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Intraoperative Uterine Artery Embolization in Two Patients with Placenta Previa Accreta: Comparison of Two Approaches to Control Bleeding

於兩位患黏生性前置胎盤之病人施行手術中子宮動脈栓塞:比較兩種不同步驟之優劣

摘要


黏生性前置胎盤(placenta previa accrete)肇因於前置胎盤部份或全部不正常黏連子宮壁肌肉層,它可能造成致命性的產後大出血,而須緊急子宮切除治療。在胎兒娩出後及胎盤娩出前施以動脈栓塞可以明顯減少出血而避免子宮切除,然而,在胎盤娩出後立即出血引起的出血性休克、子宮動脈收縮及瀰漫性血管內血液凝結病變會導致動脈栓塞治療失敗。在這篇病例報告中,我們描述兩個患有黏生性胎盤病人採用不同步驟施行動脈栓塞控制出血。在第一個病患的動脈栓塞因病患接近休克、子宮動脈收縮及瀰漫性血管內血液凝結病變而失敗,之後接受緊急子宮切除才得以控制住出血。在第二個病患處置,在剖腹生產手術前我們先放置5 Fr右側股動脈導管鞘。手術中,動脈栓塞變得更容易而病患失血更少。從我們提出的病例得知在患有前置黏生性胎盤的病人,在剖腹生產前先行放置股動脈導管鞘及胎兒娩出後立即動脈栓塞是有效方法控制因黏生性胎盤引起的產後大出血。此方法可以減少出血、保留病人卵巢功能及生育力。

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並列摘要


Placenta previa accreta, the combination of placenta previa and placenta acrreta, can cause life-threatening massive post-partum hemorrhage (PPH) and may require emergent hysterectomy. Intraoperative transcatheter arterial embolization (TAE) performed after fetal delivery and before placenta expulsion can significantly reduce blood loss and preserve the uterus. However, TAE may fail under the status of hemorrhagic shock, vasospasm of the uterine arteries, and disseminated intravascular coagulopathy (DIC) due to immediate blood loss after placental delivery. We describe two cases of pregnancy complicated by placenta previa accreta and embolization was performed via different approaches to control bleeding. Emergent TAE failed in the first patient due to impending shock, vasospasm of the uterine artery and DIC. Eventually, an emergent hysterectomy was performed in this patient. Preoperative insertion of a 5 French right femoral arterial angiosheath was done in the second patient. It was easier to perform intraoperative TAE and the blood loss was much less. In our case, insertion of a right femoral arterial sheath before cesarean section with subsequent UAE after fetal delivery is an effective method to control the post-partum hemorrhage due to placenta previa accreta. It may reduce blood loss, preserve ovary function and the patient’s uterus for further fertility.

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