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中华产科急救电子杂志

中华产科急救电子杂志 ›› 2023, Vol. 12 ›› Issue (03) : 187 -192. doi: 10.3877/cma.j.issn.2095-3259.2023.03.013

论著

不同程度胎盘植入患者剖宫产的麻醉决策及母婴结局
陆晓勤, 刘先保, 龙尚乾, 宋可欣, 邓艳红, 张春芳†()   
  1. 广州医科大学附属第三医院麻醉科，广州　510150
    广州医科大学附属第三医院妇产科　广东省产科重大疾病重点实验室　广州重症孕产妇救治中心，广州　510150
  • 收稿日期:2022-03-03 出版日期:2023-08-18
  • 通信作者: 张春芳
  • 基金资助:
    2023年度广东省医学科研基金适宜技术推广项目; 广州医科大学第二临床学院2023年高水平大学"一流本科专业建设经费"资助项目

Anesthetic decision-making, maternal and neonatal prognosis of cesarean section in patients with different degrees of placenta accreta

Xiaoqin Lu, Xianbao Liu, Shangqian Long, Kexin Song, Yanhong Deng, Chunfang Zhang†()   

  1. Department of Anesthesiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
    Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou Medical Center for Critical Pregnant Women, Guangzhou 510150, China
  • Received:2022-03-03 Published:2023-08-18
  • Corresponding author: Chunfang Zhang
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引用本文：

陆晓勤, 刘先保, 龙尚乾, 宋可欣, 邓艳红, 张春芳. 不同程度胎盘植入患者剖宫产的麻醉决策及母婴结局[J]. 中华产科急救电子杂志, 2023, 12(03): 187-192.

Xiaoqin Lu, Xianbao Liu, Shangqian Long, Kexin Song, Yanhong Deng, Chunfang Zhang. Anesthetic decision-making, maternal and neonatal prognosis of cesarean section in patients with different degrees of placenta accreta[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2023, 12(03): 187-192.

目的

探讨不同程度胎盘植入剖宫产手术麻醉方式的选择及母婴结局。

方法

收集2018年至2021年在广州医科大学附属第三医院诊断为"胎盘植入"的562例患者的临床资料，排除剖宫取胎、人工流产、数据缺失等病例，共纳入353例产妇；根据磁共振成像影像检查的胎盘植入程度将产妇分成三组：粘连组(63例)，植入组(249例)，穿透组(41例)；分析三组产妇的术前一般情况、麻醉方式选择、术中管理情况及母婴结局。

结果

三组产妇中，粘连组有27例(42.9%)选择腰硬联合麻醉，而穿透组仅2例(4.9%)；穿透组有39例(95.1%)选择全身麻醉，占比高于粘连组(57.1%)和植入组(81.5%)，三组麻醉方式选择差异有统计学意义( χ2＝24.82，P<0.05)。穿透组36例(87.8%)术中需行子宫切除术，明显高于粘连组(38.1%)和植入组(57.4%)，差异有统计学意义(P<0.05)。穿透组的新生儿1 min Apgar评分(17.33±1.57)低于粘连组(8.64±1.70)和植入组(7.77±1.84)，差异有统计学意义(F＝9.35，P<0.05)，而三组的新生儿5 min、10 min Apgar评分差异无统计学意义(P>0.05)。

结论

麻醉医师应根据术前影像学提示的植入程度选择麻醉方式，植入程度越重，越倾向选择全身麻醉。术中经过产科医师、麻醉医师及新生儿科医师合作，母婴预后结局良好，但穿透性胎盘植入患者子宫切除率高。

关键词: 侵入性胎盘, 剖宫产术, 麻醉
Objective

To investigate the anesthetic choices and the maternal and neonatal prognosis for patients undergoing cesarean section complicated with different degrees of placenta accreta.

Methods

A retrospective case review of 562 patients complicated with placenta accreta from 2018 to 2021 in The Third Affiliated Hospital of Guangzhou Medical University was conducted. Patients with abortion and missing data were excluded, and the total of 353 cases were enrolled in this study. According to the degree of placenta accreta reported by MRI, they were divided into the accreta group (n=63), increta group (n=249) and percreta group (n=41). We analyzed the perioperative management, and maternal and neonatal prognosis.

Results

There was statistical significance in the selection of anesthesia methods in three groups (P<0.05), 27 cases (47.9%) in the accreta group, 46 cases (18.5%) in the increta group and 2 cases (4.9%) in the percreta group underwent spinal anesthesia, 36 cases (57.1%) in accreta group, 203 cases (81.5%) in increta group, 39 cases (95.1%) in percreta group underwent general anesthesia, 3 cases (11.1%), 12 cases (26.1%) in increta group and 1 case (50.0%) in percreta group underwent spinal anesthesia were eventually switched to general anesthesia from initial spinal anesthesia during the operation. In the percreta group, 36 cases (87.8%) of patients underwent hysterectomy, which were significantly higher than accreta group and increta group (P<0.05). There were no statistically significant differences in the postoperative complications in three groups (P>0.05). There were no statistically significant differences in the total length of hospitalization and postoperative length of hospitalization (P>0.05). The 1 min Apgar score in percreta group was significantly lower than the accreta group and increta group (P<0.05) while there was no statistically significants in the 5 min and 10 min Apgar scores in three Group (P>0.05).

Conclusions

Anesthesiologists choose anesthesia according to the degrees of placenta accrete reported by MRI preoperatively and general anesthesia should be considered in placenta percreta. With the cooperation of obstetricians, anesthesiologists and neonatologists, the prognosis of mother and infant is good. However, patients complicated with placenta percreta have a high rate of hysterectomy.

