甲氨蝶呤联合子宫动脉栓塞术后定点吸胚术治疗剖宫产术后子宫瘢痕妊娠51例临床分析

目的:探讨甲氨蝶呤(MTX)预处理联合子宫动脉栓塞术(UAE)后超声引导下定点吸胚术治疗剖宫产术后子宫瘢痕妊娠(CSP)的临床疗效和最佳给药方法。方法:回顾性分析首都医科大学附属朝阳医院2011年1月—2014年12月收治的采用MTX预处理联合UAE后超声引导下定点吸胚术治疗的51例CSP患者资料,按MTX不同给药方式分为3组。A组(23例):MTX全身用药后行UAE,然后行定点吸胚术;B组(11例):MTX子宫动脉灌注化疗栓塞(UACE)后行定点吸胚术;C组(17例):MTX全身用药联合UACE,再行定点吸胚术。比较各组患者的基本信息、治疗前情况和术中情况,并评估治疗效果指标。结果:3组患者均一次性手术成功,无需腹腔镜手术等二次处理,无膀胱损伤、子宫穿孔和子宫切除等并发症发生。3组患者出血量、手术时间、血清人绒毛膜促性腺激素β亚单位(β-hCG)转阴时间、包块吸收时间、手术成功率和并发症发生率比较,差异无统计学意义(均P>0.05)。B组的住院时间和住院费用较另2组减少,差异有统计学意义(均P<0.05)。孕囊或包块最大直径在Logistic回归模型中有统计学意义(OR=1.094,95%CI:1.012～1.183,P=0.024)。结论:MTX预处理联合UAE后定点吸胚术疗效确切、手术难度小、创伤小且花费少,可广泛用于治疗内生型和外生型CSP,推荐UACE作为术前预处理的首选方式,该方法对于病灶最大直径<4.3 cm的患者更安全。     

导管动脉栓塞术在难治性产后出血中的应用

目的　探讨经导管动脉栓塞术（TAE）在难治性产后出血中的应用价值。方法　以Seldinger技术对14例难治性产后出血患者,行经皮双髂内动脉前干或子宫动脉超选择插管术,应用数字减影血管造影（DSA）技术明确出血部位后灌注抗生素(头孢噻甲羧肟),并以明胶海绵颗粒栓塞。结果　（1）14例经保守治疗无效的难治性产后出血患者,经TAE治疗后一次性止血成功,止血时间3～10min,平均时间(6.1±3.6)min,手术时间30～50min,平均（41.8±6.4）min;（2）应用DSA发现,出血均来源于单侧或双侧子宫动脉,表现为宫腔内弥漫性、局灶性出血或单侧子宫动脉分支出血;（3）随访2～60个月,14例患者均恢复规律月经,无严重并发症发生。结论　应用TAE治疗难治性产后出血有较好的临床效果,具有止血快、并发症少的特点。     

动脉栓塞治疗难治性产后出血6例分析

目的 :探讨动脉栓塞治疗难治性产后出血的临床价值。方法 :用Seldinger技术对 6例难治性产后出血患者行经皮髂内动脉或子宫动脉超选择插管术 ,通过数字减影血管造影 (DSA)明确盆腔血管走向及造影剂外溢情况后 ,双侧分别注入明胶海绵条栓塞。结果 :6例插管栓塞均 1次成功 ,手术时间短 ,止血速度快 ,并且保留子宫及其生理功能。其中 2例术后再次生育。但 1例术后发生右下肢动脉血栓形成 ,手术取栓后愈合。结论 :动脉栓塞术治疗难治性产后出血快速 ,有效 ,安全 ,并保留了子宫。     

Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury

Six patients with uncontrollable postpartum hemorrhage due to genital tract injury were treated with transcatheter arterial embolization. The causes of hemorrhage were laceration of the cervix and vagina in five cases and rupture of the uterus in one. Four cases included a large hematoma in the paravaginal and/or retroperitoneal space. Two women had a hysterectomy before arterial embolization. Angiography revealed extravasation in five cases. All six subjects had their hemorrhage arrested dramatically using transcatheter arterial embolization with gelatin sponge particles. No major complication was encountered in any case. Normal menstruation resumed in the women who did not undergo a hysterectomy. Transcatheter arterial embolization therapy seems to be the treatment of choice in patients with uncontrollable hemorrhage.     

