凶险性前置胎盘一例诊治体会

张苗苗 李道成

【摘要】随着剖宫产率的增加，凶险性前置胎盘合并胎盘植入的几率也随之增加，由于产时胎盘剥离困难，导致产后大出血，是产科严重的并发症之一。该文报道1例既往有剖宫产史患者，此次妊娠为前置胎盘，孕晚期出现无痛性阴道大量流血，急诊行剖宫产手术，胎盘剥离处大量出血，出现失血性休克及DIC，术中止血均不能奏效，实施多学科协助抢救，最终切除子宫，术后转入ICU。术后病理检查提示子宫胎盘粘连并胎盘植入改变。虽然最终母女平安，但是患者却因此切除了子宫，丧失了再生育能力。因此，对有高危因素的产妇，临床医师应提高警惕性，可由经验丰富的医师进行反复多方位检查，做到早期诊断，减少漏诊及误诊率。

【关键词】凶险性前置胎盘；胎盘植入；大出血；DIC；子宫切除

【Abtract】The risk of pernicious placenta previa complicated with placenta accreta has been elevated along with the increase of cesarean section rate. Due to the difficulty of placental stripping， postpartum hemorrhage is one of the serious complications of obstetrics. In this article， we reported one case of placenta previa with a medical history of cesarean section. The patient presented with painless and massive vaginal bleeding during the late stage of pregnancy. She underwent emergent cesarean section. Intraoperatively， she suffered from massive bleeding， hemorrhagic shock and disseminated intravascular coagulation. Intraoperative massive bleeding could not be controled after multidisciplinary emergent treatment. Eventually， she had to undergo hysterectomy and was transferred to the intensive care unit. Postoperative pathological examination prompted the coexistence of placental adhesion and placenta accreta. The mother and infant were both safe. However， she lost the reproduction capability due to uterine removal. Consequently， extensive attention and comprehensive examinations should be performed by experienced obstetricians to make early diagnosis and reduce the missing and misdiagnosis rate of pernicious placenta pevia.

【Key words】Pernicious placenta previa； Placenta accreta； Massive hemorrhage； Disseminated intravascular coagulation； Hysterectomy

1993年Chattopadhyay等提出兇险性前置胎盘的概念，是指既往有剖宫产史，此次妊娠为前置胎盘，且胎盘附着于子宫瘢痕处，伴或不伴胎盘植入。其胎盘粘连、植入发生率高，可引起致命性大出血，甚至危及生命。凶险性前置胎盘临床处理需要多学科协助诊治，早期诊断，尽早到有医疗条件的医院住院、适时终止妊娠、做好围生期的处理是预防产后大出血，保证母胎安全的重要条件。

病例资料

一、病史与体格检查

患者女，34岁。因停经37周，阴道流血半小时于2016年11月21日急诊收入院。患者平素月经规则，月经周期30 d，持续7 d，末次月经2016年3月5日，孕期无腹痛及阴道流血。2017年6月1日患者在本院彩色多普勒超声（彩超）提示NT值在正常范围内。……