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．     

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.     

Portal hypertension

The management of both acute and recurrent variceal bleeding continues to be a significant challenge to the clinician. The cause and pathogenesis of portal hypertension has been described. Alcoholic cirrhosis is the most common cause of intrahepatic sinusoidal and postsinusoidal obstruction in the United States. Long term survival depends on rapid institution of an established protocol of surgical management for variceal hemorrhage. A patient who presents with variceal bleeding must be rapidly stabilized with fluid resuscitation, and specific measures, such as the use of vasopressin and balloon tamponade, must be instituted to control hemorrhage so that endoscopy can be used to establish the diagnosis. Sclerotherapy achieves a high rate of success in the acute situation, but if hemorrhage cannot be controlled, percutaneous transhepatic embolization or emergent shunting must be performed, depending on the condition of the patient. Angiography, prior to surgical treatment, is necessary to define venous anatomy and determine portal hemodynamics, both of which provide information vital in choosing the type of shunt. If bleeding is massive and the patient is unstable, H-grafts are most appropriate, for they are technically easier and give excellent short term results. In a stable Child's A or B patient with minor ascites as well as suitable anatomy and hepatopedal flow, DSRS is the procedure of choice because it produces the smallest degree of HE postoperatively and increases the survival rate for nonalcoholics. If this is not feasible or if the surgeon lacks the technical expertise to perform DSRS, PCS is the logical alternative. In view of the data from the series observed in the United States, ablative procedures cannot be recommended at the present for the treatment of variceal bleeding. In the Child's C poor-risk patient, the operative mortality rate is prohibitive, and only nonsurgical means should be used to establish control of bleeding. In the elective situation, the surgical options change. The efficacy of ES as a definitive procedure to control recurrent variceal bleeding is unproved, and rebleeding can be significant; therefore, it cannot be recommended. H-grafts have a prohibitively high rate of long term thrombosis and are also not recommended, and the Linton or proximal splenorenal shunt offers no advantages over conventional portacaval shunting. Moreover, arterialization of the hepatic stumps of the portal vein does not prevent hepatic encephalopathy or alter the survival rate. Both PCS and DSRS prevent rebleeding, yet neither alters the survival rate for alcoholic patients.(ABSTRACT TRUNCATED AT 400 WORDS)     

Transcatheter arterial embolization in the management of gynecological neoplasms

Six patients were treated with transcatheter arterial embolization (TAE). Three patients suffered from intractable genital bleeding; the other three patients were preoperative cases of a stage III adenocarcinoma of the uterine cervix and two of these had gestational trophoblastic disease. Bleeding was stopped in all three cases of intractable hemorrhage; one patient rebled after 6 days. In the three preoperative cases, transcatheter arterial embolization was thought to be effective in decreasing intraoperative blood loss. There are no other reports of application of this technique to preoperative cases to decrease intraoperative blood loss in gynecological cases.     

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。     

电刀电切整形术治疗宫颈陈旧性裂伤伴慢性宫颈炎的临床研究

目的 探讨电刀电切整形术在治疗宫颈陈旧性裂伤伴慢性宫颈炎中的疗效。方法 采用电刀电切宫颈陈旧性裂伤伴宫颈炎性增生组织。治疗352例，术后随访2周～10年。结果 平均手术时间5min，平均术中出血量3ml，术后2个月复查：352例宫颈陈旧性裂伤伴慢性宫颈炎患者一次治愈343例，有效9例，治愈率97．4％，有效率100％，远、近期随访，无一例复发。并发症术后出血29例，占8．2％。结论 电刀电切整形术治疗宫颈陈旧性裂伤伴慢性宫颈炎，治愈率高、并发症少、复发率低，且操作简单、方便、费用低。     

Sequential Doppler sonographic studies of embolization in a patient with hepatic involvement in hereditary hemorrhagic telangiectasia: correlation with angiographic findings.