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.     

Percutaneous transcatheter angiographic embolization in the management of obstetric hemorrhage

OBJECTIVE: To describe the results of percutaneous arterial embolization in the management of obstetric hemorrhage. STUDY DESIGN: From February 1992 to May 2000, 33 patients with pregnancy-related hemorrhage underwent angiographic embolization to control the hemorrhage. In all cases, hemostatic embolization was performed because of intractable hemorrhage unresponsive to conservative management. All available hospital records were reviewed and detailed, and the clinical data related to complications, clinical status, estimated blood loss and blood replacement requirements, length of time of procedure, emboli used, complications associated with the procedure and results obtained were analyzed. RESULTS: Successful embolization was achieved in 31 of 33 patients. No major complications related to embolization occurred, and 3 women subsequently became pregnant. CONCLUSION: Angiographic embolization is a safe and effective method of controlling pregnancy-related hemorrhagic complications unresponsive to conservative management and maintains reproductive ability.     

难治性产后出血干预性治疗方法的对比研究

目的探讨难治性产后出血的各种干预性措施在抢救过程中的合理应用及应用价值。方法分析1998年1月至2003年8月间，采用宫腔填塞纱布(塞纱)、盆腔动脉结扎、经导管动脉栓塞术等干预性措施的88例难治性产后出血病人的临床资料。结果全部抢救成功，其中18例宫腔塞纱者成功12例(66．7％)，12例盆腔动脉结扎中成功4例(33．3％)，30例经导管动脉栓塞术(TAE)治疗全部成功(100％)，42例一次开腹行全子宫切除术或加盆腔塞纱者成功36例(85．7％)。结论宫腔塞纱可压迫止血。TAE可替代子宫切除术。当子宫成为凝血功能障碍的病因时，主张行子宫切除．     

Angiographic embolization for control of pelvic genital tract hemorrhage. Report of 14 cases.

Fourteen patients with intractable bleeding of obstetric or gynecological origin underwent transcatheter angiographic arterial embolization. Three patients had postpartum hemorrhage associated with dilutional coagulopathy, anticoagulant therapy and placental leukemic metastases, or placenta percreta. One patient had locally advanced gestational trophoblastic tumor, one had uterine sarcoma and 8 had advanced cervical malignancy. Bleeding was completely controlled in all patients regardless of the initiating event. The embolizing material was gelatin sponge particles in 12 patients, and spring coil in 2. In experienced hands, angiographic arterial embolization is a safe, effective and less invasive alternative to surgical ligation in some clinical states of pelvic female genital tract hemorrhage.     

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.     

Percutaneous embolization in the management of intractable vaginal bleeding

AIM: To assess the effectiveness of arterial embolization in gynecological malignancies by Polyvinyl Alcohol particles. MATERIAL AND METHODS: Six patients, four with cervix carcinoma, one endometrium carcinoma, and one vaginal metastasis of ovarian carcinoma underwent percutaneous embolization due to intractable vaginal bleeding. As an embolic agent PVA particles were used. RESULTS: Cessation of the bleeding was observed immediately after the embolization. Complete embolization has been achieved in all the patients Recurrent bleeding did not occur in any of the cases. There were no complications related to the embolization procedure. CONCLUSION: Transarterial embolization is a lifesaving procedure in treating intractable vaginal bleeding. PVA particles are effective and it is a simple way in ceasing the hemorrhage due to pelvic malignancies.     

胎盘植入患者血管栓塞治疗

胎盘植入是严重威胁母胎健康的疾病,其治疗手段尚未统一,目前血管栓塞治疗为治疗手段之一。胎盘植入患者预防与治疗产后出血的血管栓塞方法包括：术前预防性血管球囊闭塞术、术中及术后血管栓塞术。血管栓塞的优势为减少手术失血量与输血量,术后并发症及住院时间等。但同时也存在发生一定并发症的风险,包括盆腔内感染、器官缺血、发热、白细胞升高、组织神经疼痛、血管栓塞等。血管栓塞的应用还有待临床大样本的研究进一步评价。     

Transcatheter embolization of pelvic arteries as the safest method for postpartum hemorrhage

Two cases of intractable postpartum hemorrhage could be controlled by Gelfoam embolization via an angiographic catheter. The data presented here indicate that transcatheter embolization for postpartum hemorrhage is a safe and effective method compared to surgical ligation of the injured artery.     

