“一站式”双介入技术在凶险型前置胎盘并胎盘植入剖宫产中的应用

Application of "one-stage" dual interventional technique in treatment of pernicious placenta previa with placenta accrete undergoing cesarean section

目的:分析球囊导管临时封堵双侧髂内动脉+选择性血管栓塞术"一站式"应用于凶险型前置胎盘并胎盘植入剖宫产术的疗效。方法:2016年5月—2017年11月我院应用复合手术室治疗凶险型前置胎盘并胎盘植入患者23例;所有患者于剖宫产术前行双侧髂内动脉球囊置入,待胎儿娩出脐带结扎后充盈球囊,剖宫产术后取出球囊导管并行子宫供血动脉栓塞术。记录剖宫产术中出血量、术后24 h出血量、球囊置入过程X线曝光时间及照射剂量、子宫切除情况、术后住院时间及并发症情况。结果:23例均成功置入双侧髂内动脉球囊(球囊规格为8 mm×40 mm 5例,10 mm×40 mm 11例,12 mm×40 mm 7例);胎盘娩出后撤出球囊导管,产科医生按压宫底,均发现不同程度的活动性出血,遂行子宫供血动脉栓塞术,其中,22例子宫供血动脉均源自髂内动脉;1例同时合并髂外动脉供血,活动性出血经栓塞治疗后均好转;1例因胎盘植入子宫下段肌层至浆膜层,并部分植入膀胱,行全子宫切除及膀胱部分切除修补术;球囊置入X线曝光时间平均为(88.7±16.8)s,球囊置入过程接收放射线剂量平均为(18.2±4.5)mGy;术中出血量平均为1000 ml(500~3 000 m1);术后24 h出血量580 ml(70~1 200 m1),术后平均住院时间7 d(4~10 d);产出23名新生儿,1分钟Apgar评分:10分19名,9分2名,8分、7分各1名;5分钟Apgar评分均10分;随访期间未发现术中及术后的严重相关并发症。结论:"一站式"双介入技术可有效降低剖宫产术中及产后出血量,有效降低子宫切除的风险;复合手术室为凶险型前置胎盘并胎盘植入提供了理想的治疗平台。

Objective:To analyze the efficacy of"one-stage"temporary bilateral internal iliac arteries balloon occlusion and selective artery embolization in treatment of women with pernicious placenta previa complicated with placenta accreta undergoing cesarean section.Methods:A total of 23 cases of pernicious placenta previa complicated with placenta accreta were treated in the hybrid operation room in our hospital during May 2016 to November 2017.Balloons were placed in bilateral internal iliac arteries before cesarean section.After the fetus was delivered and the umbilical cord was ligated,the balloons were filled up.Then the balloon and the catheter sheath were pulled out immediately after cesarean section,together uterine artery embolization was implemented.The amount of blood loss during cesarean section,postoperative volume of blood loss within 24 h,the X-ray exposure time and radiation dose for balloon placement,uterine hysterectomy rate,length of stay and postoperative complications were recorded.Results:Successful bilateral internal iliac artery balloon implantation was accomplished in all 23 patients(as to the balloon specification,5 cases were 8 mm×40 mm,11 cases were 10 mm×40 mm,7 cases were 12 mm×40 mm).After the delivery of placenta,the balloon and the catheter sheath were pulled out.The patients were all found with different levels of active bleeding through the gentle press on the fundus of eterus by obstetrician,and then uterine artery embolization was carried out.The uterine blood supply artery of 22 cases were originated from internal iliac artery,and 1 case was simultaneous combined from external iliac artery.Active bleeding was improved after embolization in all cases.The placenta of one patient penetrated through myometrium to percreta,and partially into the bladder,and then resection of the uterus together with partial repair of bladder was operated.The mean X-ray exposure time for balloon placement was(88.7±16.8)s;the mean radiation dose for balloon placement was(18.2±4.5)mGy;the mean amount of blood loss during cesarean section was 1 000 ml(500-3 000 ml);the mean postoperative volume of blood loss within 24 h was 580 ml(70-1 200 ml);the mean hospitalization time was 7 d(4-10 d).Of all the 23 newborns,Apgar scores within 1 min:19 cases scored 10 points,2 cases scored 9;with additional 2 cases,scored 8 and 7 each;and for all neonates,Apgar scores within 5 min were all rated as 10.During follow-up,significant complications were not found during and after operation.Conclusions:"One-stage"dual interventional technique not only can reduce the amount of blood loss during and after cesarean section,but also can greatly reduce the risk of undesirable hysterectomy,and the hybrid operation room can provide an optimal treatment platform for patients with pernicious placenta previa complicated with placenta accrete.