介入治疗产后大出血7例

我院2002-2006年因各种原因产后大出血经保守治疗无效行次全子宫切除术或全子宫切除术患者14例，2005-2006年介入治疗7例，两组病例年龄、孕周，出血量差异无显著性意义（采用统计学软件SPSS10．0处理）。手术组：常规行子宫次全或全子宫切除术。介入组：采用Ssldinger法穿刺股动脉，经导丝入5F猪尾导管，置入腹主动脉处造影并行数字减影血管造影技术（DSA），观察盆腔动脉走行方向、管径大小后，更换4-5F Cobra导管，并调整导管头进入对侧髂内动脉再次造影，当确认出血血管后，     

次全子宫切除术后残端宫颈切除18例临床分析

目的:探讨次全子宫切除术的手术适应证、残端宫颈病变特点及切除残端宫颈的手术技巧。方法:回顾分析次全子宫切术后再次行残端宫颈切除的18例患者的临床资料。结果:行次全子宫切除术时患者平均年龄41.7岁,手术原因包括子宫肌瘤、产后出血、手术困难等;残端宫颈切除的主要病因是宫颈上皮内瘤变、宫颈肌瘤、卵巢病变等。结论:行次全子宫切除术前需常规仔细检查宫颈,排除子宫颈及内膜病变,术后严密随访;切除残端宫颈应注意盆底解剖结构,防止出血和副损伤。     

对重度产后出血介入治疗安全性的评估

目的　评估重度产后出血介入治疗的安全性。　方法　对 18例经保守治疗无效的重度产后出血患者行介入治疗 (经皮双髂内动脉或子宫动脉栓塞术 ) ,从手术时间、治疗效果、侧支循环的建立、栓塞术后宫体肌层病理变化及术中卵巢 X线负荷量等的角度 ,探讨重度产后出血介入治疗的安全性。　结果　 (1) 18例患者均一次止血成功 ,止血时间 3～ 10 m in,平均时间 (6± 4) m in,手术时间 30～ 5 0 min,平均 (39± 5 ) min;(2 )介入治疗后虽然栓塞了双髂内动脉或子宫动脉 ,但仍有卵巢动脉、腹壁下动脉等向子宫供应少量的血流 ;(3) 3例患者于术后 5～ 10 d行宫体穿刺活检 ,病理显示 :子宫体肌层呈散在的、非连续性凝固性坏死 ,范围不超过肌层的 1/4 ,临床未见术后子宫坏死的病例 ;(4 )监测 5例患者术中卵巢所受 X线辐射量为 (17± 7) c Gy,在正常允许耐受量范围内。　结论　重度产后出血行介入治疗是安全的     

阴道高位次全子宫切除术的探讨

目的 :探讨经阴道高位次全子宫切除术的临床实用价值。方法 :对 45例患者行经阴道次全子宫切除术 ,均在子宫峡部上方 1～ 2cm处向下楔行切除宫体。并选择 2 0例经腹次全子宫切除术病例作为对照 ,比较两组手术各项指标。结果 :平均术中出血量 ,平均手术时间两组比较差异无显著性P >0 .0 5 ;肠功能恢复时间研究组较对照组快 (9.2小时vs 30小时 ,P <0 .0 1) ;研究组术后平均住院 4天较对照组短 (8天 ) (P <0 .0 1) ;术后病率研究组 8%,对照组 15 %(P<0 .0 1)。结论 :经阴道高位次全子宫切除术是一种安全、微创的手术 ,有助于改善手术患者的生活质量。     

