子宫动脉栓塞术在宫颈妊娠治疗中的临床应用研究
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摘要
目的:探讨子宫动脉栓塞术(UAE)在治疗宫颈妊娠中的临床应用疗效、副反应及并发症并和其它方法进行对比。
方法:收集 2000 年以来我院 8 例在刮宫前行子宫动脉栓塞术(UAE)的宫颈妊娠病人。其中 2 例为刮宫时大出血,急行 UAE;6 例为宫颈妊娠刮宫前预防性子宫动脉栓塞术。8 例患者年龄 22～35 岁,平均 27.63 岁。UAE方法:局麻下,用 Seldinger’s 技术进行右侧股动脉穿刺,进行超选择性左侧子宫动脉插管,插管成功后首先行子宫动脉数字减影血管造影(DSA),明确出血部位及妊囊。经导管灌注半量的药物甲氨蝶呤(MTX),用新鲜明胶海绵颗粒或明胶海绵条和半量甲氨蝶呤(MTX)的混合物栓塞子宫动脉。用导管成襻技术行右侧子宫动脉超选择性插管,必要时运用微导管技术。栓塞后 1 周,复查 β-HCG,然后行刮宫术。收集 1996 年 2 月～2004 年 10 月我院未应用子宫动脉栓塞术治疗(包括刮宫术、宫颈局部注射甲氨蝶呤、药流或几种方法联合)的宫颈妊娠患者 10 例,年龄 23～40 岁,平均 31 岁。其中 6 例行宫颈局部注射甲氨蝶呤(MTX)或和其他方法联合治疗。然后进行应用 UAE 和未用 UAE 治疗方法疗效的对比。研究指标:①治疗前后患者阴道出血量。②治疗前后血清β-hCG 的变化。③用彩色多普勒观察④观察子宫动脉栓塞术的副反应和并发症。⑤随访月经恢复时间、是否怀孕。
结果:①双侧子宫动脉超选择插管及栓塞成功率均为100 %,达到彻底的止血效果。②子宫动脉栓塞术后1周血清β-HCG降低(P<0.01),妊囊体积未见明显缩小(P>0.05),彩色多普勒示妊囊局部的血流栓塞后1周较栓塞前明显减少(P<0.01)。③宫颈局部注射甲氨蝶呤后1周、2周较治疗前妊囊体积明显缩小(P<0.01)、血清β-HCG值治疗后1周和2周下降(P<0.01),妊囊局部的血流信号未见明显减少。④UAE 的副反应包括不同程度的栓塞后综合征(100 %) ,尿频、尿急、尿痛(0 %) 和阴道少量血性分泌物
Objective To investigate the clinical effect and adverse reactions and complications of the uterine artery embolization(UAE) in the treatment of cervical pregnany while compared the effects with the others.
Methods 8 women with clinical and ultrasonic diagnosis of cervical pregnancy was treated by selective uterine artery embolization before artifical abortion. UAE has been performed in 2 cases for the emergency control of pelvic hemorrhage, after failure of artifical abortion. Prophylactic UAE has been performed in 6 cases. Eight patients,age ranging from 22 to 35 years,underwent UAE. The procedure was performed with seldinger’s technique through the right common femoral artery access under local anaesthesia with 1 percent lidocaine. First, the left uterine artery were selectively catheterized .The left uterine artery and the gestational Sac was clearly show by digital subtraction angiograph(DSA).Subsequently, intraarterial infusion(half of methotrexate,MTX) was performed then embolization of the left uterine artery was performed with Gelfoam pledgets and half MTX remained. Similar procedures were then performed on the right uterine arteries. Microcatheter could be used necessarily during the procedure.1 week after the embolization ,all cases underwent artifical abortion. From February 1999 to October 2004,10 patients with cervical pregnancy, age ranging from 23 to 40 years, were treated by non-UAE. They were treated by intraamniotic methotrexate injection, artifical abortion , medication or a combined therapy. In 6 of the 8 cases were treated by intraamniotic methotrexate injection or by the treatment combined with other treatments. We made a comparison between UAE and non-UAE. We researched on: ①The volume of vaginal bleeding of pre-and-posttreatment. ②β-hCG serum level. ③The parameter of color Doppler ultrasound.④The adverse
