Aloui Haithem, Azouz Eya, Frikha Hatem, Binous Mohamed Mehdi, Hammami Rami, Abouda Saber Hassine
Tunis Faculty of Medicine El Manar University, Gynecology and Obstetrics Department C at the Tunis Maternity and Neonatology Center, Tunisia.
Tunis Faculty of Medicine El Manar University, Radiology Department La Rabta Hospital of Tunis, Tunisia.
Int J Surg Case Rep. 2024 Oct;123:110202. doi: 10.1016/j.ijscr.2024.110202. Epub 2024 Aug 20.
The increasing incidence of obstetric complications, such as post-partum hemorrhage in the case of placenta accreta spectrum, calls for innovative and adapted therapeutic approaches. This presentation highlights the effectiveness of arterial embolization of the hypogastric artery, properly known as the internal iliac artery, in managing obstetric bleeding, even after initial surgical ligation. An approach never described in the literature.
1st Case: A 38-year-old patient, in her fourth pregnancy with two previous caesarean sections, was admitted for moderate metrorrhagia at 19 weeks gestation. Ultrasound showed a monofetal pregnancy at 17 WG with a 6 cm placental abruption and an anterior placenta with accretion signs. An emergency subtotal hysterectomy with triple Tsirulsikov arterial ligation was performed after transfusion. Due to persistent bleeding, bilateral hypogastric artery ligation and abdominal packing were added, but without improvement. The patient was referred for embolization after hemodynamic stabilization. The procedure was carried out successfully and no complications were reported. 2nd Case: A 35-year-old patient with vaginal bleeding from placenta accreta at 25 WG required hemostasis hysterectomy. Despite the procedure, bleeding continued, leading to bilateral hypogastric artery ligation and pelvic packing. The patient was hemodynamically stabilized and transferred for hypogastric artery ligation, which was successfully performed without complication.
The role of interventional radiology in managing postpartum hemorrhage (PPH) is well established, with substantial literature supporting the benefits of uterine artery embolization as a lifesaving and often uterine-sparing procedure in PPH. While its indication for prevention is well-known, what about post-operatively? Our experience indicates that consulting a radiologist specializing in pelvic embolization can yield satisfactory outcomes despite technical difficulties.
Embolization of the hypogastric arteries as well as embolization followed by surgical ligation of these arteries have been well described in the literature, the originality in our case reports is the embolization performed after surgical ligation which has not been described before according to our knowledge and which despite its technical difficulty can be a satisfactory alternative for the control of post-partum hemorrhage.
产科并发症的发生率不断上升，例如胎盘植入谱系疾病中的产后出血，这就需要创新且适用的治疗方法。本报告强调了对腹下动脉（即髂内动脉）进行动脉栓塞在处理产科出血方面的有效性，即便在初次手术结扎后依然有效。这是一种文献中从未描述过的方法。
首例病例：一名38岁患者，第四次怀孕，此前有两次剖宫产史，因妊娠19周时出现中度子宫出血入院。超声检查显示单胎妊娠，孕周17周，胎盘早剥6厘米，胎盘前置且有植入迹象。输血后进行了紧急次全子宫切除术并实施了三次齐鲁尔西科夫动脉结扎。由于持续出血，又进行了双侧腹下动脉结扎和腹部填塞，但出血情况仍未改善。患者在血流动力学稳定后接受了栓塞治疗。手术成功实施，未报告并发症。第二例病例：一名35岁患者，妊娠25周时因胎盘植入出现阴道出血，需要进行止血性子宫切除术。尽管进行了手术，但出血仍在继续，于是进行了双侧腹下动脉结扎和盆腔填塞。患者血流动力学稳定后转院接受腹下动脉结扎，手术成功实施，未出现并发症。
介入放射学在处理产后出血（PPH）中的作用已得到充分确立，大量文献支持子宫动脉栓塞作为PPH中一种挽救生命且通常能保留子宫的手术的益处。虽然其预防指征广为人知，但术后情况如何呢？我们的经验表明，尽管存在技术困难，但咨询一位专门从事盆腔栓塞的放射科医生可取得令人满意的结果。
文献中已对腹下动脉栓塞以及先进行这些动脉的栓塞再进行手术结扎进行了充分描述，我们病例报告的独特之处在于在手术结扎后进行栓塞，据我们所知此前尚未有过相关描述，尽管存在技术困难，但这对于控制产后出血可能是一种令人满意的替代方法。
