Translated Abstract
Background：Postpartum hemorrhage is a serious complication in labor, it is a major cause of maternal morbidity and mortality. The incidence of it is 2% to 3% of the total deliveries. In recent years, with the improvement of medical technology and growing concern, the mortality has declined, but the cause of maternal death in our country is still headed by postpartum hemorrhage. Postpartum hemorrhage is often defined as the blood loss of more than 500 ml through the vaginal delivery or 1,000 ml through cesarean deliveries within the first 24 hours following childbirth;severe postpartum hemorrhage refers to the amount of bleeding≥1000ml within the first 24 hours following childbirth;intractable postpartum bleeding is defined as after contractions, sustained uterine massage or press and other conservative measures the bleeding can not been stopped, for severe postpartum hemorrhage, surgery、interventional treatment and even hysterectomy is needed. Applications of contractions, sustained pressing uterus, birth canal laceration suture, curettage surgery for many patients with postpartum hemorrhage is effective. If conservative treatment of postpartum hemorrhage is ineffective, usually surgery is needed, including: uterine packing, uterine suturing pressure, pelvic artery ligation, transcatheter arterial embolization, hysterectomy and so on. Uterine packing once had fewer used in clinical practice , because of intrauterine infection and occult bleeding problems.With the development of antibiotics, uterine packing is used frequently now in clinical. Clinical efficacy of pelvic artery ligation is not exact, especially for patients with multiple surgeries, severe pelvic adhesions is difficult to implement in a short time. Clinical efficacy of hysterectomy is exact, but fertility of patients is lost everlasting.Transcatheter arterial embolization includes internal iliac artery embolization and superselective uterine artery embolization.
Objective: The study was conducted to evaluate the clinical value of superselective uterine arterial embolization in the treatment of intractable postpartum hemorrhage compared with hysterectomy and uterine packing.
Methods: Clinical data of 107 patients with intractable postpartum hemorrhage hospitalized from June 2010 to June 2014 in the First affiliated hospital of Xi’an Jiaotong University and Shaanxi Province People’s Hospital were retrospectively analyzed.All patients were divided into three groups by different hemostasia ways, group A including 58 consecutive patients who underwent superselective uterine arterial embolization(SUAE); group B including 18 consecutive patients who were treated by hysterectomy including total hysterectomy and supercervical hysterectomy; group C including 31 consecutive patients those underwent uterine packing.The following items were investigated: the effective power of haemostasis、operating time、median postoperative hospital、postoperative complications and long-term impact.
Results:
1. The majority of intractable postpartum hemorrhage was caused by single factor, uterine atony of 53 cases (49.53%), 30 cases of placental factors(28.04%);14 cases of coagulation disorders (13.08%). In addition,cases caused by two causes accounted for 6.34%.
2. 56 cases in group A were performed successfully for the first time while one case was performed successfully for the second time and a conversion to hysterectomy was required in one case because of bleeding after SUAE,effective power of first haemostasis was 96.55% and effective power of total haemostasis was 98.28% in group A.
3. Effective power of total haemostasis,operation time,hemostatic time,blood loss during operation and ICU stay in group A caused by uterine atony,placenta accreta and DIC was similar (P＞0.05).Median postoperative hospital stay in group A caused by DIC was significantly shoter than uterine atony,placenta accreta (P＜0.05),and there was no statistically significant difference between uterine atony and placenta accreta(P＞0.05).
4. Effective power of total haemostasis was 98.28% in group A,which was 100.00% in group B and 64.52% in group C, comparison between three groups showned that superselective uterine arterial embolization and hysterectomy were more effective than uterine packing (P＜0.05),difference between superselective uterine arterial embolization and hysterectomy had not statistical significance(P＞0.05).
5. Operation time and median blood loss during operation in group A were (41.53±7.31)min,(250.00±82.71)ml respectively, those were (167.80±56.81)min,(847.62±279.95)ml respectively in group B, group A was significantly less than group B, the difference had statistical significance(P＜0.05).ICU stay in group A and group C was significantly shoter than group B (P＜0.05) ,and there was no statistically significant difference between group A and group C (P＞0.05).Postoperative hospital stay in group A was (6.26±2.64)d, it was (8.57±1.75)d、(5.51±1.72)d respectively in group B and group C. Postoperative hospital stay in group A was significantly shoter than group B(P＜0.05) ,and there was no statistically significant difference between group A and group C (P＞0.05).
6. Percentage of reservated uterus was 98.28% in group A,which was 100.00% in group B and100.00% in group C. Percentage of reservated uterus in group A and group C was significantly more than group B(P＜0.05) ,and there was no statistically significant difference between group A and group C (P＞0.05).
7.All patients in the three groups had no serious postoperative complications, and hemorrhagic shock ,anemia, fever, puerperal infection was no significant difference between groups(P＞0.05).
8.All 46 patients which were followed up in group A resumed normal menstruation in 2 to 6 months,moreover 5 women got re-pregnant and 3 of them successfully given birth to a child,besides,2 patients chose abortion. All 24 patients which were followed up in group C resumed normal menstruation in 2 to 6 months,moreover 1 woman got re-pregnant.
Conclusion:
1.Superselective uterine arterial embolization is effictive in intractable postpartum hemorrhage caused by uterine atony, placenta accreta and DIC which unincorporated other internal bleeding;
2.The clinical effect has not defference between superselective uterine arterial embolization and hysterectomy in the treatment of intractable postpartum hemorrhage and two treatment methods were effective,all better than uterine packing;
3.Compared to hysterectomy, transcatheter arterial embolization has many advantages including minimal trauma、less postoperative dysfunction、shorter hospital stay and uterus and its physiological function were reserved;
4.Superselective uterine arterial embolization is a new way to treat intractable postpartum hemorrhage,it deserves to spread and utilize in the conditioned hospital. But sometimes hysterectomy is still required. According to the situation, superselective uterine arterial embolization should be considered prior to hysterectomy.
KEY WORDS：Intractable postpartum hemorrhage; Superselective uterine arterial embolization;
Hysterectomy;Uterine packing;Clinical efficacy
TYPE OF THESIS：Applied Research
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