【摘要】 目的 探讨中央性前置胎盘合并胎盘植入孕妇产后大出血的相关因素及预防措施。方法 收集2005年4月至2019年6月浙江大学医学院附属妇产科医院收治的355例中央性前置胎盘合并胎盘植入孕妇的临床资料，根据患者剖宫产术中及术后24 h内阴道出血量将患者分成产后大出血组（出血量≥2 000 mL）和对照组（出血量<2 000 mL），回顾性分析两组患者的一般资料、合并产前出血、妊娠合并症并发症、子宫畸形、胎盘位于子宫位置、分娩孕周、术中情况和手术操作等与产后大出血的关系。结果 影响中央性前置胎盘合并胎盘植入孕妇发生产后大出血的相关因素单因素分析显示，既往剖宫产次数、胎盘位于前壁、周围脏器浸润、子宫动脉结扎术、宫腔填塞术可能与产后大出血的发生相关（P <0.05）。进一步多因素logistic回归分析发现，周围脏器浸润（OR=28.821, 95%CI:3.741～222.033, P=0.001）、胎盘位于子宫前壁（OR=1.704, 95%CI:1.013～2.866,P=0.044）是中央性前置胎盘合并胎盘植入孕妇发生产后大出血的独立危险因素；子宫动脉结扎术（OR=0.593,95%CI:0.356～0.989, P=0.045）和宫腔填塞术（OR=0.600, 95%CI:0.371～0.971, P=0.037）是其独立保护因素。联合此四者预测中央性前置胎盘合并胎盘植入的孕妇发生产后大出血的ROC曲线下面积为0.687。结论 中央性前置胎盘合并胎盘植入时，术前需着重了解胎盘位置及与周围脏器浸润情况，针对产后大出血高危人群，术中行预防性子宫动脉结扎和（或）宫腔填塞术，以降低母儿不良妊娠结局发生。更多还原

【Abstract】 Objective To explore the related factors and preventive measures of postpartum hemorrhage in pregnant women with central placenta previa with placenta implantation. Methods Clinical data of 355 pregnant women with central placenta previa with placenta implantation admitted to the Obstetrics and Gynecology Hospital Affiliated to Zhejiang University School of Medicine from April 2005 to June 2019 were collected. According to the amount of vaginal bleeding during cesarean section and within 24 h after surgery, the patients were divided into postpartum massive hemorrhage( ≥ 2 000 mL) and control groups( < 2 000 mL). The relationship between the general data, prenatal bleeding, complications of pregnancy, uterine malformations, placenta location in uterus, gestational weeks, intraoperative conditions and operation and postpartum massive bleeding were analyzed retrospectively. Results Univariate analysis of factors influencing postpartum massive hemorrhage in pregnant women with central placenta previa with placenta implantation showed that the previous number of cesarean section, placenta location in the anterior wall, peripheral organ infiltration, uterine artery ligation, uterine packing might be related to the occurrence of postpartum massive hemorrhage(P < 0.05). Multivariate logistic regression analysis showed that the peripheral organ infiltration(OR = 28.821, 95%CI: 3.741 ～ 222.033, P = 0.001) and the placental location in the uterus(OR = 1.704, 95%CI: 1.013 ～ 2.866, P = 0.044) were independent risk factors and the uterine artery ligation(OR = 0.593, 95%CI:0.356 ～ 0.989, P = 0.045) and uterine packing(OR = 0.600, 95%CI : 0.371 ～ 0.971, P = 0.037) were independent protective factors for postpartum hemorrhage. Combined with these four factors, the area under the ROC curve of postpartum hemorrhage is 0.687 in pregnant women with central placenta previa with placenta implantation. Conclusions It is necessary to focus on understanding the position of placenta and the infiltration of surrounding organs before operation in patient with central placenta previa with placental implantation. For such high risk of postpartum hemorrhage, prophylactic uterine artery ligation and/or uterine packing can reduce the risk of poor pregnancy outcome.更多还原