子宫颈锥形切除术后全子宫切除95例临床分析

目的:分析子宫颈锥形切除术(宫颈锥切)后全子宫切除的指征,重点探讨宫颈锥切后腹腔镜子宫切除(LH)的可行性、安全性和手术要点。方法:回顾性分析2005年11月~2007年10月北京协和医院开展的95例宫颈锥切后全子宫切除术的手术指征、手术时间、出血量、残余宫颈病理、术中及术后并发症等。结果:(1)95例宫颈锥切后全子宫切除中,80例为LH,15例为开腹子宫切除(AH)。患者年龄43.2±5.9岁,术前诊断包括宫颈上皮内瘤变(CIN)Ⅲ及以下18例(18.9%)、CINⅢ累腺35例(36.8%)、宫颈原位癌(CIS)23例(24.2%)、宫颈浸润性鳞癌ⅠA1期19例(20.0%);(2)15例AH和25例LH是在宫颈锥切6周后施术,55例LH是在宫颈锥切后72h内。LH组和AH组手术时间分别为60.8±17.1min和88.0±19.8min(P<0.01),术中出血分别为54.3±24.4ml和103.3±48.1ml(P<0.01)。LH组和AH组的术后住院时间为4.5±1.1天和5.8±1.4天(P<0.01);(3)子宫切除标本的阴道断端边缘均未见病变,但残余宫颈中48例(50.5%)存在持续性病变(39例为CINⅡ及以下病变,4例为CINⅢ,3例为CIS,2例为浸润癌);(4)全组无1例需术中/术后输血,无膀胱、输尿管和肠道损伤发生。LH组患者无1例中转开腹,但4例放置专用举宫器困难,其中1例发生子宫穿孔但未引起并发症;(5)宫颈锥切后72h内行LH的55例中,7例(12.7%)术后出现发热(超过38.5℃),宫颈锥切6周后行LH或AH的40例中,仅1例(2.5%)术后发热。LH组1例患者术后发生阴道残端出血。结论:全子宫切除是某些诊断性宫颈锥切患者锥切后再处理措施之一。对于宫颈锥切后全子宫切除,LH具有优势和特点,其手术时间短,术中出血少,术后住院时间短。正确放置LH专用举宫器最大限度地上举子宫、锐性分离子宫膀胱腹膜返折是减少锥切后LH并发症的关键。     

筋膜内子宫全切术100例分析

目的通过筋膜内子宫全切除术与传统经腹子宫全切除术、次全子宫切除术3种手术方式的比较，探讨筋膜内全子宫切除术的优越性。方法选择同期施行的筋膜内子宫全切除术100例，经腹子宫全切除术120例，次全子宫切除术60例，观察3组手术时间、术中出血量、术后排气时间、术后病率及术后恢复情况（住院天数、术后阴道出血、阴道残端息肉）等并进行比较。结果3组在手术时间、术中出血量、术后排气时间、术后病率及住院天数方面差异无显著性（P〉0．05）。术后阴道出血，传统的经腹子宫全切除术较筋膜内子宫全切除术、次全子宫切除术略多，但差异无显著性（P〉0．05）。筋膜内子宫全切除术残端有小宫颈宴体，无息肉形成，传统的经腹子宫全切除术有9例残端息肉形成。结论筋膜内子宫全切除术取传统经腹子宫全切除术和次全子宫切除术的优点，手术创面小，手术难度降低，不破坏盆底结构，减少术后残端出血及残端肉芽的发生，并且由于切除了宫颈内膜及移行带，消除了次全子宫切除术式发生宫颈残端癌的顾虑。因此，在良性子宫疾病需切除子宫时该术式值得推崇。     

凶险型前置胎盘患者术前介入置管对改善母婴结局的探讨

目的探讨凶险型前置胎盘患者术前介入治疗对围手术期指标、子宫切除率及母婴结局的影响。方法收集2015年2月至2019年2月于山东省淄博市第一医院分娩的凶险型前置胎盘患者64例,根据治疗方法分为观察组(介入组,30例)和对照组(非介入组,34例)。比较两组患者围手术期指标(术中出血量、手术时间、术后24 h出血量、住院时间)、术后并发症[子宫切除、产褥感染、弥漫性血管内凝血(DIC)、产后出血2 000 ml]发生率以及母婴结局(早产、新生儿窒息、新生儿死亡、1 min后Apgar评分)差异性。结果观察组患者术中出血量、术后24 h出血量均较对照组少,手术时间、住院时间均较对照组短(P0.05),子宫切除、产褥感染、DIC、产后出血2 000 ml、早产发生率均较对照组低(P0.05);两组新生儿窒息、新生儿死亡发生率和1 min后Apgar评分指标比较,差异均无统计学意义(P0.05)。结论凶险型前置胎盘患者剖宫产术前行介入治疗可有效缩短手术时间、减少术中术后出血,并降低子宫切除、产褥感染等并发症发生率,有利于改善妊娠结局。     

不同子宫切除术式对女性排便功能的影响

目的探讨不同子宫切除术式对女性排便功能的影响.方法75例患者分为全子宫切除组(A组)60例,次全子宫切除组(B组)15例,对两组术后排便次数、排便难易程度的变化进行计数分析.结果75例子宫切除术后有52%的患者排便次数改变,A组术后排便次数减少发生率为53.33%,B组为20%,两者有显著性差异(P＜0.05).子宫切除术后有49.33%的患者排便难易程度改变,A组术后排便费力发生率为48.33%,B组为13.33%,两者有显著性差异(P＜0.05).结论子宫切除术后可影响女性排便功能,全子宫切除患者较次全子宫切除患者更明显.因此,次全子宫切除术是一种可选择的手术.     

