腹主动脉球囊阻断法预防凶险性前置胎盘合并胎盘植入剖宫产术中出血的价值

Value of temporary ballon occlusion of abdominal aorta in prevention of bleeding during cesarean section in women with pernicious placenta previa and placenta accreta

目的探讨腹主动脉球囊阻断法预防凶险性前置胎盘合并胎盘植入剖宫产术中出血的手术技巧及效果。方法2013年5月1日至2014年6月30日，在郑州大学第一附属医院就诊的凶险性前置胎盘合并胎盘植入的孕妇中，共41例采用腹主动脉球囊阻断法预防剖宫产术中出血。所有患者术前均行彩色多普勒超声及MRI证实。在数字减影手术室，剖宫产术前由介入科医生行右侧股动脉穿刺及腹主动脉球囊导管预置术。胎儿娩出的同时，立即向球囊内注人生理盐水10ml，使球囊充盈阻断腹主动脉。依据胎盘植入面积大小、深度及是否植人或穿透膀胱后壁，相应行胎盘剥离、局部子宫壁切除或部分膀胱切除并修补术。手术同时逐步分次抽出球囊内的生理盐水，直至球囊全部放空。分析孕妇的胎盘植入情况、术中出血量、输血量、术中和术后并发症情况，以及胎儿射线暴露时间和剂量、新生儿Apgar评分。结果41例胎盘植入病例中，5例部分肌层植入，36例穿透肌层植入（其中28例植入膀胱后壁，8例穿透膀胱后壁）。平均手术时间（68．5±15．3）min。平均术中出血量（1058±960）ml。8例（19．5％，8／41）予输血治疗，平均输血量（600±400）ml。41例平均住院天数（8．2±2．3）d，无一例子宫切除，胎儿射线暴露平均时间为（8．1±3．6）S，平均剂量为（5．2±2．9）mGy。新生儿Apgar评分，1min为（8．7±0．5）分，5min为（9．5±0．3）分。随访至2014年10月31日，6例失访，6例尚在产褥期，18例处于哺乳期，11例月经复潮。结论对凶险性前置胎盘合并胎盘植入患者在剖宫产术前行腹主动脉球囊导管预置术，剖宫产术中暂时阻断腹主动脉，可有效减少术中出血，降低子宫切除的风险。

Objective To study the operative technique and effect of temporary balloon occlusion of the abdominal aorta for preventing intraoperative bleeding during cesarean for patients with pernicious placenta previa and placenta accreta. Methods Retrospective analysis was conducted on the intraoperative situation of forty-one cases and information of follow-up twenty-nine cases, which were pernicious placenta previa and placenta accreta and delivered in the First Affiliated Hospital of Zhengzhou University from May 1, 2013 to June 30, 2014. Diagnosis was confirmed by line of color Doppler ultrasound and MRI for all patients before operations. An interventional physician performed right femoral artery puncture and preset the abdominal aortic balloon catheter in the digital subtraction angiography operation room before cesarean. At the same time of fetal delivery, 10 ml normal saline was injected into the balloon immediately, which results in filling of the balloon and blocking of the aorta. According to the area and depth of placenta implantation and implantation or penetration of the posterior bladder wall, placenta separation, partial resection of the uterine wall and partial bladder resection and repair were performed correspondingly. Meanwhile, saline in the balloon was pumped out gradually until empty. Condition of placenta implantation, blood loss and blood transfusion volume during the operation, intraoperative and postoperative complications, the duration and dose of fetal radiation exposure, and Apgar score of neonates were analyzed. Results Among the 41 cases, penetrative placenta and implanted placenta were observed in five cases and 36 cases, respectively. The latter 36 cases including 28 cases of bladder posterior wall accreta and eight cases of bladder posterior wall penetration. For all cases, the average operation time was （68.5±15.3） min, the mean blood loss in the operation was （1 058±960） ml, among which eight received blood transfusion with an average of （600±400） ml, and the mean hospital stay was （8.2 ± 2.3） d. Uteruses were reserved in all cases. The mean duration and dose of fetal radiation exposure was （8.1 ±3.6） s and （5.2± 2.9） mGy, and the Apgar score of neonates was 8.7 ± 0.5 at 1 rain and 9.5 ±0.3 at 5 min, respectively. The patients were followed up until October 31, 2014. Among them, six were lost, six were still in puerperium, 18 were breast-feeding, and the menses of 11 had returned. Coneluslon Preset abdominal aortic balloon catheter in pernicious placenta previa and placenta accrete patients might effectively reduce the blood loss during cesarean section as well as the risk of hysterectomy through temporary occlusion of the abdominal aorta.