reactions and complication of UAE for cervical pregnancy. ⑤ After embolization , the time of return of normal menses; subsequent pregnancies. Results ①The successful rate of catheterization and embolization reached 100%.The hemorrhage was controlled effectively by UAE. ②1 week after UAE, quantitative serumβ-hCG declined significantly compared with those before UAE(P<0.01), and the size of the sacs didn’t decreased statistically significant compared with those before operation(P>0.05).1 week After UAE , the blood perfusion of the sacs reduced significantly , even disappeared(P<0.01). ③The size of the sacs in 1,2 week after local MTX injection shrunk significantly compared with those before operation(P<0.01) . 1,2 week after UAE, quantitative serum-hCG declined significantly compared with those before operation(P<0.01). 1 ,2 week after local MTX injection , the blood perfusion of the sacs didn’t changed significantly(P>0.05). ④Adverse reactions of UAE included postembolization syndrome ( n = 8) ; urinary irritation ( n = 0); and hyporrhea of vagina ( n = 1). Complications of UAE included expelling of cruors per vagina ( n = 1) ; urinary retention ( n = 1). All the above mentioned side effects of UAE recovered to normal after expectant or especial treatment without any sequels left. ⑤After embolization , menses came back mostly within 1-2 months.One year after embolization, l patient who become pregnant and successfully gave birth to a girl at 38 weeks’ gestation.She was one year old and healthy so far. Conclusion ①Effective control of severe cervical pregnancy hemorrhage was obtained with UAE in time. Prophylactic UAE could lower risk and complicalion during artifical abortion .②The adverse reactions of UAE are reversible and the complications of UAE are preventable and curable.③Local MTX injection could restrained embryo from developing, but effective control of cervical pregnancy hemorrhage wasn’t obtained.
方法:收集 2000 年以来我院 8 例在刮宫前行子宫动脉栓塞术(UAE)的宫颈妊娠病人。其中 2 例为刮宫时大出血,急行 UAE;6 例为宫颈妊娠刮宫前预防性子宫动脉栓塞术。8 例患者年龄 22～35 岁,平均 27.63 岁。UAE方法:局麻下,用 Seldinger’s 技术进行右侧股动脉穿刺,进行超选择性左侧子宫动脉插管,插管成功后首先行子宫动脉数字减影血管造影(DSA),明确出血部位及妊囊。经导管灌注半量的药物甲氨蝶呤(MTX),用新鲜明胶海绵颗粒或明胶海绵条和半量甲氨蝶呤(MTX)的混合物栓塞子宫动脉。用导管成襻技术行右侧子宫动脉超选择性插管,必要时运用微导管技术。栓塞后 1 周,复查 β-HCG,然后行刮宫术。收集 1996 年 2 月～2004 年 10 月我院未应用子宫动脉栓塞术治疗(包括刮宫术、宫颈局部注射甲氨蝶呤、药流或几种方法联合)的宫颈妊娠患者 10 例,年龄 23～40 岁,平均 31 岁。其中 6 例行宫颈局部注射甲氨蝶呤(MTX)或和其他方法联合治疗。然后进行应用 UAE 和未用 UAE 治疗方法疗效的对比。研究指标:①治疗前后患者阴道出血量。②治疗前后血清β-hCG 的变化。③用彩色多普勒观察④观察子宫动脉栓塞术的副反应和并发症。⑤随访月经恢复时间、是否怀孕。
结果:①双侧子宫动脉超选择插管及栓塞成功率均为100 %,达到彻底的止血效果。②子宫动脉栓塞术后1周血清β-HCG降低(P<0.01),妊囊体积未见明显缩小(P>0.05),彩色多普勒示妊囊局部的血流栓塞后1周较栓塞前明显减少(P<0.01)。③宫颈局部注射甲氨蝶呤后1周、2周较治疗前妊囊体积明显缩小(P<0.01)、血清β-HCG值治疗后1周和2周下降(P<0.01),妊囊局部的血流信号未见明显减少。④UAE 的副反应包括不同程度的栓塞后综合征(100 %) ,尿频、尿急、尿痛(0 %) 和阴道少量血性分泌物
Objective To investigate the clinical effect and adverse reactions and complications of the uterine artery embolization(UAE) in the treatment of cervical pregnany while compared the effects with the others.
Methods 8 women with clinical and ultrasonic diagnosis of cervical pregnancy was treated by selective uterine artery embolization before artifical abortion. UAE has been performed in 2 cases for the emergency control of pelvic hemorrhage, after failure of artifical abortion. Prophylactic UAE has been performed in 6 cases. Eight patients,age ranging from 22 to 35 years,underwent UAE. The procedure was performed with seldinger’s technique through the right common femoral artery access under local anaesthesia with 1 percent lidocaine. First, the left uterine artery were selectively catheterized .The left uterine artery and the gestational Sac was clearly show by digital subtraction angiograph(DSA).Subsequently, intraarterial infusion(half of methotrexate,MTX) was performed then embolization of the left uterine artery was performed with Gelfoam pledgets and half MTX remained. Similar procedures were then performed on the right uterine arteries. Microcatheter could be used necessarily during the procedure.1 week after the embolization ,all cases underwent artifical abortion. From February 1999 to October 2004,10 patients with cervical pregnancy, age ranging from 23 to 40 years, were treated by non-UAE. They were treated by intraamniotic methotrexate injection, artifical abortion , medication or a combined therapy. In 6 of the 8 cases were treated by intraamniotic methotrexate injection or by the treatment combined with other treatments. We made a comparison between UAE and non-UAE. We researched on: ①The volume of vaginal bleeding of pre-and-posttreatment. ②β-hCG serum level. ③The parameter of color Doppler ultrasound.④The adverse
reactions and complication of UAE for cervical pregnancy. ⑤ After embolization , the time of return of normal menses; subsequent pregnancies. Results ①The successful rate of catheterization and embolization reached 100%.The hemorrhage was controlled effectively by UAE. ②1 week after UAE, quantitative serumβ-hCG declined significantly compared with those before UAE(P<0.01), and the size of the sacs didn’t decreased statistically significant compared with those before operation(P>0.05).1 week After UAE , the blood perfusion of the sacs reduced significantly , even disappeared(P<0.01). ③The size of the sacs in 1,2 week after local MTX injection shrunk significantly compared with those before operation(P<0.01) . 1,2 week after UAE, quantitative serum-hCG declined significantly compared with those before operation(P<0.01). 1 ,2 week after local MTX injection , the blood perfusion of the sacs didn’t changed significantly(P>0.05). ④Adverse reactions of UAE included postembolization syndrome ( n = 8) ; urinary irritation ( n = 0); and hyporrhea of vagina ( n = 1). Complications of UAE included expelling of cruors per vagina ( n = 1) ; urinary retention ( n = 1). All the above mentioned side effects of UAE recovered to normal after expectant or especial treatment without any sequels left. ⑤After embolization , menses came back mostly within 1-2 months.One year after embolization, l patient who become pregnant and successfully gave birth to a girl at 38 weeks’ gestation.She was one year old and healthy so far. Conclusion ①Effective control of severe cervical pregnancy hemorrhage was obtained with UAE in time. Prophylactic UAE could lower risk and complicalion during artifical abortion .②The adverse reactions of UAE are reversible and the complications of UAE are preventable and curable.③Local MTX injection could restrained embryo from developing, but effective control of cervical pregnancy hemorrhage wasn’t obtained.
引文
1 Hung TH ,Jeng CJ ,Yang YC ,et al. Treatment of cervical pregnancy with methotrexate[J] . Int J Gynaecol Obstet ,1996 ,53 :243.
2 Honey L ,Leader A ,Claman P,et al.Human artery embolization—a successful treatment to control bleeding cervical pregnancy with a simultaneous intrauterine gestation[J] . Human Reproduction ,1999 ,14 :1553.
3 Marston LM,Dotters DJ,Katz VL,et al.Methotrexate and angiographic embolization for conservative treatment of cervical pregnancy. South Med J , 1996 ,89 :246-248.
4 Hansch, Ernst MD; Chitkara, Usha MD; McAlpine, Jessica MD; et al. Pelvic arterial embolization for control of obstetric hemorrhage: A five-year experience.America J of Obstetrics and Gynecology,1999,180(6):1454-1460.
5 Vashisht A,Smith JR,Thorpe-Beeston G,McCall.Pregnancy subsequent to uterine artery embolization.Fertil Steril 2001;75:1246-8.
6 Ravina JH,Ciraru-Vigneron N,Aymard A,Le Dref 0,Merland JJ.Pregnancy after embolization of uterine myoma:Report of 12 cases.Fertil Steril 2000;73:1241-3.
7 Pelage JP , Dref OL, Mateol J, et al. Lift-threatening primary postpartum hemorrhage:treatment with emergency selective arterial embolization. Radiology,1998,208:359-362.
8 Eun-Hwan J,Yong-Beom K,Ill-Woon J,et al. Triplet Cervical Pregnancy Treated With Intraamniotic Methotrexate. Obstet Gynecol 2002;100:1117–9.
