病理性胎盘粘连患者的标准输血路径
本公众号每天分享一篇最新一期Anesthesia & Analgesia等SCI杂志的摘要翻译，敬请关注并提出宝贵意见
A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta
背景与目的
在美国由于出生率提高（2014年32.2％）的推动，每1000个孕妇，粘连型胎盘（PA）的发生率从0.8增加到3.0。PA的平均综合失血量为2000〜5000 mL，经常需要大量输血输液。5年来，我们运用多学科方法连同输血结果对这些患者实施医疗管理。
方 法
我们回顾了2009年7月1日至2014年7月1日参与我们胎盘疾病计划患者的记录。实施胎盘疾病术前检查，以确保围产期出血患者的最佳医疗管理。
结 果
在产后检查胎盘的136名患者中，21名患有PA，39名患有微小PA，17例植入型胎盘，17例穿透性胎盘，42例没有胎盘粘连（其中11例有前置胎盘）。对于每个亚型，接受血液制品的患者的百分比为71％（PA），28％（微小PA），82％（植入型），82％（穿透型）和19％（无粘连）。在患有PA或变异的患者中，89％的PA或变异体患者接受了产后子宫切除术，而仅有5％的无或微小PA患者行子宫切除。
结 论
基于我们的经验及回顾分析，出现产前放射学证据或临床怀疑病理胎盘粘连的患者将从临床医疗管理标准化方案中获益，包括输血输液支持。我们发现，无论胎盘侵袭程度如何，通过异常胎盘产前识别，并且使用实质性的血液制品支持，大量出血是可预测的。我们机构的方案可以为处于严重的危及生命的产科出血患者快速提供足够的血液制品。因此，对病理性粘连型胎盘患者行剖宫产术后可行子宫切除术，多学科团队的程序化检查包括主动性的输血输液。
原始文献摘要
Panigrahi A K, Yeaton-Massey A, Bakhtary S, et al. A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta[J]. Anesthesia & Analgesia, 2017
PURPOSE:The incidence of placenta accreta (PA) has increased from 0.8 to 3.0 in 1000 pregnancies, driven by increased rates of cesarean deliveries (32.2% in 2014) of births in the United States. The average blood loss for a delivery complicated by PA ranges from 2000 to 5000 mL, frequently requiring substantial transfusion medicine support. We report our own institutional multidisciplinary approach for managing such patients, along with transfusion medicine outcomes, in this setting over a 5-year period.
METHODS: We reviewed records for patients referred to our program in placental disorders from July 1, 2009, to July 1, 2014. A placental disorders preoperative checklist was implemented to ensure optimal management of patients with peripartum hemorrhage.
RESULTS:Of 136 patients whose placentas were reviewed postpartum, 21 had PA, 39 had microscopic PA, 17 had increta, 17 had percreta, and 42 had no accreta (of which 11 had placenta previa). For each subtype, the percentage of patients receiving blood products were 71% (PA), 28% (microscopic PA), 82% (increta), 82% (percreta), and 19% (no accreta). Among patients with PA or variants, 89% of patients with PA or variants underwent postpartum hysterectomy, compared to only 5% of patients with no or microscopic PA.
CONCLUSION:
Based on our experience and on the fndings of our retrospective analysis, patients presenting with either antepartum radiological evidence or clinical suspicion of morbidly adherent placenta will beneft from a standardized protocol for clinical management, including transfusion medicine support. We found that massive hemorrhage is predictable when abnormal placentation is identifed predelivery and that blood product support is substantial regardless of the degree of placental invasiveness. The protocol at our institution provides immediate access to suffcient volumes and types of blood products at delivery for patients at highest risk for life-threatening obstetric hemorrhage. Therefore, for patients with a diagnosis of morbidly adherent placenta scheduled for planned cesarean delivery with possible hysterectomy, a programmatic checklist that mobilizes a multidisciplinary team, including proactive transfusion medicine support, represents best practices.
麻醉学文献进展分享
联系我们