穿透型胎盘植入行腹主动脉球囊置入的围术期管理1例

Perioperative management of abdominal aortic balloon occlusion in patients complicated with placenta percteta: a case report

当前置胎盘合并胎盘穿透时,血液供应极其丰富,手术视野难以暴露,常规止血方法难以有效控制出血,术中出血量可以达到上万毫升,甚至危及患者生命。Sumigama等[1]报道胎盘植入平均出血量3 630 m L,而胎盘穿透出血量达12 140 m L。球囊阻断是指应用球囊导管阻断供血血管,Hughes[2]报道可以利用球囊控制腹部创伤患者的大出血,并获得成功,术中膨胀球囊暂时性阻断动脉血流,

When placenta previa complicated with placenta percreta,the exposure of operative field is difficult and the routine methods are difficult to effectively control the bleeding,even causing lifethreatening results. A 31-year-old woman,who had been diagnosed with a complete type of placenta previa and placenta percreta with bladder invasion at 34 weeks gestation. Her ultrasound results showed a complete type of placenta previa and there was a loss of the decidual interface between the placenta and the myometrium on the lower part of the uterus,suggestive of placenta increta. For further evaluation of the placenta,pelvis magnetic resonance imaging was performed,which revealed findings suspicious of a placenta percreta. She underwent elective cecarean section at 36 weeks of gestation. Firstly,two ureteral stents were placed into the bilateral ureter through the cystoscope. After the infrarenal abdominal aorta catheter was inserted via the femoral artery（ 9 F sheath）,subarachnoid anesthesia had been established. A healthy 2 510 g infant was delivered,with Apgar scores of 10 at 1 min and 10 at 5 min. Immediately after the baby was delivered,following which there was massive haemorrhage and general anaesthesia was induced. The balloon catheter was immediately inflated until the wave of dorsal artery disappeared. With the placenta retained within the uterus,a total hysterectomy was performed. The occluding time was 30 min. The intraoperative blood loss was 2 500 m L. The occluding balloon was deflated at the end of the operation. The patient had stable vital signs and normal laboratory findings during the recovery period and the hemoglobin was 116 g / L. She was discharged six days after delivery without interventionrelated complications. This case illustrates that temporary occlusion of the infrarenal abdominal aorta using balloon might be a safe and effective treatment option for patients with placenta previa complicated with placenta percreta,who were at high risk for peripartum hemorrhage. Early removal of the endovascular catheter and close postoperative surveillance of the vascular system are required with this procedure to minimize the risk of vascular complications. However,further studies are needed to determine whether the potential benefits of temporary occlusion of the infrarenal abdominal aorta using balloon outweigh the potential risks.