子宫动脉栓塞术治疗难治性产后出血的临床分析

Clinical Analysis of Cases of UAE in the Treatment of Refractory Postpartum Hemorrhage

目的:探讨子宫动脉栓塞术(UAE)治疗难治性产后出血(RPPH)的时机以及可能失败的原因。方法:选择2012年1月至2020年12月因RPPH行UAE治疗的85例患者进行回顾性分析,按照UAE是否止血成功分为UAE失败组((印)n(正)=25)和成功组((印)n(正)=60),收集两组患者的年龄、体质量指数(BMI)、既往剖宫产史、多胎妊娠、是否并发子痫前期、分娩方式、产后出血原因、出血量、是否发生弥散性血管内凝血(DIC)、休克指数、UAE前血红蛋白(Hb)、血小板计数(PLT)、纤维蛋白原(Fib)、使用促子宫收缩药物、决定介入手术至转运到介入手术室时间及手术时间、异常侧支血管、卵巢动脉供血等指标,并进行比较分析。结果:(1)85例RPPH患者采取UAE治疗成功率70.59%,失败组和成功组患者的年龄、BMI、孕产次、多胎妊娠及是否并发子痫前期比较,差异无统计学意义((印)P(正)>0.05),失败组与成功组比较,在剖宫产手术史上差异有统计学意义((印)P(正)<0.05)。(2)失败组和成功组的患者,在分娩方式、是否发生胎盘植入、血管介入手术前大出血量、休克指数、Fib(1.58±0.93 g/L vs.2.99±2.47 g/L)、介入手术持续时间、子宫是否存在侧支血管供血方面比较,差异均有统计学的意义((印)P(正)<0.05)。另一方面,宫缩乏力至大出血、决定介入至患者转运至介入手术室时间、有无使用多种促子宫收缩剂、DIC、造影发现有卵巢动脉显影以及在介入手术前Hb(87.88±18.00 g/L vs.80.97±16.61 g/L)、PLT[(112.52±33.10)×10^(9)/L vs.(131.00±58.38)×10^(9)/L]方面,两组间比较差异无统计学意义((印)P(正)>0.05)。结论:UAE是治疗RPPH的有效方法,但对于胎盘植入导致的RPPH,UAE止血失败率较高。UAE前产后出血量多、休克指数高,UAE的失败率高。有异常侧支血管供血的RPPH患者单一的UAE并不能达到良好的止血效果,需联合其它止血方式。

Objective:To review the cases of refractory postpartum hemorrhage(RPPH)treated with uterine arterial embolization(UAE),and explore the timing of UAE treatment and the possible failure causes.Methods:85 patients who were treated with UAE due to RPPH from January 2012 to December 2020 were studied.According to the success of UAE in hemostasis,the patient data were divided into UAE failure group(n=25)and success group(n=60).Patients′information including age,BMI,previous cesarean section history,multiple pregnancy,concurrent preeclampsia,mode of delivery,cause of postpartum hemorrhage,amount of bleeding,occurrence of disseminated intravascular coagulation,shock index,hemoglobin before UAE,platelets,fibrinogen,use of uterine contractile drugs,determination of the time from interventional operation to transfer to interventional operation room and operation time,abnormal collateral vessels,ovarian artery blood supply and other indexes were compared and analyzed.Results:(1)The success rate of UAE treatment in 85 patients with RPPH was 70.59%.There were no significant differences among age,body mass index,number of pregnancies,multiple pregnancies and preeclampsia between the failure group and the success group(P>0.05).There was significant difference in the history of cesarean section between the failure group and the success group(P<0.05).(2)There were significant differences between the failure group and the success group in the mode of delivery,whether placenta implantation occurred,the amount of massive bleeding before vascular intervention,shock index,fibrinogen(1.58±0.93 g/L vs.2.99±2.47 g/L),the duration of intervention,and whether there was collateral blood supply to the uterus(P<0.05).There were no significant differences between the two groups in terms of uterine weakness to massive bleeding,decision of the time from intervention to patient transfer to the intervention operating room,use of various uterine contractile agents,DIC,ovarian artery development found by angiography,hemoglobin(87.88±18.00 g/L vs.80.97±16.61 g/L)and[(112.52±33.10)×10^(9)/L vs.(131.00±58.38)×10^(9)/L]platelets before intervention(P>0.05).Conclusions:UAE is an effective method for the RPPH treatment.However,for RPPH caused by placenta implantation,UAE has a high hemostatic failure rate.The more postpartum hemorrhage happened before UAE,the higher of the patients′shock index,and the failure rate of UAE.In RPPH patients with abnormal collateral blood supply,UAE alone cannot achieve good hemostatic effect,whichneeds to be combined with other hemostatic methods.