胎盘植入的影像学表现及介入治疗临床研究

目的探讨胎盘植入的影像学表现及介入治疗方法和疗效。资料与方法本组11例患者,术前作CT平扫、术前术后作超声检查、查血绒毛膜促性腺激素(HCG),行双侧子宫动脉造影。治疗采用改良式Seldinger技术穿刺插管行盆腔动脉造影,明确出血血管后将5 F Cobra导管超选择插入出血侧子宫动脉,立即用明胶海绵颗粒和明胶海绵条栓塞。栓塞前经导管注入甲氨喋呤(MTX)200 mg。结果 CT发现11例患者均有盆腔软组织包块,造影示子宫动脉异常增粗、迂曲,并见粗条状血窦及包块染色;11例患者栓塞治疗后植入性胎盘均在3～28天(平均12.3天)内自行剥离、脱落,其中3例1年后自然怀孕。结论胎盘植入通过CT、超声及子宫动脉造影可明确诊断,经导管超选择性子宫动脉栓塞术是治疗胎盘植入安全性高、疗效肯定的方法。     

Imaging Findings and Clinical Research in Interventional Treatment of Placenta Increta

目的 探讨胎盘植入的影像学表现及介入治疗方法和疗效.资料与方法 本组11例患者,术前作CT平扫、术前术后作超声检查、查血绒毛膜促性腺激素(HCG),行双侧子宫动脉造影.治疗采用改良式Seldinger技术穿刺插管行盆腔动脉造影,明确出血血管后将5 F Cobra导管超选择插入出血侧子宫动脉,立即用明胶海绵颗粒和明胶海绵条栓塞.栓塞前经导管注入甲氨喋呤(MTX) 200 mg.结果 CT发现11例患者均有盆腔软组织包块,造影示子宫动脉异常增粗、迂曲,并见粗条状血窦及包块染色;11例患者栓塞治疗后植入性胎盘均在3～28天(平均12.3天)内自行剥离、脱落,其中3例1年后自然怀孕.结论 胎盘植入通过CT、超声及子宫动脉造影可明确诊断,经导管超选择性子宫动脉栓塞术是治疗胎盘植入安全性高、疗效肯定的方法.     

子宫动脉栓塞术治疗植入胎盘的临床分析

目的 探讨子宫动脉栓塞治疗植入胎盘的价值.方法 16例经超声或磁共振检查确诊为植入胎盘患者行双侧子宫动脉注药栓塞术,栓塞后5～7 d在超声监视下行清宫术.结果 16例子宫动脉注药栓塞及清宫术治疗均成功.5～12个月内恢复正常月经.结论 双侧子宫动脉注药栓塞术及在B超监视下清宫术是一种治疗植入胎盘安全可靠有效方法.     

超选择性子宫动脉栓塞在植入性胎盘治疗中的初步疗效观察

目的 探讨超选择性子宫动脉栓塞(UAE)治疗植入性胎盘的疗效.方法 行盆腔动脉造影明确出血血管后,将5 F Cobra导管超选择性插入出血侧子宫动脉,注入甲氨喋呤,而后采用明胶海绵颗粒和明胶海绵条栓塞.术后随访观察出血、血压、胎盘组织排出、子宫复旧和血绒毛膜促性腺激素β亚单位(β-HCG)等情况.结果5例胎盘植入患者均找到出血位置并1次性栓塞成功.手术时间25.0～60.0 min,平均为(37.4±5.8)min;急性出血者术后3.0～12.0 min阴道大量流血停止,平均为(5.7±2.4)min.患者生命体征平稳,术后血压回升.术后5 d至4周排出胎盘组织,平均排出时间为17 d,子宫如期复旧,血β-HCG恢复正常,随访月经正常,自测排卵正常.结论UAE治疗植入件胎盘具有手术时间短、创伤小、疗效肯定和可保留子宫等优点,有较好的临床应用价值.     

子宫动脉栓塞术联合利凡诺在前置胎盘患者引产中的应用

目的 探讨子宫动脉栓塞术联合利凡诺治疗前置胎盘患者引产中的安全性及疗效.方法 采用子宫动脉栓塞术对26例中晚期妊娠前置胎盘患者行子宫动脉栓塞,同时应用利凡诺羊膜腔注射引产治疗.结果 中晚期妊娠子宫动脉及其分支明显增多增粗扭曲,与妊娠月龄成正比,胎盘血供丰富.26例患者术后平均25h排出胎儿及附属物,产后出血量平均（225±36）ml,平均34天恢复月经.结论 子宫动脉栓塞术联合利凡诺在前置胎盘患者引产中疗效安全、可靠,保留生育功能.     

