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中华妇幼临床医学杂志(电子版) ›› 2013, Vol. 09 ›› Issue (04) : 512 -516. doi: 10.3877/cma.j.issn.1673-5250.2013.04.021

所属专题： 经典病例； 文献；

论著

大剂量甲氨蝶呤子宫动脉灌注栓塞术治疗胎盘植入产后出血56例分析
马壮1,*,*(), 蔡舒1, 宁华丽1, 金新安1, 刘翔1, 黄波涛1   
  1. 1. 523945　广东东莞，广东医学院附属东莞市厚街医院介入中心
  • 收稿日期:2013-01-09 修回日期:2013-03-28 出版日期:2013-08-01
  • 通信作者: 马壮

Anlysis of the Bilateral Uterine Artery Embolization Combined With Methotrexate in Large Dose for Treatment of 56 Cases With Postpartum Hemorrhge of Placenta Accrete

Zhuang MA1(), Shu CAI1, Hua-li NING1, Xin-an JIN1, Xiang LIU1, Bo-tao HUANG1   

  1. 1. Intervention Center, Affiliated Houjie Hospital of Guangdong Medical College, Dongguan 523945, Guangdong Province, China
  • Received:2013-01-09 Revised:2013-03-28 Published:2013-08-01
  • Corresponding author: Zhuang MA
  • About author:
    (Corresponding author: MA Zhuang, Email: )
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马壮, 蔡舒, 宁华丽, 金新安, 刘翔, 黄波涛. 大剂量甲氨蝶呤子宫动脉灌注栓塞术治疗胎盘植入产后出血56例分析[J]. 中华妇幼临床医学杂志(电子版), 2013, 09(04): 512-516.

Zhuang MA, Shu CAI, Hua-li NING, Xin-an JIN, Xiang LIU, Bo-tao HUANG. Anlysis of the Bilateral Uterine Artery Embolization Combined With Methotrexate in Large Dose for Treatment of 56 Cases With Postpartum Hemorrhge of Placenta Accrete[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2013, 09(04): 512-516.

目的

探讨采用大剂量甲氨蝶呤(MTX)进行子宫动脉灌注栓塞术(UAE)治疗胎盘植入导致产后出血(PPH)的疗效及可行性。

方法

选择2003年4月至2012年7月因胎盘植入导致PPH，采用Seldinger技术行右股动脉穿剌，经导管进行大剂量MTX UAE治疗的56例患者为研究对象。其中，完全性胎盘植入患者为9例，部分性胎盘植入为47例。对治疗相关指标进行分析(本研究遵循的程序符合本院人体试验委员会所制定的伦理学标准，得到该委员会批准，征得受试对象本人的知情同意，并与之签署临床研究知情同意书)。

结果

56例患者的平均手术时间为(40±5) min，UAE后平均止血时间为(10.0±4.2) min，均抢救成功并保留子宫，术后随访6个月均无明显UAE并发症发生。

结论

大剂量MTX UAE治疗胎盘植入所致PPH具有止血迅速、微创、患者恢复快及经济等优点，且能保留患者子宫及生育功能等。

关键词: 甲氨蝶呤, 胎盘植入, 子宫动脉, 子宫动脉灌注栓塞术
Objective

To explore the efficacy and feasibility of uterine arterial infusion and embolization(UAE) via bilateral uterine arteries for treatment of postpartum hemorrhage(PPH) of placenta implants by methotrexate(MTX) in large dose.

Methods

From April 2003 to July 2012, using Seldinger technique, 56 patients were treated for PPH via UAE by MTX in large dose individually. Among them, 9 cases were complete placenta implants and 47 cases were partial placenta implants. Informed consent was obtained from all participants.

Results

The average operating time was (40±5) min in total cases. After UAE, the average hemostatic time was (10.0±4.2) min. Each patient was rescued and retained the uterus. In the following up of 6 months, there was no evident complications among all cases.

Conclusions

UAE via bilateral uterine arteries for the treatment of PPH of placenta implants by MTX in large dose features fast, microinvasive, economic, retaining the uterus and fertility.

Key words: methotrexate, placenta accrete, uterine artery, uterine arterial embolization
图1 UAE前MIR(增强)见宫底胎盘植入
Figure 1 Placenta accrete in fundus of uterus on contrast enhancement MIRpre-UAE
图2 UAE前MIR T2WI压脂横断面见宫底胎盘植入
Figure 2 Placenta accrete in fundus of uterus on MIR T2WI pre-UAE
图3 UAE前MIRT2WI压脂矢状面见宫底胎盘植入
Figure 3 Placenta accrete in fundus of uterus on MR T2WI pre-UAE
图4 UAE前DSA造影见宫底部造影剂散在斑片状染色(A，B)
Figure 4 Placenta accrete in fundus of uterus on DSA radiography pre-UAE
图5 采用大剂量MTX进行UAE后第7天MIRT2WI矢状面见胎盘与宫壁出现间隙
Figure 5 Space appeared between placeta and uterine wall on MIR T2WI in 7 th d after UAE
表1 成功清除宫内胎盘组织与清除宫内胎盘组织失败患者不同时间段β-hCG水平比较(±s，mIU/mL)
Table 1 Comparison of the levels of β-hCG at different period of time between successful curettage and the failure curettage(±s，mIU/mL)
清宫术结果 n 3 d (8～12) d 14 d 28 d (55～60) d
成功 49 2740.0±30.5 730.0±30.5 130.0±30.5 0.8±0.4 －
失败 7 4560.0±30.5 1120.0±30.5 330.0±30.5 120.0±30.5 0.9±0.4
表2 56例患者采用大剂量MTX进行UAE后相关并发症发生率比较[n(%)]
Table 2 Comparison of rate of complication after treatment by UAE among 56 patients [n(%)]
并发症 n 疼痛 发热 胃肠道反应 白细胞降低
阳性率 56 56(100.0) 22(39.2) 31(55.3) 9(16.0)
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