背景:胎盘植入谱系障碍(PASDs)增加母亲和新生儿的死亡率超过十年。因此,本研究的目的是评估紧急剖宫产(CS)和计划手术以及剖宫产子宫切除术和改良的一步保守子宫手术(MOSCUS)的新生儿结局.次要目的是揭示与新生儿结局不良有关的因素。
方法:这是2019年至2020年在涂都医院进行的单中心回顾性研究,在越南南部地区。总共招募了497名怀孕28周以上的PASD孕妇。关于胎龄的临床结局,出生体重,APGAR评分,新生儿干预,新生儿重症监护病房(NICU)入院,和NICU住院时间(LOS)在急诊和计划手术之间进行了比较,在剖宫产子宫切除术和MOSCUS之间。采用单因素和多因素logistic回归评估新生儿不良结局。
结果:在全麻下行CS的468例术中诊断为PASD患者中,急诊CS(n=65)的新生儿结局明显差于计划分娩(n=403).急诊CS增加了早期胎龄的比值比(OR),较低的出生体重,在5分钟时降低APGAR评分,新生儿干预率较高,NICU入院,和更长的NICULOS≥7天,或,95%置信区间(CI)为10.743(5.675-20.338),3.823(2.197-6.651),5.215(2.277-11.942),2.256(1.318-3.861),2.177(1.262-3.756),3.613(2.052-6.363),和2.298(1.140-4.630),分别,p<0.05。相反,剖宫产子宫切除术(n=79)和MOSCUS方法(n=217)的新生儿结局无统计学差异.使用多变量逻辑回归,与5-min-APGAR评分小于7分独立相关的因素包括从皮肤切口到胎儿分娩的持续时间(min)和胎龄(周).从皮肤切口到胎儿分娩的时间减少一分钟有助于将新生儿不良结局的风险降低2.2%,95%CI:0.978(0.962-0.993),p=0.006。同时,胎龄减少1周时,校正OR导致新生儿不良结局的几率增加约2倍,95%CI:1.983(1.600-2.456),p<0.0001。
结论:在患有PASDs的妊娠中,与计划剖宫产组相比,急诊组的新生儿结局较差。此外,使用MOSCUS方法进行保守性手术的新生儿合并症与剖宫产子宫切除术相似.在PASD手术中可以考虑从皮肤切口到胎儿分娩的持续时间和胎龄。需要进一步的数据来加强这些发现。
BACKGROUND: Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the
study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes.
METHODS: This was a single-center retrospective
study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes.
RESULTS: Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001.
CONCLUSIONS: Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings.