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1 Korean Journal of Obstetrics and Gynecology Vol. 53 No. 9 September 2010 산후출혈의치료를위한동맥색전술의실패와관련된인자의분석 고려대학교의과대학산부인과학교실 소경아 오윤경 황효순 홍혜리 조금준 오민정 허준용 Analysis of failed arterial embolization for postpartum hemorrhage Kyeong A So, M.D., Yoon Kyung Oh, M.D., Hyo Soon Hwang, M.D., Hye Ri Hong, M.D., Geum Joon Cho, M.D., Min Jeong Oh, M.D., Jun Yong Hur, M.D. Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea Objective: To investigate what factors are associated with a failed arterial embolization for postpartum hemorrhage (PPH) and to attempt to estimate efficacy of arterial embolization. Methods: Between 2004 and 2008, 60 patients at Korea University Medical Cencter underwent arterial embolization to control obstetrical hemorrhage. In all cases, arterial embolization was performed because of intractable hemorrhage unresponsive to conservative management. Medical records and angiographic results were reviewed. Arterial embolization failure was defined as the requirement for subsequent surgical procedure to control PPH with the procedure, and its results. Results: Arterial embolization was attempted in 60 of deliveries. Failures occurred in 7 of 60 cases (11.7%) and in 4 of 7 cases (57.1%) of abnormal placentation (placenta previa totalis with or without placenta accrete or increta). Comparison of the failed and successful arterial embolization groups showed no differences in maternal characteristics, clinical status, and angiographic finding. Amount of total transfusion in failed arterial embolization group were larger than successful group although hemoglobin before embolization was not different. Conclusion: The only factor significantly associated with failed arterial embolization was an abnormal placentation. Arterial embolization is a safe and highly effective method to control PPH. Key Words: Postpartum hemorrhage, Arterial embolization, Abnormal placentation 산후출혈은모성사망의중요한원인중의하나로출혈원인과출혈부위의빠른진단과신속하고적절한대처가매우중요하다. 1 출혈의처치시에는환자의활력징후, 나이, 산과력, 생식능력의보존여부, 출혈부위, 출혈량이고려되어야한다. 치료를위한전통적인방법으로는옥시토신, 프로스타글란딘등의자궁수축제사용, 자궁마사지, 소 접수일 : 수정일 : 채택일 : 교신저자 : 오민정 joyfulplace@hanmail.net 파수술로잔류태반조직의제거, 산도열상의봉합등을우선적으로시행한다. 2 이를통해서도출혈이조절되지않는경우과거에는혈관결찰술및자궁절제술과같은수술적방법이많이이용되었는데, 혈관결찰술의경우높은실패율과기술상의어려움이있고, 자궁절제술의경우에는불가피하게임신능력이소실되고요관이나방광손상등의합병증들이있어최근에는이런수술적방법들의문제점을피하면서덜침습적인치료방법으로혈관색전술이많이이용되고있다. 3 심한산후출혈에서더이상의임신을원치않는여성의경우에는처음부터자궁절제술을시행하고, 임신을원하는여성의경우에는 gelform, stainless steel ring,