改良式经阴道全子宫切除术与经腹全子宫切除术的临床对比分析

目的:探讨改良式经阴道全子宫切除术(ITVH)与经腹全子宫切除术(TAH)的临床效果.方法:回顾性分析2007年1月至2009年2月我院采用ITVH病例55例(研究组),并与同期TAH 50例(对照组)比较两种术式的手术并发症、手术时间、术中出血量、术后病率、术后排气时间、住院天数.结果:研究组并发症发生率明显低于对照组,并且手术时间短、术中出血少、术后排气时间早.结论:ITVH拓宽了传统全子宫切除的方式和适应证,手术难度不大、并发症少、术后恢复快、手术创伤小,符合微创原则.     

双侧子宫动脉栓塞术治疗难治性产后出血21例分析

目的探讨双侧子宫动脉栓塞术治疗难治性产后出血的疗效及安全性。方法于2003年4月至2005年9月采用Seldinger技术行双侧子宫动脉栓塞术,治疗东莞市厚街医院各种原因导致难治性产后出血21例。其中胎盘早剥合并DIC10例,部分性胎盘植入8例,子宫下段裂伤3例。结果21例患者平均手术时间(40±5)min,栓塞术后平均止血时间(10.0±3.2)min。均抢救成功并保留了子宫,近期无明显并发症。结论双侧子宫动脉栓塞术治疗难治性产后出血具有止血快,且能保留子宫等优点。     

难治性产科出血时子宫切除术和子宫动脉栓塞术的临床分析

目的探讨产科急性出血性疾病治疗过程中进行子宫切除术和动脉栓塞术的临床特点以及选择时机。方法回顾性分析35例产科出血因素行子宫切除或者动脉栓塞病例的临床资料。结果16例子宫切除的患者中,胎盘因素10例,占62.5%（前置胎盘/胎盘植入7例,胎盘早剥伴有凝血功能障碍3例）,子宫异常4例（子宫收缩乏力2例、子宫切口延裂致阔韧带血肿和子宫破裂各1例）占25%;羊水栓塞致DIC后切除子宫2例占12.5%。19例行子宫动脉栓塞术中,前置胎盘3例,占15.8%,子宫收缩异常13例（原发性宫缩乏力产程中剖宫产4例、双胎4例,急产产后出血2例,巨大儿1例,巨大子宫肌瘤2例）占68.4%,剖宫产并发症3例（子宫切口延裂致阔韧带血肿和子宫动脉瘤各1例,剖宫产术后晚期产后出血1例）占15.8%,其中2例栓塞失败,分别行子宫切除术和开腹探查血肿清除术。子宫切除术平均出血量（4 593±2 727）ml,子宫动脉栓塞术时平均出血量（2 601±904）ml,两组比较差异有统计学意义（P〈0.05）。子宫切除组有11例出现了DIC表现占68.7%。行子宫动脉栓塞术时发生DIC1例,占10.5%,差异有统计学意义（P〈0.05）。结论二者均为治疗产后出血的有效手段,但是栓塞术作为保守治疗可以保留生育功能,对于改善患者的预后具有重要的意义,要求尽早采用,一旦发生了严重的DIC和休克,则失去了机会。而保守治疗不能短时间见效,应果断行子宫切除术。     

Selective arterial embolization of the uterine arteries in the management of intractable post-partum hemorrhage.

BACKGROUND: To evaluate the efficacy and safety of selective arterial embolization in the management of intractable post-partum hemorrhage. METHODS: Thirty-five consecutive women with severe post-partum hemorrhage (primary, n=25; secondary, n=10) were treated by selective embolization of the uterine arteries. The main cause of immediate post-partum hemorrhage was atonic uterus. Retained placental fragments with endometritis was the main cause of delayed hemorrhage. In all cases, hemostatic embolization was performed because of intractable hemorrhage. Hysterectomy had been performed in two cases before embolization but it had also failed to stop the bleeding. RESULTS: Angiography revealed extravasation in ten cases, spasm of the internal iliac artery in four cases, false aneurysm in two cases and arteriovenous fistula in one case. After embolization, immediate cessation or dramatic diminution of bleeding was observed in all cases. Two patients required repeated embolization the following day. No major complication related to embolization was found. In one patient with placenta accreta, delayed hysterectomy was necessary. Normal menstruation resumed in all women but two who had hysterectomy. One woman became pregnant after embolization. CONCLUSION: Selective emergency arterial embolization is an effective means of controlling severe post-partum hemorrhage. This procedure avoids high risk surgery and maintains reproductive ability.     