A 41-year-old man was admitted for symptoms of progressive congestive heart failure. His family history and the results of a physical examination were highly suggestive of Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia, HHT). Cardiac catheterization and hepatic angiography demonstrated HHT with left-to-right shunting from the liver. The patient underwent transcatheter arterial embolization (TAE) of the right hepatic artery. We performed both Doppler sonography and angiography before and after TAE. The treatment improved the clinical manifestations of congestive heart failure, including the edema of the leg and dyspnea. Doppler sonographic studies also showed an increased resistive index in the right hepatic artery and decreased flow volumes and velocities in the right and middle hepatic veins, respectively, after treatment. Corresponding changes on angiography after TAE showed decreased right hepatic arterial flow and nonopacified branches distal to the coils, disappearance of the mottled hepatogram in the right lobe, reduction of contrast agent staining, and enhanced calibers in the right and middle hepatic veins. This case illustrates that qualitative and quantitative studies with duplex and color Doppler ultrasound can be used to detect or define the extent of hepatic involvement in HHT patients before TAE, monitor hemodynamic changes of the intrahepatic vasculature after TAE, evaluate the efficacy of treatment, and possibly obviate the need for repeated angiography for diagnosis only.     

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.     

Rating of transvaginal sonography in the evaluation of postmenopausal bleeding

OBJECTIVE: The purpose of this study was to evaluate transvaginal ultrasonography (TVS) in differential diagnosis of vaginal bleedings in postmenopausal patients. MATERIAL AND METHODS: Between January 1990 and December 1996, 1198 postmenopausal patients with vaginal bleedings were sent to our clinic for a histological evaluation. Eight hundred and seventy-nine patients (73.4%) were preoperatively scanned by transvaginal probe, and endometrial thickness (< 5, 5-7, 8-10, > 10 mm) was measured. RESULTS: Atrophy was found in 46.3%, endometrial polyps in 19.8%, endometrial cancer in 17.5%, and hyperplasia in 6.7%. An endometrial thickness of lower than 5 mm (p < 0.0001) was shown in TVS patients with atrophy in 71%, with endometrial polyps in 10.9%, with endometrial cancer in 3.9% and hyperplasia in 6.8%. In 55.2% of these eases with endometrial cancer the preoperatively estimated thickness was 10 mm or more. The additionally morphologic examination in cases with an endometrium smaller than 5 mm was false positive in 75% (9/12). Thus an endometrial thickness of > 5 mm had a sensitivity of 92.5%, specificity of 71.0%, positive and negative predictive value of 75.6, respectively 90.9% for the detection of endometrial pathology. CONCLUSIONS: TVS allows the detection of an endometrial pathology in the vast majority of patients with postmenopausal bleedings. In cases with a single postmenopausal bleeding and an endometrium smaller than 5 mm we recommend expectative procedures with repeated ultrasound examination of the endometrium.     

Intrauterine balloon tamponade in the management of postpartum hemorrhage

This article reviews our experience with the use of intrauterine tamponade with balloon catheters in the management of severe postpartum hemorrhage. This is a case series report of 23 patients with postpartum hemorrhage unresponsive to medical therapy managed with intrauterine balloon tamponade. We identified these patients by International Classification of Diseases (ICD-9) codes and by reviewing labor and delivery logs. Balloon tamponade was attempted in 23 patients. When properly placed, catheters controlled postpartum hemorrhage in 18 of 20 cases (90%). In two cases, hysterectomy was required despite successful placement of the catheter. For hemorrhage due to uterine atony, our success rate was 100% (11/11 cases). In three cases, technical difficulties led to placement failure. For bleeding due to retained placenta, our success rate was 80% (4/5; failure with placenta percreta). Vaginal bleeding was stopped with the catheter in two of three cases of amniotic fluid embolus and in one case after dilation and curettage for postpartum septic shock. Thus balloon tamponade is an effective adjunct in the treatment of severe postpartum hemorrhage, especially when due to uterine atony when medical therapy fails.     

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.     

Stimulation of vasopressin release in women with primary dysmenorrhoea and after oral contraceptive treatment--effect on uterine contractility.

