Transfusion therapy for placenta accreta

doi:10.3877/cma.j.issn.2095-3259.2014.01.004

Abstract

Abstract:

With the cesarean delivery rate increase, the incidence rate of placenta accreta has been parallel increased. Placenta accrete is one of severe postpartum haemorrhage factors. For decreasing maternal mortality of severe postpartum haemorrhage, the average blood loss at delivery in women with placenta accreta is 3 000-5 000 ml. As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells. Transfusion therapy is an important management. To improve outcomes of pregnant, we introduce assessment, prepare and management of transfusion therapy for the pregnant with placenta accreta.

Key words: Placenta accreta, Postpartum hemorrhage, Transfusion therapy, Blood component transfusion

Tianying Pan, Xinghui Liu. Transfusion therapy for placenta accreta[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2014, 03(01): 13-17.

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References 29

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项目		诊断或处理时机	操作及注意事项
怀疑胎盘植入		20～28周	彩色多普勒超声或磁共振成像
术前评估、多科会诊、预估出血情况		分娩前一周	获取患者病史，产检情况、辅助检查，多科合作：产科医生、妇科医生(盆腔外科医生)、麻醉科医生、介入治疗医生、新生儿科医生、血液科医生、检验科医生、护理团队
确定手术方式及时机		分娩前一周	计划性剖宫产，>34周胎肺成熟后，无活动性出血者一般可在36周左右，减少急诊手术
医患沟通		怀疑胎盘植入时尽早并多次沟通，分娩前、手术中需再次沟通	根据病情选择合适的分娩方式和手术时间；医患沟通包括子宫切除的可能性，产时、产后出血的风险及孕妇死亡的可能
实验室检查		入院时、分娩前一周、输血后重复检查	血尿常规、凝血常规、血生化、输血免疫全套
血库配血		分娩前1～3 d	ABO血型正反定型、Rh(D)血型鉴定、抗体筛查和交叉配血，提前准备红细胞悬液8～10 U，新鲜冰冻血浆800～1 000 ml
术前准备、建立静脉通道		分娩当日	建立两条以上静脉通道，14～18G针头，保证通畅输血输液，有条件医院建立中心静脉通道
术中出血评估		术中	术中多种方法综合评估：(1)容积法、称重法、面积法；(2)监测生命体征、尿量和精神状态；(3)休克指数法；(4)血红蛋白量测定法等
诊断产后出血，建立抢救团队		出血量>500 ml时	产科医生、妇科医生(盆腔外科医生)、麻醉科医生、介入治疗医生、血液科医生、检验科医生、护理团队
容量复苏		出血量>500 ml时	液体、血液预温，患者保温，注意评估隐形出血，同时供氧、检测生命体征
止血		及时、积极止血	使用缩宫素、子宫按摩及按压、B-Lynch及各种改良缝合术、宫腔填塞、水囊压迫、盆腔动脉结扎、血管栓塞、髂总或髂内动脉及腹主动脉预防性球囊阻断术等；胎盘原位保留、子宫切除
输血治疗		?	?
?	红细胞悬液	(1)失血量约30%～40%时；(2)血红蛋白<70 g/L；(3)血红蛋白<100 g/L仍有活动性出血者	保证组织灌注和氧供，维持血红蛋白>70 g/L
?	新鲜冰冻血浆	(1)PT/APTT>1.5倍正常值；(2)输注红细胞悬液4 U后	补充凝血因子和扩充血容量，胎盘植入大出血时预防凝血因子稀释
?	血小板	(1)血小板计数<75×10⁹/L时，如继续输注红细胞和血浆，应早期输注血小板；(2)血小板计数<50×10⁹/L时必须输注血小板	止血
?	冷沉淀	大量失血致DIC且血小板计数<1 g/L时	纠正血小板计数和FVIII、vW因子缺乏，治疗严重出血

项目		诊断或处理时机	操作及注意事项
怀疑胎盘植入		20～28周	彩色多普勒超声或磁共振成像
术前评估、多科会诊、预估出血情况		分娩前一周	获取患者病史，产检情况、辅助检查，多科合作：产科医生、妇科医生(盆腔外科医生)、麻醉科医生、介入治疗医生、新生儿科医生、血液科医生、检验科医生、护理团队
确定手术方式及时机		分娩前一周	计划性剖宫产，>34周胎肺成熟后，无活动性出血者一般可在36周左右，减少急诊手术
医患沟通		怀疑胎盘植入时尽早并多次沟通，分娩前、手术中需再次沟通	根据病情选择合适的分娩方式和手术时间；医患沟通包括子宫切除的可能性，产时、产后出血的风险及孕妇死亡的可能
实验室检查		入院时、分娩前一周、输血后重复检查	血尿常规、凝血常规、血生化、输血免疫全套
血库配血		分娩前1～3 d	ABO血型正反定型、Rh(D)血型鉴定、抗体筛查和交叉配血，提前准备红细胞悬液8～10 U，新鲜冰冻血浆800～1 000 ml
术前准备、建立静脉通道		分娩当日	建立两条以上静脉通道，14～18G针头，保证通畅输血输液，有条件医院建立中心静脉通道
术中出血评估		术中	术中多种方法综合评估：(1)容积法、称重法、面积法；(2)监测生命体征、尿量和精神状态；(3)休克指数法；(4)血红蛋白量测定法等
诊断产后出血，建立抢救团队		出血量>500 ml时	产科医生、妇科医生(盆腔外科医生)、麻醉科医生、介入治疗医生、血液科医生、检验科医生、护理团队
容量复苏		出血量>500 ml时	液体、血液预温，患者保温，注意评估隐形出血，同时供氧、检测生命体征
止血		及时、积极止血	使用缩宫素、子宫按摩及按压、B-Lynch及各种改良缝合术、宫腔填塞、水囊压迫、盆腔动脉结扎、血管栓塞、髂总或髂内动脉及腹主动脉预防性球囊阻断术等；胎盘原位保留、子宫切除
输血治疗		?	?
?	红细胞悬液	(1)失血量约30%～40%时；(2)血红蛋白<70 g/L；(3)血红蛋白<100 g/L仍有活动性出血者	保证组织灌注和氧供，维持血红蛋白>70 g/L
?	新鲜冰冻血浆	(1)PT/APTT>1.5倍正常值；(2)输注红细胞悬液4 U后	补充凝血因子和扩充血容量，胎盘植入大出血时预防凝血因子稀释
?	血小板	(1)血小板计数<75×10⁹/L时，如继续输注红细胞和血浆，应早期输注血小板；(2)血小板计数<50×10⁹/L时必须输注血小板	止血
?	冷沉淀	大量失血致DIC且血小板计数<1 g/L时	纠正血小板计数和FVIII、vW因子缺乏，治疗严重出血

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