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  • Title: [Risk factor assessment and adverse outcome prediction of placenta accreta in pregnant women after cesarean section complicated with placenta previa: a national multicenter retrospective study].
    Author: Bai GQ, Chen WL, Huang XH, Zhao SJ, Zhao SP, Chen XJ, Chen SW, Yang H, Lu X, Liu GY, Chen QH, Zhang LA, Jin L.
    Journal: Zhonghua Fu Chan Ke Za Zhi; 2023 Jan 25; 58(1):26-36. PubMed ID: 36720612.
    Abstract:
    Objective: To study the risk factors of adverse pregnancy outcomes for the diagnosis and treatment of pregnancy after cesarean section complicated with placenta previa. Methods: A national multicenter retrospective study was conducted to select a total of 747 pregnant women with the third trimester singleton pregnancy after cesarean section complicated with placenta previa from 12 tertiary hospitals in January 1st to December 31st, 2018. The risk factors of severe adverse outcomes [hysterectomy, intraoperative blood loss ≥1 000 ml, intraoperative diagnosis of placenta accreta spectrum disorders (PAS)] in pregnant women with second pregnancy complicated with placenta previa after cesarean section were investigated by logistic regression analysis. The roles of prenatal ultrasonography and magnetic resonance imaging (MRI) in the prediction of PAS and severe adverse outcomes were observed. According to whether vascular intervention was performed (uterine artery embolization or abdominal aortic balloon occlusion), the pregnant women were divided into the blocked group and the unblocked group, and the maternal and infant perinatal outcomes between the two groups were compared. Results: (1) General information: the hysterectomy rate of 747 pregnant women with second pregnancy complicated with placenta previa after cesarean section was 10.4% (78/747), the intraoperative blood loss ≥1 000 ml in 55.8% (417/747), and PAS was confirmed in 47.5% (355/747). The incidence of uterine rupture was 0.8% (6/747). (2) Analysis of risk factors for severe adverse outcomes: based on binary unconditioned logistic regression univariate and multivariate analysis, the risk factors for hysterectomy were the mode of vascular embolization and intraoperative blood loss. The probability of hysterectomy with uterine artery embolization was 5.319 times higher than that with abdominal aortic balloon occlusion (95%CI: 1.346-21.018). The risk factors of intraoperative blood loss ≥1 000 ml were the number of cesarean section delivery, ultrasonography indicated PAS and suspected PAS, intraoperative PAS and complete placenta previa. The risk factors for intraoperative PAS were uterine scar thickness, ultrasonography indicated PAS and suspected PAS, MRI indicated PAS and suspected PAS, and complete placenta previa. (3) The roles of ultrasonography and MRI in predicting PAS: the sensitivity and specificity of ultrasonography in predicting PAS were 47.5% and 88.4%; the kappa value was 0.279 (P<0.001), with fair agreement. The sensitivity and specificity of MRI to predict PAS were 79.2% and 97.8%, respectively. The kappa value was 0.702 (P<0.001), indicating a good agreement. The intraoperative blood loss and hysterectomy rate of pregnant women with PAS indicated by ultrasonography and MRI were significantly higher than those with PAS only by ultrasonography or MRI. (4) Influence of vascular occlusion on pregnancy outcome: there were no significant differences in intraoperative blood loss and incidence of intraoperative bleeding ≥1 000 ml between the blocked group and the unblocked group (all P>0.05). There was no significant difference in intraoperative blood loss between the pregnant women with abdominal aortic balloon occlusion, uterine artery embolization and those without occlusion (P=0.409). The hysterectomy rate of pregnant women with uterine artery embolization was significantly higher than those with abdominal aortic balloon occlusion [39.3% (22/56) vs 10.0% (5/50), P=0.001]. Conclusions: In the third trimester of pregnancy with placenta previa after cesarean section, MRI examination has better consistency in predicting PAS than ultrasonography examination. Ultrasonography examination combined with MRI examination could effectively predict the hysterectomy rate and intraoperative blood loss. Vascular occlusion could not reduce the amount of intraoperative blood loss. The hysterectomy rate of pregnant women with uterine artery embolization is higher than those with abdominal aortic balloon occlusion. 目的： 探讨剖宫产术后再次妊娠合并前置胎盘孕妇的胎盘植入性疾病（PAS）影像学诊断及血管阻断方式对妊娠结局的影响。 方法： 采用全国多中心回顾性研究，于2018年1月1日至12月31日选取12家三级甲等医院的剖宫产术后再次妊娠合并前置胎盘的妊娠晚期单胎妊娠孕妇共747例。采用单因素及多因素logistic回归分析，观察剖宫产术后再次妊娠合并前置胎盘孕妇严重不良结局（子宫切除、术中出血量≥1 000 ml、术中诊断PAS）的危险因素；观察产前超声和磁共振成像（MRI）检查在胎盘PAS及严重不良结局预测中的作用。根据是否行血管介入（子宫动脉栓塞术或腹主动脉球囊阻断术）分为阻断组（106例）与未阻断组（641例），比较两组孕妇的母儿结局。 结果： （1）一般情况：747例剖宫产术后再次妊娠合并前置胎盘孕妇的子宫切除率为10.4%（78/747），术中出血量≥1 000 ml者占55.8%（417/747），术中确诊PAS者占47.5%（355/747）。子宫破裂的发生率为0.8%（6/747）。（2）严重不良结局的危险因素：子宫切除的危险因素是血管阻断方式和术中出血量，子宫动脉栓塞术者子宫切除的可能性是腹主动脉球囊阻断术者的5.319倍（95%CI为1.346~21.018）；术中出血量≥1 000 ml的危险因素是剖宫产术次数、超声检查提示PAS及可疑PAS、术中是否诊断PAS、完全性前置胎盘；术中诊断PAS的危险因素是子宫瘢痕厚度、超声检查提示PAS及可疑PAS、MRI检查提示PAS及可疑PAS、完全性前置胎盘；（3）超声和MRI检查在预测PAS中的作用：超声检查预测PAS的敏感度为47.5%，特异度为88.4%；kappa值为0.279（P<0.001），一致性一般。MRI检查预测PAS的敏感度为79.2%，特异度为97.8%；kappa值为0.702（P<0.001），一致性较好。超声且MRI检查均提示PAS孕妇的术中出血量及子宫切除率均显著高于仅超声或仅MRI检查提示PAS的孕妇。（4）血管阻断对妊娠结局的影响：阻断组与未阻断组孕妇的术中出血量、术中出血量≥1 000 ml发生率分别比较，差异均无统计学意义（P均>0.05）。阻断组腹主动脉球囊阻断者、子宫动脉栓塞者与未阻断组孕妇的术中出血量无显著差异（P=0.409）；阻断组子宫动脉栓塞孕妇的子宫切除率显著高于腹主动脉球囊阻断孕妇［分别为39.3%（22/56）、10.0%（5/50），P=0.001］。 结论： 剖宫产术后再次妊娠合并前置胎盘的妊娠晚期孕妇，MRI检查比超声检查预测PAS的一致性好，超声检查结合MRI检查可有效地预测子宫切除率和术中出血量。血管阻断不能降低术中出血量，子宫动脉栓塞孕妇的子宫切除率高于腹主动脉球囊阻断孕妇。.
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