再次子宫动脉栓塞术治疗获得性子宫动静脉瘘反复阴道流血临床疗效研究(附7例报告)

目的探讨再次子宫动脉栓塞术治疗获得性子宫动静脉瘘反复阴道流血的临床价值。方法回顾性分析北京协和医院1997年6月至2015年6月收治的7例获得性子宫动静脉瘘于子宫动脉栓塞术后反复阴道流血患者的临床诊断和再次子宫动脉栓塞术治疗的效果。结果 7例患者经彩色多普勒和血管造影明确诊断子宫动静脉瘘,均再次行双侧子宫动脉栓塞术治疗。5例患者再次栓塞治疗成功(成功率为5/7),另2例分别于再次栓塞术后1周、2年因经期阴道大出血行全子宫切除术。所有患者于术后3个月内恢复月经,随访1~17年,均未再出现阴道大出血,其中1例于再次栓塞术后10个月自然妊娠。术后1例出现高热、1例伴有轻微腹痛,余无并发症发生。结论年轻并要求保留生育功能的获得性子宫动静脉瘘反复阴道流血患者,再次子宫动脉栓塞术仍可做为首选治疗方法。     

彩色多普勒超声检查子宫动静脉瘘14例临床分析

目的探讨子宫创伤所致子宫动静脉瘘患者彩色多普勒超声血流特征及指导临床治疗的价值。方法采用彩色多普勒超声观察14例既往有流产或剖腹产史子宫异常出血患者的子宫血流情况。结果14例创伤性子宫异常出血患者彩色多普勒频谱超声均观察到子宫肌层丰富血流信号；表现为特征性动静脉瘘区五彩镶嵌血流信号，瘘口处探及高速动脉血流频谱3例，表现为肌层回声不均，肌层湖泊样低速低阻血流频谱11例，其中1例动静脉瘘合并假性动脉瘤保守治疗成功；1例单纯子宫动静脉瘘行球囊压迫止血成功；1例子宫动静脉瘘合并宫腔残留，在子宫动脉栓塞后刮宫治愈；另11例抗炎止血保守治疗。结论子宫动静脉瘘是创伤性子宫异常出血的原因之一，彩色多普勒超声可用于其诊断并指导临床治疗和监测治疗效果。     

子宫动静脉瘘诊治进展

了解子宫动静脉瘘致阴道出血的病因、临床特点、诊断及治疗进展。查阅Medline电子数据库。搜索到1952-2013年相关文献326篇,其中2008-2013年的文献69篇,近5年的文献资料着重报道子宫动静脉瘘新的诊断手段及治疗方法,特别是保留生育功能的方法。子宫动静脉瘘是导致阴道大出血的较罕见但严重病因之一,彩色多普勒超声是最常用的筛查方法,子宫动脉造影＋栓塞术是较有效的保守治疗方法,以保护患者的生育功能。     

剖宫产术后子宫瘢痕妊娠13例临床分析

目的探讨剖宫产术后子宫瘢痕妊娠（cesarean scar pregnancy，CSP）的诊断及治疗方法。方法对北京协和医院1994—2004年收治的13例CSP患者临床资料进行回顾性分析。结果13例患者中10例诊断为宫内早孕行人工流产或药物流产。6例刮宫术中或术后发生大量阴道出血伴失血性休克。13例均经超声检查明确诊断。10例行子宫动脉栓塞（uterine artery embolisation，UAE）的患者均迅速有效的控制了阴道出血并减少了术中出血，其中9例患者栓塞后联合药物、手术或期待治疗均成功的保留了生育功能，仅1例因合并子宫肌瘤要求行全子宫切除术；3例单纯甲氨蝶呤（MTX）保守治疗，2例成功，1例治疗失败行开腹局部病灶切除术。结论超声是诊断CSP的简便可靠方法。子宫动脉栓塞可以迅速止血，栓塞后联合药物或手术治疗是可选择的安全有效的治疗方法，单纯MTX保守治疗的安全性及有效性有待进一步观察。     

