摘要目的:探讨术前阴道填塞联合术中子宫环形缝合及子宫动脉下行支结扎在重型胎盘植入患者剖宫产术中的应用价值。方法:前瞻性随机对照研究。纳入2019年1月—2021年8月枣庄市妇幼保健院高危产科120例B超提示重型胎盘植入患者的临床资料。患者年龄27～41岁，均行剖宫产手术。随机分为观察组和对照组，每组60例。观察组采用术前阴道填塞联合术中子宫环形缝合及子宫动脉下行支结扎处理，对照组采用腹主动脉球囊阻断处理。观察指标：（1）比较2组患者的年龄、孕周、孕产次、术前血红蛋白水平、人工助孕、既往手术医院、剖宫产次数、超声评分系统评分等基线资料。（2）比较2组患者的疗效、手术时间、术中出血量、术后24 h出血量、入住监护室时间、术后72 h血红蛋白水平、术后住院时间、医疗费用及子宫切除、新生儿窒息、术后并发症等围手术期指标。结果:所有患者手术顺利完成，无死亡。术中确认观察组发生胎盘植入57例，对照组发生胎盘植入58例；观察组3例、对照组2例胎盘娩出顺利，未作特殊处理。（1）2组患者基线资料比较差异均无统计学意义（ P值均>0.05）。（2）观察组胎盘植入57例中54例（94.74%）治疗有效，对照组胎盘植入58例中54例（93.10%）治疗有效，差异无统计学意义（ χ2=0.00， P=0.981）。观察组患者的手术时间、术后24 h内出血量、入住监护室时间、术后住院时间、医疗费用分别是（64±23）min、（185±31）mL、（1.2±0.5）d、（5.1±0.7）d、（1.6±0.3）万元，对照组分别为（82±35）min、（334±96）mL、（1.7±0.6）d、（5.6±0.8）d、（2.8±0.4）万元，差异均有统计学意义（ t=3.26、11.24、4.86、3.57、18.22， P值均<0.01）；而术中出血量、子宫切除、术后血红蛋白水平、新生儿窒息、术后并发症，2组间比较差异均无统计学意义（ P值均>0.05）。 结论:在重型胎盘植入患者剖宫产手术时使用术前阴道填塞联合术中环形缝合及子宫动脉下行支结扎的方法是安全可行、经济、有效的。

abstractsObjective:To explore the application value of preoperative vaginal tamponade combined intraoperative annular suture of uterus and ligation of descending branch of uterine artery during cesarean section in patients with severe placental implantation.Methods:The prospective randomized controlled study was conducted. A total of 120 patients in the Zaozhuang Maternal and Child Health Hospital from January 2019 to August 2021 were included. The clinical data of these patients, with severe placental implantation as suggested by B-ultrasound in high-risk obstetrics, were obtained. The age of the patients ranged from 27-41 years, and all patients underwent cesarean section. They were randomly divided into observation group and control group, with 60 cases each. The observation group was treated with preoperative vaginal packing, intraoperative uterine circular suture, and ligation of the descending branch of uterine artery. The control group was treated with abdominal aortic balloon occlusion. The observation indices were as follows. (1) We compared the baseline data of the two groups, such as age, gestational weeks, times of pregnancy and delivery, preoperative hemoglobin level, artificial assisted pregnancy, previous operating hospital, times of cesarean section, ultrasound scoring system score, and so on. (2) We also compared the perioperative observation indices of the two groups, such as effective rate, operation time, intraoperative bleeding, bleeding 24 h after operation, admission time in intensive care unit, hemoglobin level 72 h after operation, postoperative hospital stay, medical expenses, hysterectomy, neonatal asphyxia, and postoperative complications.Results:All patients completed the operation successfully without death. (1) No significant difference in baseline data existed between the two groups (all P values > 0.05). (2) During the operation, we confirmed that 57 cases of the patients in the observation group had placental implantation, among which 54 cases (94.74%) were effective after treatment; and 58 cases in the control group had placental implantation, among which 54 cases (93.10%) were effective. The difference was not statistically significant ( χ2=0.00， P=0.981). The operation time, bleeding 24 h after operation, time in intensive care unit, postoperative hospital stay, and medical expenses in the observation group were (64±23) min, (185±31) mL, (1.2±0.5) d, (5.1±0.7) d, and (16±3) thousand yuan, whereas those in the control group were (82±35) min, (334±96) mL, (1.7±0.6) d, (5.6±0.8) d, and (28±4) thousand million Yuan. The differences were significant ( t=3.26,11.24,4.86,3.57,18.22; all P values < 0.01). No significant difference existed in intraoperative bleeding, hysterectomy rate, postoperative hemoglobin level, neonatal asphyxia rate, and postoperative complications between the two groups (all P values > 0.05). Conclusion:Preoperative vaginal tamponade, intraoperative circular suture, and ligation of descending branch of uterine artery are safe, effective, economical, and feasible to use during cesarean section in patients with severe placental implantation.