Uterine artery embolization in the treatment and prevention of postpartum hemorrhage.

OBJECTIVES: The study was conducted to evaluate the efficacy of superselective transcatheter uterine artery embolization for control of obstetric hemorrhage. METHODS: Between January 2002 and December 2005, 14 consecutive patients underwent uterine artery embolization to control postpartum hemorrhage, and two to prevent hemorrhage before second-trimester therapeutic abortion. RESULTS: Embolization was performed by transfemoral arterial catheterization. Pieces of absorbable gelatin sponge were used in all cases, with the addition of platinum coils in two cases for complete vessel occlusion. Optimal bleeding control was achieved in all cases but one--a patient who underwent hysterectomy due to embolization failure. No severe complications were observed. CONCLUSIONS: The high success rate, low morbidity rate, and possibility of preserving reproductive function have made superselective uterine artery embolization the technique of choice to control life-threatening, intractable postpartum hemorrhage in hemodynamically stable patients, provided multidisciplinary medical teams are promptly available.     

严重产后出血产妇保留子宫的可能性

目的 探讨严重产后出血时产妇保留子宫的可能性。方法 回顾性分析2003年1月1日至2009年12月31日138例严重产后出血（出血量≥2000 ml）病例资料。结果 138例严重产后出血的病例中，子宫收缩乏力所致者占首位（60例，43.48％），其次为胎盘因素(55例，39.86％)，出血量2000～10 000ml，平均(3004±1473) ml。138例均输血，输血量800～7200ml。其中108例保留子宫病例出血量2000～7500 ml，平均(2546±932) ml；30例子宫切除病例，出血量2500～10 000ml，平均(4653±1857) ml，差异有统计学意义(t=8.57，P=0.00)。将所有病例分成前后2阶段比较：2003年至2005年子宫切除12例，发生率0.47‰，2006年至2009年子宫切除18例，发生率0.36‰；2组平均出血量分别为(3783±861) ml及（5233±2124）ml，差异有统计学意义(t=2.234，P=0.034)。产后出血达3000 ml以上病例中，保留子宫24例，平均出血量(3818±1284) ml；切除子宫27例，平均出血量(4900±1789) ml，2组差异有统计学意义(t=2.453，P=0.018)。2组出血量达3000ml所用时间分别为(160±129) min及(100±67) min，差异有统计学意义(t=2.113，P=0.04)。6例产后出血≥4000 ml且成功保留子宫的病例，平均出血量5570 ml。138例产妇中2例死亡，皆为羊水栓塞所致。围产儿死亡率3.73％。 结论产后出血量及出血速度是决定能否保留子宫的关键。对于具有出血高危因素的人群，应提前预防性应用前列腺素制剂，以减少出血量。宫腔填纱是有效的止血方法，尤其适用于前置胎盘引起的出血。     

严重产后出血及与其相关的子宫切除危险因素分析

目的探讨严重产后出血(severe postpartum hemorrhage，SPPH)的独立危险因素及导致子宫切除不良事件发生的危险因素。 方法回顾分析2015年7月至2017年12月于广州医科大学附属第一医院分娩的157例产后出血患者的临床资料，并根据失血程度将其分为SPPH组(39例)和非SPPH组(118例)，比较两组患者产前及产时出血原因和相关因素，同时分析SPPH组患者子宫切除的相关因素。 结果SPPH组患者产前纤维蛋白原水平(4.18±1.01)g/L，非SPPH组(4.61±0.79)g/L，两组间存在显著性差异(t＝-2.689，P<0.05)，两组合并子宫肌瘤发生率分别为10.3%和0.8%，差异有统计学意义(χ²＝5.641，P<0.05)。多因素分析结果显示，SPPH与产前纤维蛋白原水平以及是否子宫肌瘤合并妊娠有关(P<0.05)。SPPH患者中，子宫切除组胎盘植入发生率为50%，非子宫切除组为3.4%，两组间差异有统计学意义(P＝0.002)。 结论产前纤维蛋白原水平偏低、子宫肌瘤合并妊娠是导致SPPH的独立危险因素。胎盘植入、凝血功能障碍、产后出血量是导致围产期子宫切除的危险因素。     

Current indications for uterine artery embolization to treat postpartum hemorrhage