子宫动脉栓塞术治疗特殊类型异位妊娠临床价值探讨

目的:探讨子宫动脉栓塞术在治疗特殊类型异位妊娠中的临床价值。方法:对17例诊断明确的特殊类型异位妊娠患者(宫颈妊娠4例、剖宫产后子宫瘢痕部位妊娠13例)行双侧子宫动脉栓塞术,术后1～3天行刮宫或清宫等手术治疗。结果:17例患者共成功栓塞34根子宫动脉,栓塞后均行刮宫或清宫术,术中平均出血40ml,胚胎组织易于剥离。所有患者血β-HCG术后2.5周恢复正常。术后并发症主要为下腹部疼痛(17例),恶心、呕吐(5例),发热(4例)。结论:子宫动脉栓塞术可安全、有效阻断宫颈妊娠和剖宫产后子宫瘢痕部位妊娠这两种特殊类型异位妊娠孕囊的血供,降低刮宫或清宫术中及术后子宫大出血的可能性。     

子宫下段妊娠人工流产术中大出血临床分析--附四例报告

目的 探讨早期子宫下段妊娠人工流产术中大出血的病例特点和保守治疗的方法。方法 回顾性分析1994年5月至2002年7月我们收治的4例子宫下段妊娠行人工流产术中大出血的病例资料。结果 4例患者均有剖宫产史;其中3例停经后有阴道不规则出血;子宫动脉造影显示子宫下段供血区出血;4例均于人工流产术中发生大出血,采用子宫动脉栓塞治疗,止血效果好。无一例因子宫动脉栓塞而行全子宫切除者。结论 有剖宫产史的患者再受孕时,有发生子宫下段妊娠的危险,行人工流产术中易发生难以控制的大出血;子宫动脉栓塞是行之有效的治疗方法。严格剖宫产指征和重视产后避孕,是主要的预防办法。     

动脉栓塞治疗妊娠滋养细胞肿瘤6例临床分析

目的:探讨妊娠滋养细胞肿瘤(GTN)患者行动脉栓塞术治疗的方法及疗效。方法:回顾分析2008年1月至2014年12月在复旦大学附属妇产科医院因大出血或子宫动静脉瘘而行子宫或股动脉栓塞术治疗的6例妊娠滋养细胞肿瘤患者的临床资料。结果:6例GTN患者中有转移病灶伴大出血者3例,超声检查发现子宫动静脉瘘3例;入院即刻行栓塞术者4例,化疗后行栓塞术者2例;6例患者均栓塞成功。栓塞后接受手术治疗3例。所有患者均采用单药或多药联合化疗平均9.12个疗程(6~11疗程),5例(83.3%)患者完全缓解。结论:有出现转移病灶、子宫动静脉瘘时采用动脉栓塞术及时安全有效地控制病情,为全身化疗提供治疗机会。栓塞术后全身化疗仍是GTN的主要治疗方法。     

剖宫产术后瘢痕处妊娠15例临床分析

目的:探讨剖宫产术后瘢痕处妊娠(CSP)的临床特点、诊断及治疗方法.方法:对15例CSP患者的临床资料进行回顾性分析.结果:15例患者均有剖宫产术后人工流产史,平均2.57±1.32次;除一般早期妊娠的临床表现外,13例(86.7%)有妊娠早期阴道少量不规则流血,3例(20.0%)有下腹隐痛;术前分别误诊为宫内早孕及(或)伴先兆流产7例,稽留流产4例,宫颈妊娠1例,侵蚀性葡萄胎1例,只有2例术前B超检查明确诊断,另13例是在人工流产或刮宫手术时大出血后B超检查明确诊断;15例中13例行甲氨蝶呤和(或)氟尿嘧啶全身或局部应用,配合米非司酮口服药物保守治疗,1例行子宫动脉栓塞(UAE)配合药物治疗,1例行子宫全切术.结论:CSP一般超声检查可确诊,应提高临床医生对CSP的认识;禁止刮宫,误行刮宫大出血时纱条压迫宫颈止血有效;甲氨蝶呤和(或)氟尿嘧啶全身或局部应用,配合米非司酮口服是有效、简便的治疗方法.     

