科研之友
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摘要
The objective of this study was to describe the natural history of a series of pregnancies identified prospectively as implanted in or over Cesarean section (CS) scars, in women who declined intervention, with the aim of adding to the evidence base for the counseling of these women. This was a prospective observational study that included pregnant women at less than 12 weeks' gestation who were seen in our early pregnancy unit and received a diagnosis of varying degrees of CS scar implantation between 2011 and 2013. Twenty-seven cases of scar implantation were diagnosed during the study period, 13 were tertiary referrals and 14 were local patients. Six women received a diagnosis of early embryonic demise, and 11 had surgical terminations. Ten women declined intervention because of their desire to continue with their pregnancy despite the possible risks associated with morbidly adherent placenta (MAP). The median gestational age at final diagnosis in the first trimester (index scan) was 8 + 2 (range, 7 + 5 to 11 + 6) weeks. Nine patients had term delivery of their previous pregnancies. All 9 patients followed up in our unit had an ultrasound examination 0 to 6 weeks before delivery (median gestational age, 32 [range, 22-34] weeks). Preoperative magnetic resonance imaging did not appear to add to the ultrasound findings. The median gestational age at delivery was 35 (range, 26-38) weeks. It was found that all 4 cases in whom more than 50% of the placenta was estimated to be morbidly adherent in the second and third trimesters underwent a hysterectomy, 1 of the 2 cases with 25% to 50% MAP had a hysterectomy, but no cases in whom there was less than 25% MAP resulted in a hysterectomy. All 5 patients with loss of the uterus-bladder interface on the final ultrasound examination experienced bladder injuries during CS, and 4 had a hysterectomy. The 2 cases with bulging of the gestational sac out of the uterine contour had a preterm emergency hysterectomy due to placenta percreta. There were no fetal or neonatal complications. The study confirmed that pregnancies implanted over or within CS scars in the first trimester evolve into pregnancies complicated by placenta previa and MAP as the pregnancy progresses. The data suggest that when a wanted pregnancy is found to be implanted in or on a CS scar very early in gestation it may be preferable to wait until the placenta has begun to develop and the cord and its insertion site are visible before making a definitive diagnosis and recommending intervention. It is finally concluded that the assessment of ongoing pregnancies implanted in CS scars is best performed between 7 and 9 weeks' gestation. Ultrasound findings such as complete implantation within the myometrial defect, bulging of the trophoblast out of the uterine contour, and large placental lakes in the first trimester may predict a severe placenta accreta or percreta and consequently a poor outcome. Placenta previa and varying degrees of MAP develop in all patients who continue the pregnancy.
- 出版日期2016-2