Uterine artery embolization is an interventional radiology technique successfully used for more than 30 years in the management of gynecological or obstetrical hemorrhage. Precise indications for uterine artery embolization to treat postpartum hemorrhage have been recently published. Uterine artery embolization is indicated in case of uterine atony despite medical treatment particularly after vaginal delivery, in case of vaginal thrombus or cervical tear after failed surgical repair. Embolization can also be discussed in case of persistent hemorrhage after arterial ligation or hysterectomy. Finally, arterial embolization can be attempted in case of placenta accreta to avoid hysterectomy. In all situations, pluridisciplinary management of patients with involvement of interventional radiologists, anesthesiologists and obstetricians is mandatory. Early transportation of patients for embolization should be discussed taking into consideration time of onset of hemorrhage, expected transfer time and treatment options available on site. For validated indications, success rates of arterial embolization as high as 80% can be expected in experienced hands.     

Pelvic arterial embolization for control of obstetric hemorrhage: A five-year experience

Objective: Obstetric hemorrhage is a significant cause of maternal morbidity and death. Postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years. Study Design: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included cervical pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2). Results: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days. Conclusions: Uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary. (Am J Obstet Gynecol 1999;180:1454-60.)     

Arterial embolization and prophylactic catheterization for the treatment for severe obstetric hemorrhage*

BACKGROUND. To evaluate indications, efficacy, and complications associated with arterial embolization and prophylactic balloon catheterization in the management of obstetric hemorrhage at a university hospital. METHODS. Twenty-two women underwent arterial embolization between February 2001 and November 2003 for the treatment for primary postpartum hemorrhage resulting from abnormal placentation (n=11), uterine atony (n=7), paravaginal laceration (n=3), and disseminated intravascular coagulopathy (n=1). Blood loss was between 3.2 and 15 l. In seven patients, abnormal placentation was diagnosed prenatally and in these patients balloon catheterization was performed prophylactically before elective cesarean section. RESULTS. Of the seven patients, who underwent prophylactic catheterization, embolization was successful in five resulting in adequate hemostasis. Hysterectomy was performed in three, in two patients for uncontrolled hemorrhage and in one patient for placental invasion to bladder. There were no complications associated with prophylactic catheterization and embolization. The other 15 patients were treated in an emergency setting. In eight patients, embolization was performed as a primary surgery, and it was successful in six. In the other seven patients, hysterectomy was performed as an emergency surgery, but bleeding continued. Of these, in six patients, hemostasis was achieved with embolization. Complications associated with emergency embolization were observed in three patients. These were thrombosis of left popliteal artery, vaginal necrosis, and paresthesia of the right leg. CONCLUSIONS. Arterial embolization is of significant value in treating obstetric hemorrhage. Prophylactic insertion of balloon catheters before cesarean section seems to be a safe and effective method in controlling anticipated bleeding. In patients with persistent bleeding following cesarean section and hysterectomy, embolization could be a primary procedure before re-surgery.     

产后出血子宫切除相关问题

子宫切除是抢救严重产后出血挽救产妇生命而采取的一种重要的治疗方法。异常胎盘及剖宫产是产后出血子宫切除常见的高危因素。前置胎盘和胎盘植入已成为目前严重产后出血子宫切除治疗的首要指征,及时准确地把握手术指征和手术时机,术中认真操作及处理突发情况,可以减少产妇的发病率和死亡率。     

产后出血急症子宫切除术46例临床资料分析

目的探讨难治性产后出血急症子宫切除术的原因、抢救难治性产后出血中的手术时机及孕产妇结局,为预防和处理产后大出血提供依据。 方法采用回顾性研究方法对2010年至2014年在西北妇女儿童医院分娩的46例因产后出血行急症子宫切除术患者的临床资料进行分析。 结果5年间共住院分娩56 436例,有582例发生了产后出血,产后出血发生率1.03%;其中46例患者经保守治疗出血仍不能控制,实施了急症子宫切除术。产后出血原因为：胎盘因素(43.48%,20/46),宫缩乏力(36.96%,17/46),胎盘因素合并宫缩乏力(10.87%,5/46),羊水栓塞(4.35%,2/46)和晚期产后出血感染(4.35%,2/46)。出血量1 500～4 000 ml,平均(2 783±625)ml。46例患者均行急症子宫切除术后痊愈出院。 结论急症子宫切除术是产后大出血经保守治疗无效时抢救孕产妇生命的有效措施,胎盘因素是急诊子宫切除的主要原因,做好产后出血的预防与处理可以有效地降低围生期子宫切除率。