血管性介入治疗在妇产科出血性疾病中的应用

经保守治疗无效的妇产科出血性疾病是临床处理上较为棘手的难题,以往临床上除阴道或宫腔填塞纱条压迫止血及手术行髂内动脉结扎、全子宫或次全子宫切除术外,无理想的处理方法。我院自2003年11月至2005年10月对12例该类患者行经导管动脉栓塞术,取得满意疗效,现报道如下。1资料和方法1·1临床资料2003年11月至2005年10月,我院共收治经各种保守治疗无效的妇产科出血性疾病12例,其中宫颈妊娠刮宫后大出血1例,子宫恶性中胚叶混合瘤阴道转移灶出血1例,宫颈癌晚期放疗后出血1例,绒癌大出血1例,剖宫产术后5个月下段切口妊娠刮宫术后反复出血1例,剖宫…     

剖宫产术后子宫瘢痕妊娠39例临床分析

目的：探讨剖宫产术后子宫瘢痕妊娠（CSP）的临床特点、诊断和治疗方法。方法：回顾分析2005年4月至2012年6月我院收治的39例CSP患者的临床资料。结果：39例CSP患者均有剖宫产手术史,其中4例有2次剖宫产史。39例CSP患者中,16例误诊为宫内妊娠,其中10例行清宫术中发生阴道大出血伴失血性休克,5例行药物流产失败,复查阴超确诊;1例引产分娩过程中发生大出血,出血量超过3000ml,彩超提示胎盘植入瘢痕;其余23例结合病史及阴道彩超确诊。12例CSP患者行天花粉蛋白＋米非司酮杀胚治疗,9例成功,3例失败者行子宫动脉栓塞术,后行腹腔镜下局部病灶切除术＋子宫修补术。26例行子宫动脉介入及栓塞治疗,22例成功,4例未能吸出孕囊而行腹腔镜下病灶切除术。1例行子宫全切术。患者均痊愈出院。结论：剖宫产史及超声检查可为CSP的诊断提供重要依据。子宫动脉介入及栓塞治疗、花粉蛋白＋米非司酮是治疗CSP的安全有效的方法。     

Diagnosis and management of uterine arteriovenous fistulas with massive vaginal bleeding.

OBJECTIVE: To study the clinical manifestations, diagnosis, management, and prognosis of uterine arteriovenous fistulas with massive vaginal bleeding. METHODS: The clinical records of 15 patients who satisfied the diagnostic criteria were retrospectively analyzed. RESULTS: All patients had massive vaginal bleeding and a history of cesarean section, curettage, or gynecologic carcinoma. The disease was diagnosed by angiography or color Doppler ultrasonography. Vaginal bleeding can be aggravated by dilation and curettage. No complications occurred in the 14 patients who were treated with uterine artery embolization. Of the 11 patients who underwent successful embolizations, all returned to a normal menstrual cycle and 5 later became pregnant. CONCLUSION: Uterine arteriovenous fistula is a rare and potentially life-threatening condition. Uterine artery embolization is a safe and effective choice of treatment for this condition, and it can preserve both uterus and ovary function.     

Embolization of uterine arteriovenous malformation for treatment of menorrhagia

Background  Uterine arteriovenous malformations are rare but potentially life-threatening conditions that should be suspected in unexplained severe vaginal bleeding. Case  A 28-year-old gravida 7, para 3 presented to the emergency department with heavy vaginal bleeding and passage of blood clots. In the emergency room, her hemoglobin dropped from 11.2 to 7.4 gm%. Transvaginal ultrasonographic scan showed a large vascular mass in the uterus measuring 2.6 cm in diameter with low resistance of flow within, concerning for arteriovenous malformation or an arteriovenous fistula. Digital subtraction arteriography confirmed the lesion. She underwent angiography and bilateral uterine artery embolization. Conclusion  The diagnosis of uterine arteriovenous malformation requires a high index of suspicion in the scenario of unexplained severe vaginal bleeding. Digital subtraction angiography is the gold standard for definitive diagnosis and allows immediate treatment by embolization.     