9. Fu-Tsai K, Shiuh-Young C. Efficacy of methotrexate treatment in viable and nonviable cervical pregnancies. Am of Obstet Gynecol 1999:181(6):1438-1444.
10 Kung FT, Chang SY, Tsai YC, Hwang FR, Hsu TY, Soong YK. Subsequent reproduction and obstetric outcome after methotrexate treatment of cervical pregnancy: a review of original literature and international collaborative follow-up. Hum Reprod 1997;12:591-5.
11. Benson CB, Doubilet PM. Strategies for conservative treatment of cervical ectopic pregnancy. Ultrasound Obstet Gynecol 1996;8:371-2.
12 Bradley EA , Reidy JF , Forman RG, et al . Transcatheter uterine artery embolization to treat large uterine fibroids. Br J Obstet Gynaecol , 1998 , 105 :235-240.
13 Sherer DM,Abramowicz JS,Thompson HO,et al.Comparison of transabdominal and endovaginal sonographic approaches in the diagnosis of a case of cervical pregnancy successful treated with mathotrexate.J Ultrasound Med,1991,10:409-411.
14. Rosenberg RD,Williamson MR.Cervical ectopic pregnancy : avoiding pitfalls in the ultrasonographic diagnosis. J Ultrasound Med,1992 ,11 :365-367.
15 Goodwin SC , Wong GC. Uterine artery embolization for uterine fibroids :a radiologist′s perspective ( Review) . Clin Obstet Gynecol , 2001 ,44 :412-424.
16 李彦豪,刘彪,曾庆乐,等. 平阳霉素碘油乳剂子宫动脉栓塞治疗症状性子宫肌瘤. 中华放射学杂志,2000 ,34 :827-830.
17 陈晓明,杜娟,左约维,等. 子宫肌瘤导管栓塞治疗的临床与病理研究. 中华放射学杂志,2001 ,35 :595-599.
18 陈君辉,胡大武,段天红,等. 子宫肌瘤介入治疗临床疗效观察(附21 例报告) . 中华放射学杂志,2001 ,35 :334-335.
19 Andersen PE , Lund N , Justesen P , et al . Uterine artery embolization of symptomatic uterine fibroids : initial success and short2term results. Acta Radiol , 2001 , 42 : 234-238.
20 Berkowitz RP , Hutchins FL Jr , Worthington-Kirsch RL. Vaginal expulsion of submucosal fibroids after uterine artery embolization : a report of three cases. J Reprod Med , 1999 ,44 :373-376.
21 Berkowitz RP , Hutchins FL Jr , Worthington-Kirsch RL. Vaginal expulsion of submucosal fibroids after uterine artery embolization : a report of three cases. J Reprod Med , 1999 ,44 :373-376.
22 Siskin GP , Englander M, Stainken BF , et al . Embolic agents for uterine fibroid embolization (Review) . AJR , 2000 , 175 :767-773.
23 Stancato-Pasik A , Mitty HA , Richard HM, et al . Obstetric embolotherapy : effect on menses and pregnancy. Radiology , 1997 ,204 :791-793.
24 Worthington-Kirsch RL , Popky GL , Hutchins FL Jr. Uterine arterial embolizaition for the management of leiomyomas : quality of life assessment and clinical response. Radiology , 1998 ,208 :625-629.
25 Chrisman HB , Saker MB , Ryu RK, et al . The impact of uterine fibroid embolizaition on resumption of menses and ovarian function. J Vasc Interv Radiol , 2000 , 11 : 699-703.
26 .Goldberg J,Pereira L,Berghella V. Pregnancy After Uterine Artery Embolization. Obstet Gynecol 2002;100:8 69–72.
2 Honey L ,Leader A ,Claman P,et al.Human artery embolization—a successful treatment to control bleeding cervical pregnancy with a simultaneous intrauterine gestation[J] . Human Reproduction ,1999 ,14 :1553.
3 Marston LM,Dotters DJ,Katz VL,et al.Methotrexate and angiographic embolization for conservative treatment of cervical pregnancy. South Med J , 1996 ,89 :246-248.
4 Hansch, Ernst MD; Chitkara, Usha MD; McAlpine, Jessica MD; et al. Pelvic arterial embolization for control of obstetric hemorrhage: A five-year experience.America J of Obstetrics and Gynecology,1999,180(6):1454-1460.