剖宫产后切口妊娠的处理

目的探讨子宫动脉灌注化疗对剖宫产切口妊娠（CSP）的可行性及临床价值。方法 2008年6月~2011年7月对剖宫产切口妊娠30例行介入治疗。结果 30例患者均行子宫动脉介入治疗＋栓塞后清宫。30例患者均治疗成功,术中出血少,无一例切除子宫。结论子宫动脉介入加栓塞治疗CSP成功率高,全身副反应少,是切口妊娠安全、有效的治疗方法。     

子宫动脉栓塞术治疗胎盘植入的临床应用

目的 探讨子宫动脉栓塞术(UAE)治疗胎盘植入及引起的产后出血的临床应用. 方法对26例经保守治疗无效的胎盘植入患者及引起的出血进行UAE治疗,采用Seldinger技术选插两侧子宫动脉后分别灌注氨甲喋呤(MTX),然后进行两侧子宫动脉栓塞. 结果 26例经介入治疗后达到快速止血且保留子宫的效果.结论 介入治疗是胎盘植入及所致产后出血有效的新治疗方法.     

子宫动脉栓塞术治疗产后胎盘植入的临床应用价值

目的 观察子宫动脉栓塞术治疗产后胎盘植入的临床疗效,总结其临床价值.方法 回顾性分析18例产后胎盘植入行双侧子宫动脉栓塞治疗患者的临床资料,分析其治疗效果和治疗中的不良反应.结果 18例患者均得到及时有效的止血,其中8例术后3～7天排出胎盘组织,10例栓塞术后第8天辅以清宫术,清除了胎盘组织且术中出血少.18例患者均成功保留子宫,治疗过程中不良反应轻微.结论 子宫动脉栓塞术治疗产后胎盘植入具有创伤小、并发症少、疗效肯定及保留患者子宫等优点,具有很高的临床使用价值.     

16例中期妊娠前置胎盘状态介入治疗的护理

目的 探讨中晚期妊娠前置胎盘状态行介入治疗的护理特点.方法 栓塞治疗16例中晚期妊娠前置胎盘状态患者时同时应用利凡诺羊膜腔注射引产治疗,术前、术中、术后予以严密的观察和护理.总结该病护理特点.结果 16例中晚期妊娠前置胎盘状态患者中,15例术后平均4.5 h胎儿及其附属组织娩出,无产后出血.1例孕26周因瘢痕子宫、有宫颈性难产史引产失败,在栓塞术后第6天行剖宫取胎术,术中出血约100 ml.16例患者均未发生护理并发症.结论 子宫动脉栓塞术应用在中晚期妊娠前置胎盘出血引产中,疗效可靠.同时加强术前、术中、术后的护理,可以提高介入治疗的成功率,预防并发症的发生.     

子宫动脉栓塞术在中晚期妊娠前置胎盘出血引产中的应用

目的探讨子宫动脉栓塞术(UAE)在中晚期妊娠前置胎盘出血引产中的应用价值。方法采用Seldinger技术穿刺及导管超选择插管技术行双侧子宫动脉造影,并栓塞治疗16例中晚期妊娠前置胎盘患者,同时应用利凡诺羊膜腔注射引产治疗。结果中晚期妊娠子宫动脉明显增粗增长,分支明显增多增粗卷曲,与妊娠月龄成正比,胎盘血供丰富。15例术后平均4.5h胎儿及其附属组织娩出,无产后出血。1例孕26周中央型前置胎盘因引产失败(合并瘢痕子宫,有宫颈性难产史),栓塞术后6d行剖宫取胎术,术中出血约100ml。术后平均32.4d恢复月经。结论子宫动脉栓塞术在中晚期妊娠前置胎盘出血引产疗效可靠,保留生育功能,有促进引产的作用。     

MRI evaluation of placenta accreta treated by embolization. Apropos of a case. Review of the literature]

Placenta accreta results from an abnormal attachment of the placenta to the uterine myometrium. The reported incidence in literature is variable, with an average of 1/7000 pregnancies. This condition is associated with a significant risk of bleeding at the time of delivery, usually requiring hysterectomy. Sonography associated with color Doppler is useful for diagnosis, but MRI can be used successfully to evaluate the degree of placental tissue invading into the myometrium, the serosa, and for follow-up after conservative management. To our knowledge, only two cases of placenta accreta evaluated with MR and six cases of placenta accreta treated by embolization have been reported in the literature. The authors report one case of placenta accreta treated successfully by embolization, and followed-up by MRI.     