Treating a recurrent uterine arteriovenous malformation with uterine artery embolization. A case report

BACKGROUND: Uterine arteriovenous malformation is a rare condition. Uterine artery embolization offers the possibility of conservative management as opposed to the traditional hysterectomy. We report a case with recurrent uterine arteriovenous malformation confirmed by angiography and successfully treated with a second embolization procedure. CASE: A 33-year-old woman presented with heavy vaginal bleeding. The diagnosis of uterine arteriovenous malformation was suspected on Doppler ultrasonography and confirmed by angiography. The first embolization procedure was performed using polyvinyl alcohol and steel coils. Recurrence was diagnosed 1 year later with the same imaging techniques. The second embolization procedure was performed using histoacryl. The patient remained asymptomatic at 1-year of follow-up. CONCLUSION: Minimally invasive management is an option in recurrent uterine arteriovenous malformation.     

Three-dimensional CT Angiography Is Useful for Diagnosis of Postabortion Uterine Hemorrhage: 3 Case Reports and Review of the Literature

Uterine hemorrhage is a major complication associated with abortion. There are various causes of postabortion uterine hemorrhage. The objective of this article is to estimate the efficacy of three-dimensional computed tomography (3D-CT) angiography in the diagnosis of this condition. We present 3 case reports of women with massive genital bleeding after abortion. 3D-CT angiography clearly demonstrated the 3-D features of the feeding artery, the draining vein, and the surrounding normal structures. The diagnosis in patient 1 was a uterine arteriovenous malformation, in patient 2 was a placental polyp mimicking a uterine arteriovenous malformation, and in patient 3 was a placental polyp. Patients were all successfully treated with uterine artery embolization or transcervical resection of the placental polyp. We conclude that 3D-CT angiography is useful for making a differential diagnosis and for preoperative planning in patients with postabortion uterine hemorrhage.     

A new fertility-preserving treatment modality for life-threatening bleeding caused by acquired uterine arteriovenous malformation (AVM): Combination laparoscopic ligation of uterine arteries and AVM suture

ObjectiveSymptomatic Uterine arteriovenous malformation (AVM) can result in sudden and massive vaginal bleeding that can be life-threatening. We report a new fertility-preserving treatment modality for disastrous bleeding caused by acquired uterine AVM: Combination laparoscopic ligation of uterine arteries and AVM suture.Case reportA 39-year-old female received Dilatation and Curettage due to missed abortion. However, she experienced heavy vaginal bleeding after surgery. Uterine arteriovenous malformation (AVM) was diagnosed by color Doppler ultrasonography, hysteroscopy, and angiography. She was successfully treated using laparoscopy bilateral uterine arteries ligation followed by application of uterine AVM suture with absorbable barbed wound closure device. After the laparoscopic surgery, vaginal bleeding stopped immediately. Complete regression of the AVM lesion on sonography was noted 8 months after laparoscopic surgery. Besides, this patient had normal menstruation after the operation.ConclusionThis case report describes for the first time a successful combination of bilateral uterine artery ligation and AVM suture to treat a patient with uterine arteriovenous malformation. We demonstrated the efficacy and safety of this fertility preserving method.     

Uterine Arteriovenous Fistula Treated With Repetitive Transcatheter Embolization: Case Report

Uterine arteriovenous fistula (AVF) is a rare entity, but may lead to life-threatening hemorrhage. Although transcatheter embolization, surgical ligation, or hysterectomy would be considered for treatment of uterine AVF, there is poor knowledge as to how gynecologists can manage the uterine AVF with multiple large inflow arteries. Herein we report a uterine AVF successfully treated using multiple-step transcatheter embolization. The patient, a 58-year-old postmenopausal woman with a history of dilation and curettage, had intermittent massive uterine bleeding. Radiologic imaging revealed the presence of a large vasculature mass. The mass occupied the entire pelvis, and the source of hemorrhage was identified as an accompanying AVF. We thought that surgical intervention was contraindicated because of the potential risk of uncontrollable intraoperative bleeding. Multiple-step transcatheter embolization was performed, with complete resolution of the AVF. Thereafter, the patient had no further uterine bleeding. Multiple-step transcatheter embolization might be the most beneficial and efficient treatment option for a uterine AVF with multiple large inflow arteries.     