5 Vashisht A,Smith JR,Thorpe-Beeston G,McCall.Pregnancy subsequent to uterine artery embolization.Fertil Steril 2001;75:1246-8.
6 Ravina JH,Ciraru-Vigneron N,Aymard A,Le Dref 0,Merland JJ.Pregnancy after embolization of uterine myoma:Report of 12 cases.Fertil Steril 2000;73:1241-3.
7 Pelage JP , Dref OL, Mateol J, et al. Lift-threatening primary postpartum hemorrhage:treatment with emergency selective arterial embolization. Radiology,1998,208:359-362.
8 Eun-Hwan J,Yong-Beom K,Ill-Woon J,et al. Triplet Cervical Pregnancy Treated With Intraamniotic Methotrexate. Obstet Gynecol 2002;100:1117–9.
9. Fu-Tsai K, Shiuh-Young C. Efficacy of methotrexate treatment in viable and nonviable cervical pregnancies. Am of Obstet Gynecol 1999:181(6):1438-1444.
10 Kung FT, Chang SY, Tsai YC, Hwang FR, Hsu TY, Soong YK. Subsequent reproduction and obstetric outcome after methotrexate treatment of cervical pregnancy: a review of original literature and international collaborative follow-up. Hum Reprod 1997;12:591-5.
11. Benson CB, Doubilet PM. Strategies for conservative treatment of cervical ectopic pregnancy. Ultrasound Obstet Gynecol 1996;8:371-2.
12 Bradley EA , Reidy JF , Forman RG, et al . Transcatheter uterine artery embolization to treat large uterine fibroids. Br J Obstet Gynaecol , 1998 , 105 :235-240.
13 Sherer DM,Abramowicz JS,Thompson HO,et al.Comparison of transabdominal and endovaginal sonographic approaches in the diagnosis of a case of cervical pregnancy successful treated with mathotrexate.J Ultrasound Med,1991,10:409-411.
14. Rosenberg RD,Williamson MR.Cervical ectopic pregnancy : avoiding pitfalls in the ultrasonographic diagnosis. J Ultrasound Med,1992 ,11 :365-367.
15 Goodwin SC , Wong GC. Uterine artery embolization for uterine fibroids :a radiologist′s perspective ( Review) . Clin Obstet Gynecol , 2001 ,44 :412-424.
16 李彦豪,刘彪,曾庆乐,等. 平阳霉素碘油乳剂子宫动脉栓塞治疗症状性子宫肌瘤. 中华放射学杂志,2000 ,34 :827-830.
17 陈晓明,杜娟,左约维,等. 子宫肌瘤导管栓塞治疗的临床与病理研究. 中华放射学杂志,2001 ,35 :595-599.
18 陈君辉,胡大武,段天红,等. 子宫肌瘤介入治疗临床疗效观察(附21 例报告) . 中华放射学杂志,2001 ,35 :334-335.
19 Andersen PE , Lund N , Justesen P , et al . Uterine artery embolization of symptomatic uterine fibroids : initial success and short2term results. Acta Radiol , 2001 , 42 : 234-238.
20 Berkowitz RP , Hutchins FL Jr , Worthington-Kirsch RL. Vaginal expulsion of submucosal fibroids after uterine artery embolization : a report of three cases. J Reprod Med , 1999 ,44 :373-376.
21 Berkowitz RP , Hutchins FL Jr , Worthington-Kirsch RL. Vaginal expulsion of submucosal fibroids after uterine artery embolization : a report of three cases. J Reprod Med , 1999 ,44 :373-376.
22 Siskin GP , Englander M, Stainken BF , et al . Embolic agents for uterine fibroid embolization (Review) . AJR , 2000 , 175 :767-773.
23 Stancato-Pasik A , Mitty HA , Richard HM, et al . Obstetric embolotherapy : effect on menses and pregnancy. Radiology , 1997 ,204 :791-793.
24 Worthington-Kirsch RL , Popky GL , Hutchins FL Jr. Uterine arterial embolizaition for the management of leiomyomas : quality of life assessment and clinical response. Radiology , 1998 ,208 :625-629.
25 Chrisman HB , Saker MB , Ryu RK, et al . The impact of uterine fibroid embolizaition on resumption of menses and ovarian function. J Vasc Interv Radiol , 2000 , 11 : 699-703.
26 .Goldberg J,Pereira L,Berghella V. Pregnancy After Uterine Artery Embolization. Obstet Gynecol 2002;100:8 69–72.