Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan.
Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University, Kyoto, Japan.
J Matern Fetal Neonatal Med. 2020 Oct;33(19):3286-3292. doi: 10.1080/14767058.2019.1571033. Epub 2019 Jan 31.
Uterine atony is the leading cause of severe postpartum hemorrhage (PPH); however, the underlying cause of intractable atonic PPH unresponsive to conventional treatments (such as uterotonics and intrauterine balloon tamponade) remains unclear. The aim of this study was to investigate whether intractable atonic PPH is associated with the type of bleeding (arterial or nonarterial) and its location, along with variations in the size and shape of the uterine cavity after delivery. This retrospective study included women who had undergone a dynamic computed tomography (CT) scan for the management of severe PPH at Kyoto University Hospital between April 2011 and March 2017. Patients' electronic medical records were reviewed, and relevant clinical information was collected. The presence of contrast extravasation (CE) on CT images in the early phase (40 s) was regarded as active arterial bleeding. Bleeding sites and size of the uterine cavity were evaluated using an coordinate system. The size of the uterine cavity was compared between groups with CE into the upper and lower parts of the uterine body. Of the 60 women assessed for eligibility, 30 were included in the current analysis. Contrast extravasation was detected in 19 women, with 14 showing CE in the early phase. The presence of CE in the early phase was significantly associated with the need for transarterial embolization (Fisher's exact test, = .0017). The upper and lower parts of the uterine cavity were 97.4 ± 2.7 mm (mean ± standard error of the mean) and 87.2 ± 3.5 mm in length, respectively. The maximum anteroposterior diameters of the upper and lower parts of the uterine cavity were 23.1 ± 2.6 and 76.0 ± 3.0 mm, respectively, and the largest transverse diameters were 67.3 ± 1.9 and 81.1 ± 2.3 mm, respectively. The group that showed CE into the upper uterine cavity had significantly larger qualitative parameters of the upper uterine cavity compared to the group with CE into the lower uterine cavity. The gate from the lower uterine cavity toward the upper uterine cavity was narrow (anteroposterior diameter of 22.6 ± 2.0 mm, transverse diameter of 40.7 ± 3.3 mm), and the intrauterine balloon was always found in the lower uterine cavity on the CT scan. The upper uterine body was characterized by a flat oval-shaped cavity ( plane), thick uterine wall, and lack of uniformity among bleeding sites ( = 62.4 ± 14.8 mm). In contrast, the lower uterine cavity was a circular shape ( plane) with thin walls, and bleeding sites were located at lateral sides around the level of the internal os ( = -18.8 ± 4.9 mm). Atonic PPH has a significant subtype, named "PRACE," which is characterized by PPH, resistance to treatment, and arterial CE. The need for embolization can be predicted by the presence of arterial bleeding and its location, along with the shape of the uterine cavity.
宫缩乏力是产后大出血（PPH）的主要原因；然而，对于常规治疗（如宫缩剂和宫腔内球囊填塞）无效的顽固性宫缩乏力性 PPH 的根本原因仍不清楚。本研究旨在探讨难治性宫缩乏力性 PPH 是否与出血类型（动脉或非动脉）及其部位以及产后子宫腔大小和形状的变化有关。这项回顾性研究纳入了 2011 年 4 月至 2017 年 3 月期间在京都大学医院因严重 PPH 接受动态 CT 扫描治疗的患者。回顾了患者的电子病历，并收集了相关的临床信息。在 CT 图像的早期（40 秒）观察到造影剂外渗（CE）被认为是活跃的动脉出血。使用坐标系评估出血部位和子宫腔大小。比较 CE 进入子宫体上下部分的子宫腔大小。在 60 名符合条件的患者中，有 30 名被纳入本研究。在 19 名女性中检测到 CE，其中 14 名女性在早期出现 CE。早期出现 CE 与需要经动脉栓塞治疗有显著相关性（Fisher 确切检验，= 0.0017）。子宫腔上下部分的长度分别为 97.4 ± 2.7 mm（平均值 ± 标准误差）和 87.2 ± 3.5 mm。子宫腔上下部分的最大前后直径分别为 23.1 ± 2.6 mm 和 76.0 ± 3.0 mm，最大横径分别为 67.3 ± 1.9 mm 和 81.1 ± 2.3 mm。CE 进入子宫上部的组与 CE 进入子宫下部的组相比，子宫上部的定性参数明显更大。从子宫下部到上部的门很窄（前后直径 22.6 ± 2.0 mm，横径 40.7 ± 3.3 mm），并且 CT 扫描上始终在子宫下部发现宫内球囊。子宫上部的特征是呈扁平椭圆形腔（平面），子宫壁较厚，出血部位不均匀（= 62.4 ± 14.8 mm）。相比之下，子宫下部呈圆形（平面），子宫壁较薄，出血部位位于水平内部口周围的侧面（= -18.8 ± 4.9 mm）。宫缩乏力性 PPH 存在一种显著的亚型，称为“PRACE”，其特征为 PPH、治疗抵抗和动脉 CE。栓塞的需要可以通过动脉出血的存在及其位置以及子宫腔的形状来预测。