Effects of prostaglandin E2 analogue suppository on blood loss in suction abortion

The purpose of the present clinical investigation was to determine the effect of preoperative treatment with a long-acting prostaglandin suppository containing 9-deoxo-16,16-dimethyl-9-methylene prostaglandin E2 on uterine blood loss in patients undergoing preoperative cervical dilatation before transcervical abortion. Ninety-five young women in the ninth to 14th week of gestation were randomly assigned to one of two groups. Patients in group 1 were treated with a long-acting prostaglandin suppository and group 2 patients acted as control subjects. At the end of three hours, patients in both groups underwent abortion with careful intraoperative measurement of blood loss in both groups. The blood loss in the prostaglandin-treated group was significantly lower than that in the control group (69.0 +/- 14.1 mL versus 151.1 +/- 26.6 mL). The difference in intraoperative blood loss was observed at all gestations between nine and 14 weeks. There was significantly greater dilation of the cervix after prostaglandin treatment (mean difference, 4.58 mm; P less than .005).     

Transcatheter Arterial Embolization for Severe Secondary Hemorrhage after Hysterectomy

Four of 1237 patients who underwent abdominal, laparoscopic, and vaginal hysterectomy between October 2013 and May 2015 had severe secondary hemorrhage after hysterectomy (2 conventional multiport total laparoscopic hysterectomies, 1 single-port access hysterectomy, and 1 total abdominal hysterectomy). The median time interval between hysterectomy and secondary hemorrhage was 28.4 days (range, 16–52 days). All 4 cases were treated with transcatheter arterial embolization (TAE), all of whom required blood transfusions to maintain vital functions before TAE. The mean operative time was 90 minutes. The median length of hospital stay after TAE was 12 days (range, 4–24 days), and the patients were discharged without complications or additional surgery. These cases show the value of minimally invasive TAE for patients experiencing severe secondary hemorrhage after hysterectomy.     

Outcomes of hypogastric artery ligation and transcatheter uterine artery embolization in women with postpartum hemorrhage

Objective

This study aimed to report our experience of emergent bilateral hypogastric (internal iliac) artery ligation (HAL) in the management of intractable postpartum hemorrhage (PPH) in a tertiary care center.

Predictive factors related to the efficacy of pelvic arterial embolization for postpartum hemorrhage: A retrospective analysis of 21 cases

ObjectiveThis retrospective study aimed to determine the predictive factors for the efficacy of pelvic arterial embolization for postpartum hemorrhage.Materials and methodsTwenty-one patients who underwent pelvic arterial embolization for postpartum hemorrhage of >1000 mL between September 2006 and September 2011 were enrolled in this study. The patients were divided into two subgroups according to the blood loss and time from the end of pelvic arterial embolization to complete hemostasis: good-response (16 patients) and poor-response groups (5 patients). The following predictive factors were compared between the groups: (1) patient characteristics; (2) blood loss; (3) time between delivery (or onset of bleeding) and pelvic arterial embolization; (4) obstetrical disseminated intravascular coagulation score comprising clinical background, clinical signs, and laboratory data; (5) individual disseminated intravascular coagulation score; (6) shock index; and (7) laboratory data including platelet count, prothrombin time-international normalized ratio, fibrinogen, fibrin degradation products, and antithrombin-III at the time of pelvic arterial embolization.ResultsIn the poor-response group, the obstetrical and individual disseminated intravascular coagulation scores and prothrombin time-international normalized ratio were higher than those in the good-response group (p < 0.05). Platelet count, fibrinogen, and fibrin degradation products were lower than those in the good-response group (p < 0.05). All obstetrical disseminated intravascular coagulation scores in the poor-response group were >9 points.ConclusionThe efficacy of pelvic arterial embolization is related to the presence or absence of coagulation disorders. When the obstetrical disseminated intravascular coagulation score is high (>9 points), the efficacy may be poor.     

