Analysis Of Extremely Simple Low Uterine Vascular Ligation In Pernicious Placenta Previa Cesarean Section

Objective:To overcome the difficult of ligating the downstream branch of uterine artery inPernicious Placenta Previa(PPP)cesarean section.To introduce the extremely simplelow uterine vascular ligation in PPP cesarean section,and evaluate the effectiveness of the operation,safety and clinical value,so as to provide help for hemostasis in PPP cesarean section.Methods:This was a retrospective analysis of prospectively collected data of 43 patients who were underwent uterine vascular ligationand 10 patients with PPP without uterine vascular ligationduring PPP cesarean section at the Affiliated Hospital of North Sichuan Medical Collegebetween December 2017 to September 2020.The clinical date such as basic information,ultrasonic scoring,intraoperative blood loss,intraoperative blood transfusion,hysterectomy rate,operation time,accessory injury,ICU transfer rate,other surgical methods.Magnetic Resonance Imaging(MRI)was used to examine the difference of MRI signal intensity in uterine body and lower uterine segment 5 days after cesarean section in 7 patients with unilateral uterine vascular ligation to detect whether the uterine smooth muscle cells are necrotic.3～6 months after cesarean sectionComputedTomography Angiography(CTA)was used to evaluate the uterine vascular recanalization in 12 patients.3～6 months after menstruation 10 cases of uterine vascular ligationand 10 cases without uterine vascular ligation,the endometrial blood supply endometrial volume,vascularization index(VI),flow index(FI),vascularizationflowindex(VFI)werescreened by ultrasound.Information on menstruation recovery was followed by telephone.Results:1.The average ultrasonic scoring of placenta previa was 8.51±2.56.69 uterine vessels were ligationed during cesarean section(17 patients were treated with unilateral uterine vascular ligation,26 patients were treated with bilateral uterine vascular ligation).1 case(2.3%)underwent subtotal hysterectomy,17 patients(39.5%)had intraoperative bleeding<1L,and 16 patients(37.2%)had intraoperative bleeding of 1～1.5L,10 patients(23.3%)had intraoperative bleeding≥ 1.5L.The intraoperative blood loss was 1(0.8,1.4)L,the intraoperative blood transfusion rate was 86%(37/43),the intraoperative blood transfusion was 2(2,3.95)U,the intraoperative blood transfusion range was 0～14 U,the average total operation time was 126.8±40.4min.No patient had the bladder,ureter,ovary and vagina damage,no patient was admitted to ICU or died.The average postoperative corrected hemoglobin was 99±13.8g/L.Nopatients underwent unscheduled reoperation due to late postpartum bleeding.2.MRI examination showed that there was no significant difference in MRI signal intensity between ligationd and unligationd sides of uterine body and lower segment of uterus.3.CTA examination showed that7 patients had complete recanalization of uterine vessels,5patients had partial recanalization of uterine vessels,the complete recanalization rate was 52.6%(10/19),and the partial recanalization rate was 47.4%(9/19).4.The endometrial volume,VI,FI and VFI had no significant difference between patients with uterine vascular ligationand patients without uterine vascular ligation.5.After cesarean section,the average time of menstrual recovery was 5.6±3.5 months,menstrual blood volume changed in 7 cases(16.7%),abnormal menstrual cycle in 3 cases(7.1%),and 1 case of pregnancy.Conclusion:1.Theextremely simple uterine vascular ligation does not need to separate the vascular tissue around the downstream branch of the uterine artery and the ureter.It can be completed in 3 to 5 minutes.Unilateral or bilateral uterine vascular ligation can be choiced,which basically does not increase the total operation time,and can safely,effectively and quickly reduce the bleeding and the hysterectomy rate of PPP cesarean section,and prevent unplanned reoperation caused by postpartum hemorrhage.2.MRI examinationshow that the uterine smooth muscle cells in the body and lower segment of the uterus have no ischemia and necrosis and have no effect on uterine contraction after extremely simple low uterine vascular ligation.3.CTA examination show that the uterine vessels after cesarean section can recanalize in a short time,perhaps due to the abundant collateral circulation in the pelvic cavity and the recanalization of uterine blood vessels with the absorption of the old uterine sutures after cesarean section.The specific mechanism remains to be further studied.4.The endometrial volume,VI,FI and VFI of the patients with uterine vascular ligation were measured by ultrasound,which suggests that the operation may have no significant effect on the blood supply of endometrium.The follow-up of recurrent menstruation suggests that uterine vascular ligation may have no significant effect on ovarian function.