子宫动脉化疗栓塞术在胎盘植入治疗中的临床应用

The clinical application of uterine artery chemoembolization in treating placental implantation.

目的探讨子宫动脉化疗栓塞术治疗胎盘植入的临床疗效。方法将24例患者分为A组（介入治疗组）和B组（药物治疗组）。A组12例患者先行髂内动脉造影,确认子宫动脉后再将导管超选择送入子宫动脉远端,经导管以甲氨蝶呤和明胶海绵颗粒行双侧子宫动脉化疗栓塞术（UACE）。术后7d内彩超监视下清除宫内残留胎盘。B组12例患者在产后给予甲氨蝶呤肌注,之后在彩超监视下分次刮宫。治疗后随访3~27个月（平均12个月）,期间观察患者阴道出血、胎盘组织排出、血β-hCG水平、子宫恢复情况、月经变化等情况。结果 A组12例中11例保留子宫,平均清宫出血量（80±38.4）ml,平均止血时间（25.0±5.4）min,平均治疗时间（45.3±6.4）min,术后4~10d内成功清除宫内胎盘组织,平均为（6.1±0.6）d,1例因穿透性胎盘行子宫次全切除术,所有患者血β-hCG于胎盘完全排出后3~8d恢复正常,平均（5.7±0.7）d,保留子宫的11例患者2~3个月恢复正常月经周期,经量如常。3个月后复查彩超示子宫基本恢复正常大小。B组12例,予MTX肌注,因治疗失败大出血切除子宫3例,除外失败病例,平均清宫出血量（102.4±7.04）ml,平均止血时间（27.1±4.5）d,所有患者平均治疗时间（10.4±5.4）d,血清β-hCG降至正常范围平均需（75.2±12.7）d,宫腔胎盘完全清除平均需（103.8±0.4）d,随访保留子宫的10例患者,5例产后3个月内月经恢复,其中3例月经恢复正常,其余5例产后4个月月经周期正常,但经量减少。结论子宫动脉化疗栓塞术治疗胎盘植入患者具有止血迅速、清宫出血量少、治疗时间短、并发症少、可保留子宫等优点,是一种安全、微创的治疗方法。

Objective To investigate clinical efficacy of uterine artery chemoembolization in treating placental implantation.Methods Twenty four patients were divided into two groups,Patients in group A（n = 12） received uterine artery chemoembolization,the intrenal iliac artery angiography was perfewmed to identify the uterine artery and bilateral uterine artery chemoembolization（UACE） with methotrexate（MTX） and gelfoam particles to the distal end of uterine artery was conducted after.The patients of group A were followed by uterine curettage in 7 days procedure under the monitoring of color Doppler ultrasound to clean up the residual placenta.Patients in group B received pure intramuscular injection of MTX,which was followed by uterine curettage as patients in group A.All cases were followed up for 3 ~ 27 months（average 12 months） to observe vaginal bleeding,placenta tissue discharge,serum human chorionic gonadotropin（hCG）,uterine involution,menses.Results 91.7% of the patients（11 /12） in group A reserved their uterus,the average time for hemostasis was（25.0±5.4） minutes and the average treatment time was（45.3 ±6.4） minutes.The placenta tissue was sussessfully cleaned up by uterine curettage within 4 ~ 10 days,with a mean of（6.1±0.6） days.1 patient underwent subtotal hysterectomy and confirmed to be placenta percreta by pathology examination.All the patients＇ serum hCG reduced to normal within 3 ~ 8 days after the placenta tissue were evacuated,with a mean of（5.7±0.7） days,regular menstruation returned within 2 ~ 3 months in those patients who reserved uterus and normal size uterus was found under sonography at 3 months.Three patients in group B had to receive hysterectomy because of massive bleeding due to failure to intramuscular injection of MTX.The average time for hemostasis was（27.1±4.5） days and the average treatment time was（10.4±5.4） days.The serum β-hCG decreased to normal range in（75.2±12.7） days after the treatment,the average time for complete cleaning of placenta tissue by uterine curettage was（103.8±0.4） days.10 patients whose uterus reserved were flollowed up.the menses returned in 5 cases within 3 months after delivery,three of them the menses regained normal regular cycle.The remaining 5 cases got their normal menses in about 4 months after delivery although the flow of menstrual cycle was scanty.Conclusion For the treatment of placenta percreta,uterine artery chemoembolization is a safe,minimal invasive technique with many advantages.It can stop bleeding quickly,shortten the treatment time,fewer complications and preserve the uterus.