2 소경아외 6 인. 산후출혈의치료를위한동맥색전술의실패와관련된인자의분석 polyvinyl alcohol 등을색전물로이용한동맥색전술이나동맥결찰술을통해자궁을보존할수있다. 4 동맥색전술은수술적치료의단점을극복하고자궁을보존할수있으며비교적시술시간이짧아최근산후출혈환자의치료에많이이용되고있다. 동맥색전술로출혈혈관을선택적으로막을수있는성공률은 79~90% 으로비교적높다. 5 부인과영역에서는 1960 년대부터골반장기의출혈을치료하기위해동맥색전술이시행되었으나, 6 산과영역에서는 1979 년최초로산후출혈의치료에동맥색전술이적용되었다. 7 특히혈역학적으로안정된상태의산모들에서동맥색전술을이용하여자궁이완증, 태반유착, 자궁동맥손상, 질부위열상에의한출혈을조절할수있다. 그러나동맥색전술을이용한경우에도측부혈관의발달로인한재출혈이일어날수있으며, 8 이런경우 2차색전술을시행하거나추가적인수술적인치료가필요하다. 9 이전연구들에서동맥색전술을시행하여성공한경우와실패한경우에대한증례보고들은많았으나실패율및실패원인의분석에대한연구는아직많이시행되지않은상태이다. 본연구에서는고려대학교의료원에서동맥색전술을시행한환자들을대상으로색전술을시행한후에도출혈이조절되지않아추가적인수술을시행한환자들을분석하여실패의원인과관련된인자들에대하여알아보고자하였다. 연구대상및방법 1. 연구대상 2004 년부터 2008 년까지고려대학교의료원에서산후출혈의치료를위해동맥색전술을시행한환자들중시술후에도출혈이지속되어추가적으로수술적치료를시행했던환자들의진료기록을후향적으로분석하였다. 위기간동안 60명의산후출혈환자가색전술로치료를받았으며이에앞서진찰을통한자궁이완증의유무와질열상의유무를확인하였으며초음파를통한자궁내잔류태반을확인하여산후출혈의원인을파악하였다. 그리고모든환자에대해대량출혈에의한쇼크의교정및예방목적으로 crystalloid 혹은 colloid 의정주와함께적절한수혈을시작하였고범발성혈관내응고장애를보이는환자에있어서는신선동결혈장및혈소판, 섬유소원제제를투여하였다. 그리고자궁이 완증의가능성이있는경우자궁마사지, 양수자궁압박등의고식적처치와함께옥시토신, 프로스타글란딘제제등자궁수축제를사용한약물치료가우선적으로적용되었다. 2. 분석항목대상환자들의의무기록을검토하여나이, 산과력, 분만방법, 산후출혈의시기, 산후출혈의원인, 전원유무와같은기본적인정보를분석하였으며색전술의성공군과실패군에있어서어떠한차이가있는지확인하였다. 또색전술당시환자의임상양상과동맥조영술및색전술방법을파악하여두군간을비교분석하였다. 환자들의임상양상을파악하기위해색전술전활력징후 ( 혈압, 맥박 ), 색전술전혈색소수치, 색전술전수혈량및총수혈량, 색전술전시행한수술방법, 분만후색전술시행까지의시간, 그리고총입원기간및중환자실치료여부를확인하여비교하였다. 분만후출혈량의평가가필요하였으나전원된환자가많고실출혈량을정확히측정할수없어색전술전측정한혈색소수치와수혈받은농축적혈구단위의평가로대신하였다. 또한동맥조영술결과를분석하여출혈부위및색전술을시행한동맥의위치를파악하였으며, 당시출혈부위확인유무와동맥색전술부위 ( 일측또는양측 ) 에따른시술실패의관련성을확인해보았다. 3. 동맥색전술시술방법우측서혜부를국소마취하에천자한후우측대퇴동맥에혈관조영용 pig tail catheter 를삽입하여대동맥조영술을시행하였다. 양측의내장골동맥에서기시하는양측자궁동맥과질동맥등의분지를확인하였다. 조영이증강되는양측자궁동맥의상태를확인한후, 자궁이완증의경우정상적으로수축되지않고커져있는자궁의상태를일차적으로평가하였으며거짓동맥류및기타출혈부위를확인하여다양한형태의 catheter 를이용하여혈관에선택적삽관을한후색전용재료 (gelfoam, polyvinyl alcohol, coil) 를주입하였다. 이후양측난소동맥에서의출혈여부도확인하였으며시술후시행한혈관조영술상지속되는출혈의증거가있을때는반복적인색전술을시행하였고반대측혈관에도같은방법으로지혈이될때까지색전술을반복적으로시행