Successful term pregnancy after selective embolization of a large postmolar uterine arteriovenous malformation

Abstract.   Tsai C-C, Cheng Y-F, Changchien C-C, Lin H. Successful term pregnancy after selective embolization of a large postmolar uterine arteriovenous malformation. Int J Gynecol Cancer 2006; 16(Suppl. 1): 339–341.
Uterine arteriovenous malformations (AVM) are very uncommon disorders. Successful conservative treatment with subsequently conceived is rarely reported. We describe a 31-year-old woman with a complex and large postmolar AVM; she was successfully treated with transarterial selective embolization for a long history of repeated excessive vaginal bleeding and anemia. She resumed normal menstrual periods soon after treatment, and she subsequently conceived about 2 years later. A healthy male baby was delivered at 39 weeks of gestation via vaginal route. Selective embolization of a complex and large uterine AVM seems to be feasible for the treatment of uterine bleeding and preservation of reproductive capability.     

Combination of B-Lynch brace suture and uterine artery embolization for atonic bleeding after cesarean section in a patient with placenta previa accreta

We report the case of a patient with placenta previa accreta. A 29-year-old multipara, who had previously undergone a cesarean section, was admitted to our hospital for vaginal bleeding. An emergency cesarean section was carried out at the 33rd week of gestation. Uterine bleeding was uncontrollable, and hence, hysterectomy was planned. However, before hysterectomy, B-Lynch brace suture was carried out to control the massive bleeding; moreover, the suturing technique enabled uterine artery embolization to be carried out as an interventional radiological technique. A good postoperative course was observed, and thus, a secondary hysterectomy was not required. A combination of the B-Lynch brace suture technique and uterine artery embolization may be an alternative treatment for emergency bleeding during cesarean section in patients with placenta previa accreta.     

Malformación arteriovenosa uterina. Un reto diagnóstico y terapéutico

IntroductionUterine arteriovenous malformations (UAVM) usually present as vaginal bleeding in women of childbearing age. Obstetric or uterine surgical history and ultrasound are key when suspecting this pathology. There are multiple treatments available, including medical surgery or interventional radiology with different effectiveness.Material and methodsWe analysed the diagnosis and management of three patients with episodes of vaginal bleeding and obstetric history, or uterine surgeries with a MAVU diagnosis.ResultsIn the three cases analysed, medical treatment was provided as first line treatment. After the failure of medical treatment with oral gestagens, methylergometrine, or tranexamic acid, transarterial embolization was performed with occlusion of the nidus or fistula point.ConclusionsBased on our experience, due to the delay between diagnosis and the wide variety of MAVU treatments, supraselective embolization could be assessed as one of the treatments with the highest rate of efficacy in a patient profile that has usually not fulfilled their reproductive desire. Although the short-term results do not seem to affect fertility, it is important to prospectively follow-up these patients regarding achievement of a new pregnancy or recurrence of MAVU.     

A syndromal and an isolated form of uterine arteriovenous malformations: two case-reports.

Uterine arteriovenous malformations are rare lesions with a considerable risk potential. Clinical presentation varies from no signs over various degrees of menorrhagia to massive life threatening vaginal bleeding. This is the first report of congenital uterine arteriovenous malformations in two patients with primary infertility. In one case, the uterine lesions were found in conjunction with other congenital malformations suggesting the diagnosis of hemihyperplasia/lipomatosis syndrome. Etiology, symptoms, diagnostic and therapeutic work-up are discussed; pathological findings are illustrated.