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.     

Immediate preoperative phlebotomy with autologous blood donation for aortic replacement

The preferential use of autologous blood provided by phlebotomy can reduce the need for homologous blood transfusion in patients undergoing extensive elective operations. This blood is usually provided either by intraoperative isovolemic hemodilution or phlebotomy one to two weeks preoperatively. To minimize the intraoperative time delay or preoperative period between phlebotomy and operation required in these patients, we performed preoperative isovolemic hemodilution in 69 patients one to two days prior to elective aortic replacement for infrarenal aneurysmal disease. Patients underwent phlebotomy a mean of 0.57 +/- 0.01 liter of whole blood; volume was replaced with lactated Ringer's solution. Hematocrit levels decreased from a mean value of 42.9 +/- 0.4 per cent to 33.7 +/- 0.3 per cent. Mean intraoperative blood loss was 1.2 +/- 0.05 liters. Hemodynamic parameters (blood pressure, cardiac output, pulmonary capillary wedge pressure, central venous pressure, oxygen delivery and systemic vascular resistance) remained stable throughout the perioperative and intraoperative time periods. In addition, we evaluated the technical modification of exclusion aneurysmorrhaphy (n = 50) versus open aneurysmorraphy (n = 19) on reduction of intraoperative homologous blood transfusion in these patients. Seventy-two per cent (36 of 50) of patients whose aneurysms were excluded received no homologous blood intraoperatively. Blood loss was decreased in the excluded versus open aneurysmorraphy group, 920 +/- 90 milliliters versus 2,030 +/- 250 milliliters, as were homologous blood transfusion requirements, 175 +/- 35 milliliters versus 570 +/- 119 milliliters. Two patients died (2.9 per cent mortality rate), and there was no increase in morbidity. Surgical treatment of large aortic aneurysms is frequently performed on an urgent basis; thus, provision of autologous blood for this operation in a short period of time may be beneficial. Isovolemic hemodilution performed during the immediate preoperative period can reduce homologous blood requirements and be safely performed without adverse effects on mortality, morbidity and myocardial performance. Exclusion aneurysmorrhaphy may further reduce dependence on homologous blood.     

选择性子宫动脉栓塞术治疗难治性产后出血13例临床分析

目的探讨子宫动脉栓塞术治疗难治性产后出血的时机、疗效及并发症。方法对北京大学人民医院13例难治性产后出血患者,利用数字减影造影（DSA）技术选择子宫动脉及其分支行栓塞治疗。结果 13例产后出血患者分娩时出血量为150～4000ml,平均出血量1200（1200±1215）ml。产后出血总量870～4000ml,平均2555（2555±995）ml。13例患者栓塞前均行按摩子宫,卡孕栓肛塞及欣母沛宫体注射促进子宫收缩,2例剖宫产术中出血患者已行子宫动脉上行支结扎、B-Lynch缝合以及宫腔填纱止血,效果均不佳,经子宫动脉栓塞后12例均成功止血,仅1例未能止血而行全子宫切除术。13例产后出血行子宫动脉栓塞术前存在不同程度的凝血功能异常,在积极纠正凝血功能异常同时行栓塞术。栓塞术后无严重并发症发生,发热为最为常见并发症,但应警惕感染。结论凝血功能障碍并非子宫动脉栓塞术的禁忌证,只要把握好子宫动脉栓塞的时机,子宫动脉栓塞术能有效治疗产后出血,并且并发症少。     

Arterio-enteric fistula following pelvic radiation: a case report.

Two cases of arterial perforation into the small bowel are reported. Etiology was not determined in one case, but surgical trauma leading to localized infection in the irradiated tissue seemed responsible in the other. After the initial episode of hemorrhage, there was a symptom-free interval before its reappearance and vascular collapse. This is believed to be due to the distensibility of the large bowel. The site of arterial perforation was determined pre-operatively in one case by selective arteriography. Review of the recent literature relevant to transcatheter arterial embolization suggests that it may have potential in management of the arterio-enteric fistula as an alternative to or an aid in surgical correction by stabilizing the patient in a favorable condition.