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英文誌(2004-)

Journal of Medical Ultrasonics

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2010 - Vol.37

Vol.37 No.01

Case Report(症例報告)

(0031 - 0035)

古典的帝王切開創部癒着胎盤の1症例 –超音波画像所見の検討–

A case report of placenta increta treated by uterine wedge resection

徳中 真由美, 長谷川 潤一, 市塚 清健, 三村 貴志, 松岡 隆, 大槻 克文, 関沢 明彦, 岡井 崇

Mayumi TOKUNAKA, Junichi HASEGAWA, Kiyotake ICHIZUKA, Takashi MIMURA, Ryu MATSUOKA, Katufumi OTSUKI, Akihiko SEKIZAWA, Takashi OKAI

昭和大学医学部産婦人科学教室

Department of Obstetrics and Gynecology, Showa University School of Medicine

キーワード : placenta increta, cesarean section, placenta lacunae, clear zone, wedge resection

近年稀となっている子宮体部縦切開術による帝王切開創部への癒着胎盤を経験したので,本症例での胎盤の超音波画像を中心に報告する.症例は31歳,1回経妊1回経産.前回妊娠は,妊娠26週に緊急帝王切開となったが,子宮筋腫のため下部横切開が出来ず古典的体部縦切開が施行された.今回の妊娠中の超音波検査では,胎盤が子宮前壁の前回帝王切開創部に一致した場所に付着していたため癒着胎盤の有無についての検索を行った.脱落膜に相当すると考えられているlow echoicな帯状エコー(clear zone)が一部途絶しており,また胎盤実質中に複数の無エコー領域(placenta lacunae)を認めたことから癒着胎盤が強く疑われた.妊娠37週3日に帝王切開術を施行し,子宮下部横切開で児を娩出した.胎盤剥離に際し,子宮底部で胎盤の一部が癒着していることが分かった.胎盤が癒着している前回帝王切開創部の子宮筋層を楔状に切除後2層縫合し手術を終了した.輸血の必要もなく順調に経過し退院した.病理検査では,漿膜下4 mmの筋層まで胎盤の侵入を認め,placenta incretaの診断であった.癒着胎盤は前置胎盤に合併することが多く,前置癒着胎盤の診断には超音波画像におけるplacenta lacunaeの存在やclear zoneの欠如が有用であると報告されている.本症例における超音波所見は,体部縦切開創部への常位癒着胎盤でも同様の超音波画像所見が診断の参考になることを示唆するものである.

We herein report the case of a 31-year-old female with a history of a cesarean delivery with a vertical incision at the anterior wall of the uterus due to chorioamnionitis and uterine myoma at 26 weeks of gestation. Ultrasonography revealed that the placenta was located on the cesarean scar on the anterior wall and the retroplacental clear zone could not be depicted at that site. Based on these findings and the existence of multiple placental lacunae, an antenatal diagnosis of adherence of the placenta was made. An elective cesarean section was performed at 37 weeks of gestation. Because the placenta and the myoma were located on the anterior wall, a lower uterine transverse incision was made. A healthy baby (3,109 g) was born with Apgar scores of 9 at 1 minute and 10 at 5 minutes. The placenta was transparent at the previous cesarean scar and could not be detached at this site. Despite the placental adherence, uterine contraction was good and hemorrhage from the uterine incision was small and controllable. A wedge resection of the previous scar with partial adherence of the placenta was successfully performed. The placenta had pathologically invaded deep into the myometrium without decidua. A pathological diagnosis of placenta increta was made. Our findings suggest that wedge resection of the uterine wall is an effective therapeutic strategy for placental adherence. Placental adherence is commonly associated with placenta previa, and previously published reports regarding the ultrasonographic diagnosis of placental adherence have primarily involved cases with placenta previa. The case presented herein suggests that ultrasonographic findings indicating the high possibility of placental adhesion are important for an accurate diagnosis of this condition in the case of a normally located placenta.