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。     

选择性动脉栓塞治疗妇产科大出血的临床应用

目的 研究选择性髂内动脉栓塞或子宫动脉栓塞技术在妇产科大出血中的临床应用。方法 选择性双侧髂内动脉或子宫动脉栓塞术治疗19例妇产科大出血患者，其中产后出血12例，功血3例，人工流产术后宫内残留2例，侵蚀性葡萄胎1例，绒癌子宫穿孔1例。产后出血、功血、宫内残留患者用明胶海绵栓塞，肿瘤患者用化疗药物加碘油混悬液、明胶海绵栓塞。结果 19例妇产科大出血患者栓塞后立即止血或出血明显减少，除1例出现右髂外动脉血栓形成，行右股动脉切开取栓术后好转外，余无严重并发症。结论 髂内动脉或子宫动脉栓塞技术的开展既避免了开腹手术，又不影响患者脏器功能，保留了年轻患者的生育功能，对抢救妇产科大出血是安全有效的。     

前置胎盘患者再次剖宫产术中发生产后出血的15例临床病例分析

目的:总结既往处理经验,结合文献复习,摸索针对前置胎盘患者施行再次剖宫产术的更好的临床路径。方法:回顾分析1999年1月至2011年12月在我院产科行再次剖宫产术中合并前置胎盘和产后出血的15例患者的临床资料。患者年龄26～43岁;既往有2次剖宫产史者2例,1次者13例;终止妊娠孕周为30～40周。15例患者中产前B超提示前置胎盘者12例,其中孕期或产前有阴道出血症状者9例。手术按常规步骤进行。结果:(1)15例患者中13例为完全性前置胎盘,胎盘主体位于前壁者8例、后壁者7例;2例为边缘性前置胎盘。胎盘完全或部分粘连者13例,其中9例存在不同程度的胎盘植入,1例胎盘部分直接侵入膀胱;(2)术中平均出血量2564ml(400～12500ml),中位出血量1100ml。11例患者术中发生休克,3例患者继发弥漫性血管内凝血(DIC)。出血后采取促宫缩剂治疗及手术方法,包括局部缝合开放的血窦,缝扎子宫动脉下行支,填塞宫纱,Blynch缝合及子宫次全切除术。2例术中同时行膀胱修补术;(3)13例患者术中止血成功,2例术后加行双侧子宫动脉栓塞术。患者预后均良好。结论:前次剖宫产史的患者如合并前置胎盘、胎盘粘连或植入,术前、术中和术后都极易并发大出血,应引起临床医生的重视。     

Selective ligation of the hepatic artery for trauma of the liver.

Selective ligation of sundry hepatic arteries in patients with hepatic trauma obviated death from hepatic bleeding in 59 of 60 patients treated with this method of hemostasis. Hepatic insufficiency did not occur in survivors. Reconstitution of intrahepatic arterial flow is rapidly accomplished by collateral arteries. When the source of hemorrhage is perihepatic, that is, hepatic veins and retrohepatic vena cava, hepatic artery ligation is ineffective. Two patients died from this kind of 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.     

Management of a bleeding aberrant cervical artery following vacuum suction termination. Case report

A 29-year old woman underwent a pregnancy termination as well as sterilization. During laparoscopic sterilization, the pelvic organs appeared normal; however, 1 hour later the patient experienced vaginal hemorrhage. When therapeutic measures proved unsuccessful, blood transfusion was begun and it was concluded that there was an injury to the uterus. The bleeding, however, was from the left side of the cervical canal and at repeat laparoscopy, the uterus had not been perforated nor had it increased in size. As an effort was made to assess the damage, the surgeon discovered an aberrant branch of the cervical artery was bleeding. Ends of the damaged and bleeding artery were clamped and ligated and the walls of the cervix and uterus were repaired. The patient experienced an uneventful recovery and at the 6-week follow-up, the pelvic organs were within the normal limit and all wounds had healed. In all likelihood, a cervical tear during previous childbirth or abortion had exposed 1 of the branches of the left cervical artery and left it the target of a Karman catheter during the current abortion procedure.     