Balloon-Assisted Occlusion of the Internal Iliac Arteries in Patients with Placenta Accreta/Percreta

Background Placenta accreta/percreta is a leading cause of third trimester hemorrhage and postpartum maternal death. The current treatment for third trimester hemorrhage due to placenta accreta/percreta is cesarean hysterectomy, which may be complicated by large volume blood loss. Purpose To determine what role, if any, prophylactic temporary balloon occlusion and transcatheter embolization of the anterior division of the internal iliac arteries plays in the management of patients with placenta accreta/percreta. Methods The records of 28 consecutive patients with a diagnosis of placenta accreta/percreta were retrospectively reviewed. Patients were divided into two groups. Six patients underwent prophylactic temporary balloon occlusion, followed by cesarean section, transcatheter embolization of the anterior division of the internal iliac arteries and cesarean hysterectomy (n = 5) or uterine curettage (n = 1). Twenty-two patients underwent cesarean hysterectomy without endovascular intervention. The following parameters were compared in the two groups: patient age, gravidity, parity, gestational age at delivery, days in the intensive care unit after delivery, total hospital days, volume of transfused blood products, volume of fluid replacement intraoperatively, operating room time, estimated blood loss, and postoperative morbidity and mortality. Results Patients in the embolization group had more frequent episodes of third trimester bleeding requiring admission and bedrest prior to delivery (16.7 days vs. 2.9 days), resulting in significantly more hospitalization time in the embolization group (23 days vs. 8.8 days) and delivery at an earlier gestational age than in those in the surgical group (32.5 weeks). There was no statistical difference in mean estimated blood loss, volume of replaced blood products, fluid replacement needs, operating room time or postoperative recovery time. Conclusion Our findings do not support the contention that in patients with placenta accreta/percreta, prophylactic temporary balloon occlusion and embolization prior to hysterectomy diminishes intraoperative blood loss.     

Focal myometrial defect and partial placenta accreta in a pregnancy following bilateral uterine artery embolization

A 29-year-old nulliparous patient was treated with uterine artery embolization (UAE) for a large symptomatic uterine fibroid, resulting in a marked reduction of the tumor volume. She subsequently conceived and progressed through pregnancy uneventfully. At cesarean section for breech presentation at term, a large fundal myometrial defect was encountered. In addition, the patient presented with unexpected partial placenta accreta, which resulted in massive atonic uterine bleeding. It is suggested that UAE was implicated in the pathogenesis of myometrial damage and abnormal placentation. It is proposed that the antenatal care of pregnancies after UAE include careful imaging of the placenta, its vasculature, and the thickness of overlying uterine wall so peripartum management can be appropriately planned.     

Management of life-threatening postpartum hemorrhage: indications and technique of arterial embolization

Pluridisciplinary management of women with postpartum hemorrhage is mandatory in order to precisely assess initial seriousness, to maintain hemodynamic parameters and to confirm the cause of bleeding. Embolization should be offered only after exploration of the uterine cavity, inspection of the vagina, cervix and perineum and failure of uterotonic drugs. Embolization should be carried out in an angiography suite under constant monitoring of the patient by the anesthesiologist. Indications to perform arterial embolization include uterine atony particularly following a vaginal delivery, cervico-uterine hemorrhage, cervicovaginal lacerations (previously repaired or if surgical repair has failed) and vaginal thrombus, particularly in case of associated coagulopathy. Arterial embolization is effective in about 85% of cases. Placenta acccreta can also be successfully managed with arterial embolization as an alternative to hysterectomy. Unilateral femoral approach allows selective study of both internal iliac arteries and branches. Selective embolization of both uterine arteries should be ideally performed. In case of spasm or difficult catheterization, embolization of the anterior division of both internal iliac arteries should be considered. In case of bleeding from the cervico-vaginal region, selective evaluation and embolization of cervicovaginal branches should be performed. In case of failure or recurrence of bleeding, ovarian and round ligament arteries should be evaluated. In most cases, resorbable gelatin sponge pledgets should be used to perform embolization. The use of microcatheters and non resorbable embolization agents should be considered by trained interventional radiologists in case of placenta accreta or vascular lesions. After embolization, the patient should be transferred to the intensive care unit for further observation in order to offer emergent surgical procedure or another session of embolization in case of recurrence of bleeding.     