OBJECTIVE: To study aspects of the aetiology of primary dysmenorrhoea and mechanisms underlying the therapeutic effect in this condition of an oral contraceptive. INTERVENTION: Intrauterine pressure was recorded before and during infusion of hypertonic saline (5% NaCl, 0.06 ml/kg/min) over 75 min on the first day of bleeding in women with dysmenorrhoea and after 3 weeks of oral contraceptive treatment. Plasma sampling every 15 min of ongoing infusion for the estimation of osmolality, arginine vasopressin, oxytocin and the prostaglandin (PG) F-metabolite, 15-keto-13,14-dihydro-PGF2 alpha. SUBJECTS: Ten healthy nulliparous women with moderate to severe primary dysmenorrhoea. MAIN OUTCOME MEASURES: Plasma levels of posterior pituitary hormones and the PGF-metabolite. Total pressure area (TPA) of the recording curve. RESULTS: In dysmenorrhoea before infusion the plasma concentration of vasopressin was in mean 2.18, oxytocin 5.05 and the PGF-metabolite 321.5 pmol/l, and the TPA 3.8 kPa x 10 min. After oral contraceptive treatment the vasopressin level and the TPA were significantly reduced. At both sessions apart from intensifying the pain, the saline infusion increased vasopressin and oxytocin levels as well as the TPA, whereas the concentration of the PGF-metabolite at both sessions decreased. CONCLUSION: Confirmation is provided of the elevated secretion of arginine vasopressin and PGF2 alpha, as well as increased uterine activity in primary dysmenorrhoea. The observations are in agreement with the concept that a lowered level of vasopressin and a decreased uterine activity contributes to the beneficial effect of OCs in the condition. Stimulation of the secretion of vasopressin increases the uterine activity and symptoms of primary dysmenorrhoea, but results suggest that this effect does not involve a mechanism of increased PGF-synthesis. The role of oxytocin in dysmenorrhoea can not yet be defined.     

Severe Vaginal Laceration in a 5-Year-Old Girl Caused by Sudden Hydro-Distention

BackgroundSevere vaginal trauma in young girls is uncommon. We describe a 5-year-old girl who presented a vaginal laceration following sudden hydro-distention.CaseA 5-year-old girl was transferred to our institution for vaginal trauma with severe bleeding. Her brother had directed the nozzle of a functioning garden hose against her vulva. She presented pain and persistent vaginal bleeding without external genital lesions. Surgical exploration revealed a laceration of the right vaginal wall. The vagina was sutured and the bleeding stopped.Summary and ConclusionThis case illustrates a rare mechanism of severe vaginal laceration, in a young girl, by hydro-distention. Though there are often no external lesions the internal lesions can be severe causing significant bleeding. Certainly in these cases aggressive diagnostic evaluation is necessary.     

Localization of obscure gastrointestinal bleeding by technetium 99m-labeled red blood cell scintigraphy.

When a bleeding source from the gastrointestinal (GI) tract cannot be identified with conventional diagnostic studies, it is known as GI bleeding of an obscure origin. In the past three years, in vivo Technetium 99m-labeled red blood cell scintigraphy (RBC scan) has been added to our armamentarium for the diagnosis of obscure GI bleeding. Out of a total of 26 cases, the bleeders could be detected in 12 or 46.2% by RBC scan. The time required ranged from 15 minutes to 24 hours (median, one hour). In 14 patients with active bleeding during the scan period, 11 had positive scans (sensitivity, 78.6%). In 12 patients with inactive bleeding, 11 had negative scans (specificity, 91.7%). Angiography was conducted in nine cases, with all showing negative findings; however, six of them had a positive focus by RBC scan. Laparotomy was performed in seven scan-positive patients, and in three scan-negative patients because of a positive Meckel's scan (two cases) or recurrent bleeding (one case). Of the 12 scan-positive patients, incorrect localization was noted in two patients due to rapid transit of the labeled RBC in the small bowel. False localization could be prevented by shortening the sequential imaging interval. It is concluded that an RBC scan is a very sensitive and safe tool for detection of GI bleeding of an intermittent nature, because the bleeder can be monitored for 24 hours after a single injection. It can be used as a preangiographic screening test and to guide the surgeon in surgical planning or decision-making.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pregnancy in cirrhotic and noncirrhotic portal hypertension.

The course of pregnancy in 1 patient with chronic active hepatitis (CAH) and cirrhosis, and another with extrahepatic portal vein obstruction (EHPVO) is described. The management of pregnancy in these diseases associated with portal hypertension is discussed and risks of pregnancy are compared. The patient with CAH presented with anovulatory cycles, and ovulation occurred following immunosuppressive therapy. Both women experienced massive upper gastrointestinal bleeding from esophageal varices. Bleeding was difficult to control and required variceal ligation in 1. Both patients manifested features suggesting cerebral edema indicating the need for caution with fluid and electrolyte therapy. Recovery of the woman with CAH after termination of pregnancy was slow. Review of literature demonstrated that variceal bleeding occurred in 43% of women with EHPVO compared to 23% of those with CAH and cirrhosis. Additional complications including hepatocellular failure (24%) occurred in patients with CAH but not in EHPVO. The management of pregnancy in portal hypertension and advice for contraception or sterilization are discussed.     

