双侧髂内动脉球囊阻断序贯子宫动脉栓塞辅助下剖宫产的临床应用

Clinical application of caesarean section assisted by bilateral internal iliac artery balloon occlusion with sequential uterine artery embolization

目的观察双侧髂内动脉球囊阻断及子宫栓塞术在凶险性前置胎盘剖宫产术中的作用。方法选取2015年3月至2021年11月于上海交通大学医学院附属新华医院接受双侧髂内动脉球囊阻断下剖宫产术的凶险性前置胎盘孕妇93例。剖宫产术前,预置球囊至双侧髂内动脉。胎儿被成功取出后,即刻手推造影剂扩张球囊,阻断髂内动脉血流。随后手术过程中,如仍有持续不可控的出血,则予以明胶海绵行术中双侧髂内动脉/子宫动脉的“一次栓塞”术。关腹后,髂内动脉造影发现子宫动脉存在再开通或者栓塞不完全的情况,给予明胶海绵补充栓塞,以加强“一次栓塞”的效果,称为“二次栓塞”。常规观察患者的术中失血量、输血量、术后住院时间、子宫切除及胎儿情况。结果所有93例剖宫产孕妇,均于剖宫产前成功预置双侧髂内动脉球囊。行术中和术后明胶海绵颗粒两次栓塞患者10例(10.8%),行腹部缝合术后单次栓塞患者83例(89.2%)。所有患者均顺利完成剖宫产手术,且剖宫产出96例活胎。术前平均血红蛋白为110 g/L,术后为97 g/L;术中失血中位数为1475 mL,输血中位数为1150 mL。术中确诊为胎盘黏连、胎盘植入和穿透性植入患者分别为30例(32.3%)、49例(52.7%)和8例(8.6%)。子宫切除患者8例(8.6%)。结论双侧髂内动脉球囊阻断下剖宫产是救治凶险性前置胎盘的有效手段;子宫动脉“二次栓塞”技术是球囊阻断术剖宫产的有效补充。

Objective To observe the effect of bilateral internal iliac artery balloon occlusion and uterine artery embolization in cesarean section of patients with pernicious placenta previa.Methods From March 2015 to November 2021,a total of 93 cases of placenta previa who underwent cesarean section assisted by bilateral internal iliac artery balloon occlusion at Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine were enrolled.Prior to the caesarean section,the balloons were prepositioned in the bilateral internal iliac arteries.Once the fetus was successfully delivered,the bilateral balloons were manually dilated by pushing the contrast agent to block the blood flow in the bilateral internal iliac arteries.Subsequently,in cases of uncontrolled hemorrhage during routine placenta dissection,a procedure referred to as"primary embolization"of the bilateral internal iliac and uterine arteries was conducted using gelatin sponge particles.In cases where uterine artery reperfusion occurred or incomplete embolization was observed during internal iliac artery angiography after abdominal wall closure,additional gelatin sponge particles were introduced to enhance the efficacy of the initial"primary embolization".This technique was referred to as"secondary embolization".The patients'intraoperative blood loss,blood transfusion,postoperative hospital stay,hysterectomy and fetal condition were observed.Results All 93 cases underwent successful prepositioning of balloons within the bilateral internal iliac arteries prior to cesarean section.Among these cases,ten(10.8%)required dual uterine artery embolizations with gelatin sponge particles during and after the cesarean section,while 83 cases(89.2%)received a single embolization following abdominal closure.All patients successfully underwent cesarean section,and 96 live fetuses were delivered.The mean preoperative hemoglobin concentration was 110 g/L,which decreased to a median of 97 g/L postoperatively.The median intraoperative blood loss and transfusion volume were 1475 mL and 1150 mL,respectively.Placenta accreta,placenta increta,and placenta percreta were diagnosed in 30 cases(32.3%),49 cases(52.7%),and 8 cases(8.6%),respectively.Hysterectomy was performed in eight patients(8.6%).Conclusion Cesarean section assisted with bilateral internal iliac artery balloon occlusion is an effective modality for the treatment of pernicious placenta previa.The utility of"secondary embolization"for uterine artery is an effective supplementary way to strengthen the effect of balloons occlusion in the procedure of cesarean section.