子宫动脉栓塞术预防和治疗子宫大出血的临床效果

目的探讨子宫动脉栓塞术预防和治疗子宫大出血的临床效果。资料与方法对12例人工流产大出血、胎盘植入性大出血和宫颈妊娠为主要表现的患者用明胶海绵颗粒进行双侧子宫动脉栓塞术,观察治疗效果。结果 12例患者全部栓塞成功,随访2～5个月无再次大出血,无严重并发症。结论子宫动脉栓塞术预防和治疗子宫大出血是一种安全、微创和有效的治疗方法,而且可以保留患者的子宫和生育功能,值得临床推广应用。     

腹主动脉预置球囊辅助前置胎盘伴胎盘植入剖宫产临床应用

目的 探讨腹主动脉预置球囊辅助前置胎盘伴胎盘植入剖宫产的临床应用价值.方法 对72例前置胎盘伴胎盘植入产妇腹主动脉预置球囊辅助剖宫产,其中33例为凶险性前置胎盘(A型),36例为瘢痕子宫、前置胎盘伴胎盘植入(B型),3例为无剖宫产史前置胎盘伴胎盘植入(C型).记录剖宫产术中出血量、子宫切除情况、球囊预置术中X线辐射量及介入操作相关并发症.结果 剖宫产术中A型、B型、C型产妇平均出血量分别为1 461 ml、947 ml、533 ml;9例子宫大部切除,32例子宫修补;2015年17例、2016年55例球囊预置术中平均X线辐射量分别为(28.5±14.1) mGy、(3.7±2.5) mGy;住院期间发生右股浅动脉血栓1例,右下肢静脉血栓1例,皮下血肿2例.结论 腹主动脉球囊预置辅助前置胎盘伴胎盘植入产妇剖宫产,可有效减少术中出血量,明显降低子宫切除率;手术操作简便,X线辐射时间短;熟练操作,能进一步减少介入操作相关并发症.     

Uterine artery embolization: an effective treatment for intractable obstetric haemorrhage

AIM: To present the findings of uterine artery embolization (UAE) in the management of obstetric haemorrhage. MATERIALS AND METHODS: From October 1999 to February 2003, 10 women with postpartum haemorrhage (n=7) and post-abortion haemorrhage with placenta accreta (n=3), were referred to our department for pelvic angiography and possible arterial embolization. RESULTS: Angiography revealed engorged and tortuous uterine arteries in all patients; and contrast medium extravasation in three patients. Eight patients (three with and five without detectable active bleeding) then underwent bilateral UAE. Medium-sized (250-355 microm) polyvinyl alcohol particles were injected via a coaxial catheter into the uterine arteries, followed by gelatin sponge pieces via a 4F Cobra catheter. Microcoil devascularization was also performed in the two patients with visible, active bleeding. The vaginal bleeding resolved in all patients, without any ischaemic complications. At follow-up, all patients who underwent UAE had normal menstruation; three of them subsequently gave birth to full-term healthy babies. CONCLUSION: Selective UAE by the coaxial method is safe and effective to control obstetric haemorrhage, with the potential to preserve fertility.     

Secondary postpartum hemorrhage: treatment with selective arterial embolization.

PURPOSE: To evaluate the efficacy and safety of selective arterial embolization of the uterine arteries in the management of intractable delayed postpartum hemorrhage. MATERIALS AND METHODS: Fourteen consecutive women with secondary postpartum hemorrhage were treated with selective embolization of the uterine arteries. In all cases, hemostatic embolization was performed because of intractable hemorrhage that could not be controlled with the administration of uterotonic drugs or with uterine curettage. RESULTS: The causes of bleeding included genital tract tears in four women and endometritis in eight women; the endometritis was associated with proved, retained portions of placenta in four women. In two women, no evident cause of bleeding was found before angiography. Angiography revealed extravasation in three women. A false aneurysm of the uterine artery was found in two women. In one patient, an arteriovenous fistula was observed. Immediate resolution of external bleeding was observed in all women. No complication related to embolization was found. Normal menstruation resumed in all women. CONCLUSION: Selective arterial embolization of the uterine arteries is a safe and effective means of controlling secondary postpartum hemorrhage.