经阴道分娩时用子宫动脉栓塞治疗植入性胎盘的结局分析—附25例病例报道

Outcome of treatment of placenta accrete by uterine artery embolization during vaginal delivery:a report of 25 cases

目的总结子宫动脉栓塞术(UAE)治疗经阴道分娩植入性胎盘的结局及影响因素。方法回顾性分析我院随诊资料完整的经阴道分娩植入性胎盘且接受UAE治疗的患者25名,其中13例同时接受甲氨喋呤(MTX)治疗,10例栓塞后行清宫手术。随诊胎盘结局、绒毛膜促性腺激素(β-HCG)下降情况、月经和生育情况。结果所有患者均保留子宫,发生官腔感染1例。胎盘去除时间距分娩的中位时间为3个月,平均(3.65±2.87)月。其中完全自然排出或吸收12例;栓塞术后清宫时胎盘完全清出3例;栓塞后清宫未完全清出而后自然排出或吸收7例;3例顽固性植入胎盘术后半年行经腹或腹腔镜病灶切除。月经恢复率为100%,平均月经恢复时间(2.2±1.37)月。血清β-HCG下降至正常距分娩时间平均为(3.06±1.59)月。残留胎盘体积、UAE距分娩时间、UAE后清官、使用MTX与否与栓塞结局无相关性(P>0.05)。3例非手术保守治疗失败的胎盘患者月经恢复时间和β-HCG下降至正常时间均较其他患者长(P<0.05)。25例患者中有生育要求的11例,已生育的4例(36.4%),孕期顺利。结论植入性胎盘行UAE后胎盘大部分可自然排出或吸收,术后清官或应用MTX不缩短胎盘排出时间,非手术保守治疗失败的病例可行病灶切除术。

Objective： To analysis the result and influencing factors of implement of uterine artery embolization for treatment of placenta accrete during vaginal delivery. Methods： This retrospective study included 25 patients with placenta accrete were treated with uterine artery embolization （UAE） during vaginal delivery. Among them, 10 patients were accepted dilatation and curettage（D＆C）after UAE,and 13 patients were administered with methotrexate （MTX） during and after UAE. The data about placenta tissue discharge, serum D-human chorionic gonadotropin （β-HCG）, menses and fertility result were followed up for all patients. Results： All patients were reserved their uterus. One patient was suffered with intrauterine infection. The removing time of the retained placenta after delivery was （3.65±2.87） months （x=s）. The retained placentas were discharged or absorbed naturally in 13 patients. Among the patients, 3 retained placentas were removed completely during D＆C, and 7 were removed partly during D＆C and absorbed later. Three retained placentas were resected half year after delivery. All the patients resumed their menstrual cycles after （2.2±1.37） months. The serum β-HCG was reduced to normal with （3.06±1.59） months. The volume of retained placenta,interval between UAE and vaginal delivery,D＆C after UAE and auxiliary MTX did not influence the outcome of UAE （P〈0.05）. Of the 11 patients who wanted children, 4 patients delivered without complication. Conclusions： UAE allows the preservation of uterus in patients with placenta accrete. The retained placenta tissues can be discharged or absorbed in most patients. D＆C or auxiliary MTX therapy does not reduce the removing time of the retained placenta. Transperitoneal laparoscopic resection of retained placenta could be a choice in refractory cases.