3 대한산부회지제 53 권제 9 호, 2010 하였다. 마지막으로최종적인혈관조영을시행하여혈관의완전한폐색을확인한후도관을제거하고천자부위를 8시간동안충분히압박지혈하였다. 4. 통계분석통계학적분석은 SPSS ver (SPSS Inc., Chicago, IL, USA) 을이용하였으며변수의특성에따라 Wann Whitney U test 와 Fisher s exact test 를이용하여통계처리하였고, P- value 0.05 미만일때통계학적유의성이있는것으로간주하였다. 결과 2004 년부터 2008 년까지고려대학교의료원산부인과에서산후출혈로동맥색전술을받은환자는총 60명이었다. 대상환자군의임상적특징을살펴보면환자들의평균나이는 31.0 세 ( 범위, 25~41 세 ) 였고, 전체환자중 37명은초산부, 23명은경산부였다. 질식분만한경우는 23명, 제왕절개는 37명이었고제왕절개술을받은환자중 17명은제왕절개술의기왕력이있었다. 분만후 24시간이내의조기산후출혈은 45명이었고 24시간이후의후기산후출혈은 15명이었으며, 타병원에서전원된환자는총 60명중 39명이었다 (Table 1). Table 1. Characteristics of the patients undergoing arterial embolization Charateristics Success (n=53) Failure (n=7) P-value Maternal age Mean (range) 30.8 (25~39) 32.3 (27~41) Parity Mean (range) 0.45 (0~2) 0.29 (0~1) Mode of delivery (%) Cesarean section 34 (64.2) 3 (42.9) Preveous c/sec (+) 11 1 Preveous c/sec ( ) 23 2 Normal labor 19 (35.8) 4 (57.1) Onset of PPH (%) Early ( 24 hr) 38 (71.7) 7 (100) Late (>24 hr) 15 (28.3) 0 (0) Hospital to hospital transfer (%) Yes 35 (66.0) 4 (57.1) No 18 (34.0) 3 (42.9) PPH: postpartum hemorrhage. Table 2. Causes of postpartum hemorrhage Cause of postpartum hemorrhage (n) Success Failure Uterine atony (36) 34 2 Abnormal placentation (13)* 9 4 Placenta accreta (5) 5 0 Placenta previa totalis without placenta accrete or increta (3) 2 1 Placenta previa totalis with placenta accrete or increta (5)* 2 3 Vaginal wall laceration (5) 4 1 Remnant placenta (1) 1 0 Others (5) 5 0 Total n=60 53 (88.3%) 7 (11.7%) *P<

4 소경아외 6 인. 산후출혈의치료를위한동맥색전술의실패와관련된인자의분석 산후출혈의원인으로는자궁이완증이 36명 (60%) 으로가장많았고, 전치태반및태반유착등의비정상태반인경우가 13명 (21.7%; 유착태반 5명, 태반유착이동반된전치태반 5명, 태반유착이동반되지않은전치태반 3명 ), 질벽열상 5명 (8.3%), 잔류태반 1명 (1.7%), 기타 5명 ( 자궁퇴축부전 3명, 가성동맥류파열 1명, 원인불명 1명, 8.3%) 이있었다 (Table 2). 동맥색전술의전체성공률은 88.3% (53/60 명 ) 였으며실패한경우는 11.7% (7/60 명 ) 로원인별로보면전치태반 4명 ( 태반유착이동반된경우 3명, 태반유착이동반되지않은경우 1명 ), 자궁이완증 2명, 질벽열상 1명이었고 (Table 2), 이들은자궁절제술, 출혈혈관결찰술, 2차색전술등의추가적인치료를받았다 (Table 3). 산후출혈의원인으로보면색전술의실패는비정상태반이있는경우통계적으로유의하게높았으며 (P=0.034), 특히태반유착이동반된전치태반의경우에서더욱그러하였다 (P=0.009) (Table 2). 출혈의원인외에색전술의실패에영향을주는요인을분석하기위해색전술의성공군과실패군의임상양상을비교하였다 (Tables 1, 4). 각대상군의나이, 분만력, 분만방 법, 출혈시기, 전원여부, 시술전수술여부 ( 자궁내막소파술, 일차봉합술, 자궁절제술 ), 시술시활력징후 ( 저혈압, 빈맥 ), 시술전혈색소수치, 분만후색전술까지시간, 중환자실치료여부등은유의한차이가나지않았다. 그러나총수혈량은실패군에서의미있게높았으며 (P=0.014) 총입원기간도실패군에서훨씬길었다 (P=0.000). 성공군과실패군에서의동맥색전술결과를비교한결과혈관조영술기록을확인할수없었던 3명 ( 성공군 2명, 실패군 1명 ) 을제외하고총 57명의환자들중혈관조영술당시출혈부위가확인된경우 26명, 확인되지않는경우가 31명이었으며출혈부위의확인유무와색전술성공유무사이에는연관성이없었다. 색전방법에서양측동맥색전술을시행한경우와일측동맥색전술을시행한경우를비교하였을때성공군과실패군간의뚜렷한차이는없었다 (Table 4). 