Outcomes and complications of severe acute postpartum hemorrhage treated with or without transarterial embolization in a single tertiary referral center: A 20-year experience

ObjectivePPH is usually unpredictable; and such fast, urgent and sudden massive life-threating hemorrhage. This study is to assess the efficacy of transarterial embolization (TAE) in treating severe PPH in a single institution over a period of 20 years.Materials and methodsFrom January 2000 to October 2019, all women with acute PPH more than 1500 cc and/or DIC were enrolled in this retrospective study. These women were divided into two groups according to whether they have received TAE as the second-line treatment. Group 1 (n = 27) included women without receiving TAE from January 1, 2000 to October 31, 2009, and group 2 (n = 30) included those who receiving TAE from November 1, 2009 to October 31, 2019.ResultsThe overall success rate of TAE in control the PPH and preserved the uterus is 80%. The hemoglobin 12 h after PPH in group 2 is significantly lower than in group 1 (7.64 ± 1.6 vs. 8.58 ± 1.9, respectively. P = 0.05). Total unit of packed red blood cell (pRBC) transfusion is significantly higher in the group 2 than group 1 (9.8 ± 5.7 vs. 6.8 ± 3.9; p = 0.03). The rate of hysterectomy is significantly higher in group 1 than group 2 (46.7 vs. 20%; p < 0.001).ConclusionIn conclusion, TAE is safe and effective in control bleeding in PPH with a high success rate to preserve uterus and prevent DIC. TAE should be routinely used as a secondary line of treatment during PPH in all hospitals.     

Conservative endovascular management of retained placenta accreta with marked vascularity after abortion or delivery

Objective

To report our experience on the value of transcatheter arterial embolization (TAE) or transcatheter arterial chemoembolization (TACE) for the uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery.

Study design

Thirty-eight consecutive women with retained placenta accreta were retrospectively analyzed over a 5-year period. When elevated levels of serum β-hCG (> 25 mIU/mL) were detected, TACE with dactinomycin was chosen for devascularization along with cytotoxic effects on active trophoblasts; in contrast, if the serum β-hCG level was low (≤ 25 mIU/mL), TAE was chosen. After confirming devascularization, the additional need for hysteroscopic resection and systemic methotrexate administration was individually determined.

Results

The most frequent sign and symptom in the abortion group was significant hemorrhaging, while a hypervascular mass detected at a regular check-up was the most frequent in the delivery group. The median time elapsed between abortion and endovascular management was 36 days, and the median time elapsed after delivery was 31.5 days. TACE was performed more frequently than TAE in the abortion group, while TAE was the more frequent procedure in the delivery group. In 10 and 11 cases, after abortion and delivery, respectively, hysteroscopic resection was performed. Systemic methotrexate administration was additionally done in three and one cases after abortion and delivery, respectively. Uterine preservation was achieved in all cases.

Conclusion

This case series emphasizes that endovascular embolization is an effective key intervention with or without additional therapies for uterus-preserving management of retained placenta accreta with marked vascularity after abortion or delivery.

     

Effect of arginine vasopressin on arterial oxygen partial pressure in the chronically catheterized fetal lamb

Fetal plasma 2,3-Diphosphoglycerate (2,3-DPG) and glucose levels were observed during infusion of arginine vasopressin into 6 chronically catheterized fetal lambs. Low dose infusion of arginine vasopressin (5-10 mIU/min.) did not change fetal arterial blood gases significantly. At a high concentration of vasopressin (20-40 mIU/min.), infusion for 60 minutes increased fetal arterial pO2 by approximately 5 mmHg (p less than 0.005 by paired t-test), and decreased pCO2 by approximately 2 mmHg (p less than 0.005 by paired t-test) without significant changes in pH. Neither low nor high dose infusion of arginine vasopressin was accompanied by significant changes in 2,3-DPG or the glucose level.     

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.

Vasopressin and operative hysteroscopy in the management of delayed postabortion and postpartum bleeding

Two women, one with refractory postabortion hemorrhage and the other with refractory postpartum hemorrhage, were managed with vasopressin, operative hysteroscopy, and a dilute vasopressin pack. Both patients had been treated by standard methods (i.e., dilation and curettage) and both were being prepared for a surgical intervention procedure. It was decided in both cases to try to slow the bleeding by injection of vasopressin paracervically and then performance of operative hysteroscopy. In both cases, the injection of dilute vasopressin paracervically when coupled with operative hysteroscopy was quite effective in determining the cause of the bleeding and was instrumental in avoiding major operative procedures.