～92.
17. Comstock C H, Love J J Jr, Bronsteen R A, Lee W, Vettraino I M, Huang R R, et al. Sonographic detection of placenta accrete in the second and third trimesters of pregnancy .Am J Obstet Gynecol 2004;190: 1135～1140.
18. Comstock C H. Antenatal diagnosis of placenta accrete :a review. Ultrasound Obstet Gynecol 2005; 26: 89～96.
19. Chestnut D H, Dewan D M, Redick L F, Caton D, Spielman F J. Anesthetic management for obstetric hysterectomy: a multi-institutional study. Anesthesiology 1989; 70: 607～610.
20. Kidney D D, Nguyen A M, Ahdoot D, Bickrnore D, Deutsch L S, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. A JR Am J Roent-genol 2001; 176: 1521～1524.
21．欧阳为相，沙慧兰，吴超英．米非司酮治疗产后胎盘残留23例．医药导报2001；20(12)：765～766．
22．严云．天花粉治疗胎盘植入40例疗效观察．青海医药杂志2002；32(6)：3．
23．周莉，吴连芳．40例植入性胎盘的回顾性分析．首都医科大学学报2005；26(1)：90～92．
24．杨利亚，李力，胡珊．胎盘植入18例临床分析．四川医学2006；27(1)：86～87．
25. Levine A B, Kuhlman K, Bonn J. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters. J Matern Fetal Med 1999; 8: 173～176.
26. Yinka O, John C S. Placenta previa, placenta accreta, and vasa previa. Obstet and Gynecol 2006; 107: 927-941.
1. Placenta accrete. ACOG Committee Opinion No.266.American College of Obstetricians and Gynecologists .Obstet Gynecol 2002; 99: 169～170.
2. O'Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative atretegies .Am J Obstet Gynecol 1996;175:1632-1638.
3. Hudon L,Belfort MA,Broome DR .Diagnosis and management of placenta percreta:a review.Obstet Gynecol Surv1998;53:509-517.
4. Kastner ES ,Figueroa R,Garry D, Maulik D. Emergency peripartum hysterectomy :experience at a commynity teaching hospital. Obstet Gynecol 2002;99:971-975.
5. DeRoux SJ, Prendergast NC, Adsay NV. Spontaneous uterine rupture with fatal hemoperitoneum due to placenta accrete percreta :a case report and review of the literature. Int J Gynecol Pathol 1999;18:82-86.
6. Williams Obstetrics, 21thedlMj. McGrawH. NewYork, 2001. 641-643.
7．曹泽毅主编．中华妇产科学,第2版．北京：人民卫生出版社,196-197,479．
8. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accrete. Am J Obetet Gynecol 1997; 177:210-214.
9. Wu S, Kocherginsky M, Hibbard JU. Abnorma placentation :twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-1461.
10. Clarke SL, Koonings PP, Phelan JP. Placenta previa/accrete and prior cesarean section. Obstet Gynecol 1985;66:89-92.
11. Zelop C,Nadel A,Frigoletto FD Jr,Pauker S,MacMillan M,Benacerraf BR.Placenta accrete/percreta/increta:a cause of elevated maternal serum alpha-fetoprotein.Obstet Gynecol 1992;80:693-694.
12. Kupferminc MJ,Tamura RK,Wigton TR,Glassenberg R,Socol ML.Placenta accerta is associated with elevated maternal serum alpha-fetoprotein.Obstet Gynecol 1993;82:266-269.
13. Benirschke K,Kaufmann P.Pathology of the human placenta.4~(th) ed.New York(NY):Spring;2000.
14. Comstock CH.Antenatal dagnosis of placenta accrete :a review. Ultrasound Obstet Gynecol 2005;26:89-96.
15. Comstock CH,Love JJ Jr, Bronsteen RA, Lee W, Vettraino IM, Huang RR, et al. Sonographic detection of placenta accrete in the second and third trimesters of pregnancy. Am J Obstet Gynecol 2004; 190:1135- 1140.
16. Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accrete by transabdominal color Doppler ultrasound. Ultrasound Obstret Gynecol 2000; 15: 28～35.
17. Comstock CH, Lee W, Vettaino IM, Bronsteen RA. The early sonographic appearance of placenta accrete.J Ultrasound Med 2003;22:19～23; quiz 24～26.
18. Thorp JM Jr, Wells SR, Wiest HH, Jeffries L, Lyles E. First-trimester disgnosis of placenta previa percreta by magnetic resonance imaging. Am J Obstet Gynecol 1998;178: 616～618.
19. Palacios Jaraquemada JM, Bruno CH. Magnetic resonance imaging in 300 cases of placenta accrete: surgical correlation of new findings. Acta Obstet Gynecol Scand 2005; 84: 716～724.
20. Levine D, Hulka CA, Ludmir J, Li W, Edelman RR. Placenta accrete: evaluation with color Doppler US. power Doppler US,and MR imaging.Radiology 1997; 205: 773～776.
21. Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ. Anesthetic management for obstetric hysterectomy: a mutli-institutional study. Anesthesiology 1989; 70: 607～610.
22. Alvarez M, Lockwood CJ, Ghidini A, Dottino P, Mitty HA, Berkowitz RL. Prophylactic and emergent arterial catheterization for selective embolization in obstetric hemorrhage. Am J Perinatol 1992;9: 441～444.
23. Kidney DD, Nguyen AM, Ahdoot D, Bickmore D, Deutsch LS, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. AJR Am J Roent-genol 2001; 176: 1521～1524.
24. Levine AB, Kuhlman K, Bonn J. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters. J Matern Fetal Med 1999; 8: 173～176.
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