Embolization for hemorrhage of liver metastases from choriocarcinoma

BACKGROUND: Because gestational trophoblastic disease (GTD) is highly sensitive to chemotherapy, life-threatening hemorrhage from metastases can occur especially early after starting therapy. CASES: Two cases of post-term choriocarcinoma with liver metastases complicated by profuse life-threatening hemorrhage are reported. Emergency treatment with transcatheter angiographic embolization of the hepatic artery was performed to control bleeding. DISCUSSION: Although embolization of the iliac vessels for gynecologic malignancies, including GTD, have been described, this is the first time that embolization of the hepatic artery to control bleeding from liver metastases in GTD is reported. The use and indications for embolization are expanding, and also in acute hemorrhagic complications in GTD, this intervention should be considered.     

Hypogastric artery ligation for obstetric hemorrhage

Ligation of the hypogastric arteries has been recommended for control of obstetric hemorrhage. However, specific information regarding its effectiveness is lacking. The hospital charts of 19 patients undergoing bilateral hypogastric artery ligation for the control of otherwise intractable obstetric hemorrhage were reviewed. Indications included uterine atony (15), lateral extension of a low-transverse uterine incision (three), and placenta accreta (one). This procedure was effective in controlling bleeding in eight of 19 patients (42%). Hysterectomy was necessary in the remaining 11 patients. In these patients, blood loss, operating time, and intraoperative morbidity was increased when compared with a group of 59 patients undergoing emergency hysterectomy for obstetric hemorrhage without prior ligation of the hypogastric arteries. Surgical approaches to hypogastric artery ligation are discussed.     

Endometrial ablation in a woman with a persistent uterine hemorrhage due to acute promyelocytic leukemia: a case report

BACKGROUND: Life-threatening uterine hemorrhage can be a presenting symptom in patients with acute promyelocytic leukemia (APML), of which one of the complications is disseminated intravascular coagulopathy. CASE: A 44-year-old, previously healthy woman, gravida 3, para 3, presented with a life-threatening uterine hemorrhage. She was subsequently diagnosed with APML by bone marrow biopsy. The uterine hemorrhage was treated with hormonal therapy and uterine artery embolization (UAE), which failed to control the bleeding. Radiofrequency, impedance-controlled endometrial ablation was successfully utilized. CONCLUSION: Endometrial ablation can be used to effectively treat a life-threatening uterine hemorrhage in patients with APML after failed medical therapy and UAE.     

Laparoscopic ligation of hypogastric arteries using the Hulka clip to arrest massive vaginal bleeding due to stage IIb cervical carcinoma

A woman experienced severe vaginal bleeding from an exophytic, eroded cervical carcinoma. When vaginal tamponade and blood transfusion were ineffective in stopping the hemorrhage, bilateral laparoscopic ligation of the hypogastric arteries was performed. A Hulka clip was used to collapse the artery walls. Two months post-operatively a second, minor episode of bleeding occurred. This might have been avoided by ligating the ovarianuterine anastomosis.     

Fracture of the upper ribs and injury to the great vessels

Although individual reports have indicated that a fracture of the first or second rib is predictive of injury to the thoracic aorta and its major branches, the results of a careful review of the literature do not support this contention. In patients suffering blunt trauma, the risk of disruption of the aorta is not greater in patients with fracture of the upper two ribs, compared with victims of trauma with fracture of other ribs or those without fracture of ribs. Clinical manifestations are often absent in patients with disruption of the aorta or the innominate artery, but evidence of mediastinal hemorrhage is almost always present on roentgenograms of the chest. Widening of the mediastinum may not be apparent, but obliteration of the normal aortic contour is a sensitive finding in aortic transection. Injury to the subclavian or carotid artery nearly always produces clinical or roentgenographic signs, or both. After blunt trauma to the chest, patients with fracture of the first or second rib without clinical signs of vascular injury and evidence of mediastinal hemorrhage on thoracic roentgenograms (with the patient in an upright position when possible) do not need aortography to exclude occult vascular injury. A few patients with injury to the great vessels may have a normal thoracic roentgenogram on initial presentation to the hospital. After the correction of hypovolemia and stabilization of hemodynamic status, evidence of mediastinal bleeding should become apparent on subsequent thoracic roentgenograms. Repeat examinations must be performed and serial roentgenograms of the chest must be obtained for several days after injury to assess the possibility of unrecognized vascular trauma. If clinical or roentgenographic evidence of vascular injury is revealed, arteriography is mandatory. Thoracic CT scanning in patients with evidence of mediastinal hemorrhage on plain film may be of value in selecting patients for angiography, but additional experience must be obtained before such a protocol becomes an established policy.     

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.)     