Key words: Placenta accreta, Cesarean section, Anesthesia
表1 三组产妇的一般情况比较
项目 例数 年龄(岁，±s) 身高(cm，±s) 体重(kg，±s) 孕周(周，±s) 孕次[次，M(Q)] 产次[次，M(Q)]
粘连组 63 35.14±4.33 157.57±4.60 66.11±8.75 35.44±2.44 4(2) 2(1)
植入组 249 33.23±4.76 157.99±4.88 66.38±9.50 35.82±1.58 4(2) 2(1)
穿透组 41 33.66±4.88 157.46±5.61 64.25±8.99 34.82±2.24 4(3) 2(1)
统计值   F＝0.46 F＝0.40 F＝1.23 F＝7.34 Z＝0.99 Z＝1.00
P值   0.06 0.66 0.29 0.00 0.60 0.60
项目 例数 清宫史[例(%)] 子宫肌瘤剔除史[例(%)] 剖宫产史[例(%)] 合并前置胎盘[例(%)]
0次 1次 2次 ≥3次
粘连组 63 39(61.9) 1(1.5) 13(20.0) 31(49.2) 18(28.5) 1(1.5) 54(85.7)
植入组 249 146(58.6) 0(0) 34(13.7) 140(56.2) 72(28.9) 3(1.2) 224(90.4)
穿透组 41 24(58.5) 2(4.9)b 3(7.3) 22(53.6) 14(34.1) 2(4.9) 6(14.6)ab
χ2值   0.23 6.14 6.14 100.66
P值   0.89 0.01 0.41 0.00
表2 三组产妇的术中管理情况
项目 例数 麻醉方式[例(%)] 出血量[ml，M(Q)] 输液量[ml，M(Q)] 输注红细胞[例(%)] 输注冰冻血浆[例(%)]
腰硬联合麻醉 全身麻醉 中转全身麻醉
粘连组 63 27(42.9) 36(57.1) 3(11.1) 800(525) 2500(1750) 26(41.3) 11(17.5)
植入组 249 46(18.5)a 203(81.5)a 12(26.1) 1200(1100)a 3500(1860)a 149(59.8)a 98(39.4)a
穿透组 41 2(4.9)ab 39(95.1)ab 1(50.0)ab 1650(1950)ab 3900(2200)ab 8(80.5)ab 23(56.1)ab
统计值   χ2＝24.82 Z＝19.61 Z＝9.87 χ2＝27.52 χ2＝18.28
P值   0.00 0.00 0.00 0.00 0.00
项目 例数 术前Hb(g/L，±s) 术后Hb(g/L，±s) 术前PLT(×109/L，±s) 术后PLT(×109/L，±s) 术中见胎盘植入深度[例(%)]
无 肌层 浆膜层 穿透
粘连组 63 104.95±13.32 92.08±13.09 226.75±57.71 209.44±55.81 8(12.7) 44(69.9) 7(11.1) 4(6.3)
植入组 249 106.88±13.84 87.63±16.31 217.44±52.41 179.72±51.42a 16(6.4) 158(63.5) 40(16.1) 35(14.0)
穿透组 41 106.80±11.49 87.00±14.52 191.53±56.71ab 149.41±52.20ab 2(4.9)ab 13(31.7)ab 6(14.6)ab 20(48.8)ab
统计值   F＝0.59 F＝2.52 F＝7.25 F＝20.66 χ2＝34.58
P值   0.55 0.08 0.00 0.00 0.00
项目 例数 输尿管导管置管术[例(%)] 双侧子宫动脉上行支结扎术[例(%)] 子宫切除术[例(%)]
否 部分切除 次全切除 全切除
粘连组 63 19(30.1) 47(74.6) 39(61.9) 8(12.7) 15(23.8) 0(0)
植入组 249 139(55.8)a 172(69.1) 106(42.6)a 65(26.1)a 71(28.5)a 7(2.8)a
穿透组 41 35(85.3)ab 10(24.4)ab 5(12.2)ab 3(7.3)ab 29(70.7)ab 4(9.8)ab
χ2值   33.19 32.69 51.69
P值   0.00 0.00 0.00
表3 三组患者母婴结局比较
项目 例数 术后转ICU[例(%)] 术后并发症[例(%)]
肠梗阻 盆腔血肿 切口浆膜下血肿 静脉血栓 术后感染 伤口愈合不良 子宫肌炎
粘连组 63 2(3.2) 2(3.2) 0 0 0 6(9.5) 0 0
植入组 249 9(3.6) 12(4.8) 5(2.0) 1(0.4) 1(0.4) 29(11.6) 3(1.2) 1(0.4)
穿透组 41 0ab 2(4.8) 3(7.3) 0 0 4(9.8) 1(2.4) 0
χ2值   2.80 10.97
P值   0.00 0.79
项目 例数 总住院时长(d，±s) 术后住院时长(d，±s) 新生儿Apgar评分(分，±s)
1 min 5 min 10 min
粘连组 63 11.15±5.39 6.07±3.35 8.64±1.70 9.47±0.94 9.84±0.58
植入组 249 11.21±4.53 6.15±1.65 7.77±1.84a 9.21±1.08 10.00±3.60
穿透组 41 11.94±5.86 6.17±1.95 7.33±1.57a 9.17±0.74 9.85±0.35
F值   0.57 0.04 9.35 1.95 0.17
P值   0.56 0.96 0.00 0.14 0.83
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