혈관조영술결과상 57명의환자중 7명에서가성동맥류가발견되었는데임상적으로산후출혈원인에따라분류하면자궁이완증 5명, 기타 2명에서가성동맥류가발견되었으며이중자궁이완증환자 1명은색전술에실패하였다. 가성동맥류가확인된환자 7명중 3명 ( 자궁이완증 1명, 기타 2 Table 3. Characteristics of failed arterial embolization Case Age (parity) Cause of PPH Delivery typeprimary proceduretransfusion (prbc) Embolization 1) Site 2) Vital signs (BP HR) 3) Hb/Hct Secondary procedure Total transfusion (prbc) 1 31 Placenta previa totalis/ ( ) placenta accreata/ 2 32 Low lying placenta/ ( ) placenta increta 3 27 Placenta previa totalis/ ( ) placenta increta C/S None 12 1) Both uterine a. 2) 88/ ) 9.4/27.9 V/D None 4 1) Both uterine a. 2) 100/ ) 12.0/38.9 C/S None 15 1) Both uterine a. 2) 123/ ) 10.8/33.5 TAH 12 TAH 4 TAH Placenta previa totalis C/S None 13 1) Both uterine a. ( ) 2) 125/ ) 11.7/ Uterine atony ( ) V/D Subtotal hysterectomy 16 1) Lt. uterine a. c pseudoaneurysm 2) 110/ ) 7.8/ Uterine atony V/D D&CB 25 1) Rt. Internal iliac a./lt. uterine a. ( ) 2) 65/48 * 3) 6.5/ Vaginal wall laceration V/D Primary repair ( ) 26 1) Cervicovaginal br. of Rt. Internal iliac a. 2) 120/ ) 13.5/41.7 TAH 13 P/cuff hematoma remove Subtotal hysterectomy Repeat embolization & Primary repair PPH: postpartum hemorrhage, BP: blood pressure, HR: heart rate, RBC: red blood cell, TAH: total abdominal hysterectomy, D&CB: dilatation and curettage. * HR was unrecorded

5 대한산부회지제 53 권제 9 호, 2010 Table 4. Comparison of succeeded and failed arterial embolization (%) Charateristics Success (n=53) Failure (n=7) Procedure before embolization (primary repair or D&CB or hysterectomy) Yes 18 (34.0) 3 (42.9) No 35 (66.0) 4 (57.1) Vital sign at embolization SBP, mean (range) (43~165) (65~125) DBP, mean (range) 64.5 (27~103) 62.1 (20~82) Hypotension (SBP<90 mm Hg) Yes 6 (11.3) 2 (28.6) No 47 (88.7) 5 (71.4) Heart rate, mean (range) 96.4 (58~170) 99.1 (65~180) Tachycardia (HR>100/min) Yes 21 (40.4) 4 (66.7) No 31 (59.6) 2 (33.3) Hemoglobin before embolization Mean (range) 8.91 (5.9~13.2) 10.2 (6.5~13.5) <10 (g/dl) 39 (73.6) 3 (42.9) 10 (g/dl) 14 (26.4) 4 (57.1) Total transfusion (packed RBC)* Mean (range) 8.5 (0~46) 15.9 (4~26) <10 pints 40 (75.5) 1 (14.3) 10 pints 13 (24.5) 6 (85.7) Transfusion before embolization Mean (range) 4.7 (0~28) 4.9 (2~11) Time to embolization 