GTN化疗后子宫动静脉瘘11例临床分析并文献复习

发布时间：2018-06-10 19:01

本文选题：妊娠滋养细胞肿瘤 + 动静脉瘘　；参考：《山东大学》2017年硕士论文

【摘要】：研究目的总结分析妊娠滋养细胞肿瘤(Gestational Trophoblastic Neoplasms,GTN)患者化疗后发生子宫动静脉瘘(Arteriovenousfistula,AVF)的临床特点、诊治方法及治疗结局,为临床治疗决策提供更多的依据。研究方法收集2006年1月至2016年12月山东大学齐鲁医院妇科住院病例资料,诊断为GTN化疗后子宫动静脉瘘共11例。总结分析所有患者的临床资料及诊治情况,随访其月经恢复、妊娠及分娩结局。研究结果1、临床特点:本组患者发病年龄在24-50岁,平均年龄为37.2岁,其中6例(55%)有生育要求。5例(45%)患者因化疗后无明显诱因的"开关式"突发性阴道大出血就诊;4例(36%)无明显临床症状;2例(19%)为化疗后持续性阴道少量出血。本组患者从接受化疗至诊断子宫动静脉瘘的间期时间范围较大(2天-13年),其中8例(73%)在接受化疗第一个疗程即因突发性阴道大量出血或典型影像学表现,诊断为子宫动静脉瘘。其中血hCG-β呈高水平的患者共9例(81.8%)。2、影像学特点:本组患者中6例(55%)患者有典型超声表现:子宫壁回声不均质,可见迂曲管状暗区,CDFI内探及丰富血流信号,呈五彩状,可探及动静脉瘘样频谱;5例(45%)示探及子宫壁不均质回声,其内探及丰富血流信号,呈高速低阻型。2例患者的MRI检查示子宫壁及周围见弥漫性条状迂曲扩张流空血管影,可见异常粗大血管影。3、治疗方法:本组中4例患者因突发性阴道大出血行急症子宫动脉栓塞术,术后阴道出血均有效控制,且无远期出血。6例行子宫切除术的患者,其中5例因无生育要求选择手术;1例因突发性阴道大出血,2次行子宫动脉栓塞术仍无法控制出血,行急症子宫切除术。1例因诊断子宫动静脉瘘时合并早孕,患者有生育要求,密切随访观察至足月妊娠。4、治疗结局:4例行子宫动脉栓塞术成功的患者中,1例于术后2年余再次成功妊娠分娩;2例无生育要求;1例化疗仍在进行中。6例行子宫切除术的患者,术后阴道出血均得到有效控制,且无远期阴道出血。因合并早孕未处理的1例患者于妊娠39周+4天在我院行剖宫产顺利分娩。结论1、GTN本身及化疗后子宫动静脉瘘均可导致阴道大出血,临床医师应提高对子宫动静脉瘘的认识。对于急症阴道大出血的患者可行急症子宫动脉造影术,既可明确诊断,又能及时治疗控制阴道大出血,为进一步治疗赢得时间。2、对于有生育要求的患者,首选治疗方式为子宫动脉栓塞术(uterine arterial embolization,UAE);但若栓塞后无法控制阴道流血,应及时、果断行子宫切除术,以挽救患者的生命。3、GTN化疗后子宫动静脉瘘的形成可能的高危因素为病灶位于子宫下段、高水平hCG-β及前次妊娠为葡萄胎。
[Abstract]:Objective to summarize and analyze the clinical characteristics, diagnosis and treatment methods and treatment outcome of Arteriovenous Fistula (AVFF) in patients with gestational trophoblastic Neoplasm tumor (GTNN) after chemotherapy. Methods from January 2006 to December 2016, 11 cases of uterine arteriovenous fistula diagnosed by GTN chemotherapy were collected from Qilu Hospital of Shandong University. The clinical data, diagnosis and treatment of all patients were analyzed, and their menstrual recovery, pregnancy and delivery outcomes were followed up. Results 1. Clinical features: the onset age of the patients was 24-50 years old with an average age of 37.2 years. Among them, 6 cases with reproductive requirement (5 cases with reproductive requirement, 45 cases) were treated with "switch" sudden vaginal hemorrhage without obvious inducement after chemotherapy. 4 cases (36 cases) had no obvious clinical symptoms and 2 cases (19 cases) were sustained vaginal bleeding after chemotherapy. The interval between chemotherapy and diagnosis of arteriovenous fistula in this group was from 2 days to 13 years. In the first course of chemotherapy, 8 patients were diagnosed as uterine arteriovenous fistula due to sudden massive vaginal bleeding or typical imaging manifestations. Among them, there were 9 cases with high level of hCG- 尾. Imaging features: 6 cases had typical ultrasonographic features: uterine wall echo was uneven, and CDFI in tubular dark area was found to be rich in blood flow signal, which was colorful, and the results were as follows: (1) among them, there were 9 cases with high blood level of hCG- 尾. The imaging features were as follows: the uterine wall echo was uneven, and the blood flow signal was abundant in the tubular dark area (CDFI). 5 cases of arteriovenous fistula like spectrum can be detected. It shows uneven echo of uterine wall and abundant blood flow signal. MRI of 2 cases with high speed and low resistance type shows diffuse strip dilatation vascular shadow in uterine wall and surrounding. In this group, 4 patients underwent emergency uterine artery embolization because of sudden massive vaginal hemorrhage. The bleeding was effectively controlled after operation, and there was no long-term bleeding in 6 patients undergoing hysterectomy. Among them, 5 cases were selected because of no fertility requirement, 1 case was treated with uterine artery embolization because of sudden vaginal hemorrhage, and 1 case underwent emergency hysterectomy with early pregnancy because of diagnosis of arteriovenous fistula, and the patient had fertility requirement. Closely followed up until term pregnancy .4, one of the 4 successful uterine artery embolization patients who had been treated with the outcome of the treatment, one of them was pregnant and delivered again more than 2 years after operation, 2 cases had no fertility requirement and 1 case was still undergoing a hysterectomy under chemotherapy, and 1 case was still undergoing hysterectomy. Postoperative vaginal bleeding was effectively controlled and there was no long-term vaginal bleeding. A patient with untreated early pregnancy underwent caesarean section at 39 weeks and 4 days of gestation. Conclusion 1 GTN itself and the uterine arteriovenous fistula after chemotherapy can lead to massive vaginal hemorrhage. Clinicians should improve the understanding of uterine arteriovenous fistula. For patients with acute vaginal hemorrhage, emergency uterine arteriography is feasible. It can be clearly diagnosed and can be treated in time to control vaginal hemorrhage. It can win time for further treatment. The first choice of treatment was uterine artery embolization arterial embolization, but if vaginal bleeding could not be controlled after embolization, hysterectomy should be carried out promptly and decisively. The high risk factors for the formation of arteriovenous fistula after GTN chemotherapy were located in the lower uterine segment, and the high level of hCG- 尾 and the previous pregnancy were hydatidiform mole.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.33

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