宫颈妊娠16例分析

目的对宫颈妊娠的诊断和治疗进行探讨。方法通过对1993年10月．2003年10月在北京大学人民医院、贵州兴义市黔西南州人民医院住院收治的16例宫颈妊娠病例做回顾性分析，对诊断和治疗结果进行比较。结果初次就诊时作B超者12例，6例明确诊断，余6例诊断为其他疾病(难免流产、先兆流产、人工流产不全、粘膜下子宫肌瘤、输卵管妊娠)；初次就诊时未作B超者4例，均误诊为难免流产及先兆流产。16例患者3例行全子宫切除术，采取联合保守性治疗13例，成功12例。9例患者采取MTX药物保守治疗，发生阴道大出血4例，其中1例行全子宫切除术，而另3例在应用子宫动脉栓塞治疗后成功止血。结论B超对宫颈妊娠的早期诊断有重要价值；宫颈妊娠大出血时，子宫全切术不是治疗的唯一手段，还可以采取子宫动脉栓塞等保守治疗手段。     

Control of arterial hemorrhage using percutaneous arterial catheter techniques in patients with gynecologic malignancies

Control of hemorrhage in seven patients with gynecologic malignancies was attempted using arterial catheter techniques. Each patient was actively bleeding, either from the malignancy itself (two cases) or from complications of the treatment of the malignancy (five cases). All patients were debilitated, and a nonsurgical approach to the control of the hemorrhage was preferred. The active bleeding site was visualized by selective arterial catheterization. In four cases the bleeding was completely controlled, in three cases employing embolization of autologous tissue or synthetic material and in one case using a balloon catheter. Three patients underwent arterial infusion of vasopressin for gastrointestinal bleeding secondary to complications of treatment of the malignancy. The infusions did not provide adequate control of the bleeding.     

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.     

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.     

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.     

Management of serious vaginal injury. A case report

Hemorrhage was the major complication of a serious vaginal injury. Failure to control such a hemorrhage with local suturing should prompt an exploratory celiotomy and ligation of the visible bleeding points. Hypogastric artery ligation is indicated in cases of intractable bleeding.     

Diagnostic computed tomographic angiography and therapeutic emergency transcatheter arterial embolization for management of postoperative hemorrhage after gynecologic laparoscopic surgery

STUDY OBJECTIVE: To evaluate the diagnostic value of 3-dimensional computed tomographic (CT) angiography and treatment efficacy of emergency transcatheter arterial embolization (TAE) for early postoperative hemorrhage after gynecologic laparoscopic surgery. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Department of gynecology at a general hospital. PATIENTS: Nine patients with early postoperative hemorrhage after gynecologic laparoscopic surgery were treated by TAE between January 2004 and October 2007. Diagnostic 3-dimensional CT angiography was performed for identification of the bleeding artery before TAE in 5 of those patients. INTERVENTIONS: Diagnostic 3-dimensional CT angiography and therapeutic emergency TAE. MEASUREMENTS AND MAIN RESULTS: In all, 2952 patients (1165 laparoscopic-assisted vaginal hysterectomy [LAVH], 1086 adnexal surgery, 417 laparoscopic-assisted myomectomy [LAM], 222 ectopic pregnancy surgery, and 62 other) were treated by laparoscopic surgery between January 1994 and October 2007. Fourteen patients developed postoperative hemorrhagic shock (5 LAVH [0.43%], 1 adnexal surgery [0.09%], 7 LAM [1.68%], 1 ectopic pregnancy surgery [0.45%]). Since 2004, instead of second laparotomy or laparoscopy, TAE was primarily chosen to manage the postoperative hemorrhage for 3 cases after LAVH and 6 cases after LAM. In 5 cases experienced in the last 2 years, diagnostic 3-dimensional CT angiography was performed to identify the bleeding artery before TAE. Transfusion of preoperatively donated autologous blood and intraoperatively salvaged autologous blood was sufficient to maintain vital functions of the patients except in 1 case of LAM that required homologous blood transfusion before TAE as a result of significant delay in establishing the diagnosis. Postembolization course was uneventful except in 1 case of LAVH that developed vaginal stump abscess and required transvaginal drainage twice after readmission. CONCLUSION: Emergency TAE is a safe and effective minimally invasive procedure for patients developing postoperative hemorrhage after gynecologic laparoscopic surgery. Diagnostic CT angiography could play a significant role in shortening the process of TAE by identifying the site of extravasation before TAE.     

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。