24 hr 35 (66.0) 6 (85.7) >24 hr 18 (34.0) 1 (14.3) Angiographic finding Bleeding focus (+) 22 (43.1) 4 (66.7) Bleeding focus ( ) 29 (56.9) 2 (33.3) Site of embolization Bilateral 46 (90.2) 5 (83.3) Unilateral 5 (9.8) 1 (16.7) Hospital day* Mean (range) 8.0 (2~25) 17.6 (9~33) 7 days 27 (50.9) 0 (0) >7 days 26 (49.1) 7 (100) ICU care Yes 12 (22.6) 2 (28.6) No 41 (77.4) 5 (71.4) D&CB: dilatation and curettage, SBP: systolic blood pressure, DBP: diastolic blood pressure, HR: heart rate, RBC: red blood cell, ICU: intensive care unit. *P<0.05. 명 ) 은분만후 24시간이지난후기산후출혈이었으며나머지 4명은조기산후출혈이었다. 고찰산후출혈은 1991 년 Combs 등 10 에의하면분만후적혈구용적율이 10% 이상감소하거나수혈이필요한경우로정의

6 소경아외 6 인. 산후출혈의치료를위한동맥색전술의실패와관련된인자의분석 하였고, 1998 년미국산부인과학회에서는질식분만후 500 ml 이상, 제왕절개술후 1,000 ml 이상의출혈이있는경우로정의하였으며, 11 질식분만인경우 3.9%, 제왕절개술시 6~8% 의빈도를보인다. 12 하지만출혈량의측정이부정확한경우가많아이런정의들보다산과적출혈에있어혈역학적안정성의변화에중요성을두고있어야한다. 13 산후출혈에이용된동맥색전술은 1979 년 Heaston 에의해처음학회에보고되었다. 동맥색전술은출혈부위를쉽게찾을수있고, 자궁을보존하여임신능력을유지할수있으며, 선택적색전술이가능함에따라수술적방법에비해원위부를색전하여측부순환을억제함으로써재출혈의위험성을감소시키고, 실패시에는수술적방법을모색할수있다는장점이있다. 3 이러한동맥색전술은비교적안전한시술로알려져있으며골반통과발열외에합병증은비교적드물다. 동맥파열, 서혜부혈종, 천자부위의감염이있을수있고, 14 조영제에따른과민반응및신독성, 15 부적절한혈관의색전으로인한방광괴사, 16 소장괴사, 17 하지마비, 18 자궁괴사 19 등이보고된적있다. 동맥색전술의성공률은최근들어 90% 이상으로높게보고되고있으며산후출혈환자의치료에보편적이고효과적인시술로강조되고있다. 20 하지만동맥색전술의실패와관련한요인에대한분석을아직부족한실정이다. 산후출혈이발생한환자는단시간에대량출혈로매우위험한상태에처할수있기때문에내원즉시고식적인치료를하는동시에처음부터환자에게가장유용한치료법을결정하는것이매우중요할것이다. 따라서본연구에서는동맥색전술의실패와관련된인자를분석하고자하였으며산후출혈의원인이비정상태반에의한경우동맥색전술의실패와유의한연관성을보였다. 이전연구에서도유착태반이동맥색전술후에지속되는출혈로자궁절제술을시행해야하는주요원인중에하나라고보고된바있으며, 년 Chauleur 등 22 은 1996 년부터 2005 년까지동맥색전술을받은 46명의산후출혈환자들을분석한결과시술이실패한경우 60% 가유착태반이었다. 그러나본연구에서는유착태반만있었던 5명은모두동맥색전술이성공적이었으며, 태반유착이동반된전치태반이었던 5명중 3명에서동맥색전술후지속되는출혈로모두자궁절제술을시행받았다. 이것은또한전치태반만있었던경우에비해동맥색전술의실패와관련하여의미있는차이를보였다. 대부분의환자들은짧은시간동안대량수혈을받게된다. 대량수혈은일반적으로 24시간이내에체내순환량에해당하는혈액량인 10단위이상의농축적혈구를수혈받는것으로정의하고있다. 23 농축적혈구의총수혈량과생존율사이에는상관성이없다는보고들이있으나, 단위이상의농축적혈구를수혈받을경우는총농축적혈구수혈량과생존율은반비례하는경향을보인다고한다. 27,28 본연구에포함된전체 60명의환자중농축적혈구를 10단위이상수혈받은경우는 19명이었고이중 7명에서는 20단위이상수혈을받았다. 그리고동맥색전술의실패군에있어서총수혈량이성공군에비해유의하게많았다. 이것은실패군에서더많은출혈이있었다는것을의미한다. 산후출혈로대량출혈이발생한경우일반적으로말초혈관수축이일어나정맥환류량을증가시킴으로써관류혈압유지를유지하게되며출혈량이많을수록더심한혈관수축을야기한다. 29 산후출혈환자에게동맥조영술을시행했을때특정혈관에서출혈을확인할수있는경우는 33~89% 로다양한데특정혈관을찾을수없는경우는자궁동맥의수축으로혈관조영이잘되지않는경우에자주나타난다는보고가있었다. 23 만약색전술을시행할때수축된부위를막게되거나, 혈관수축으로인하여발견되지않았던출혈이혈장량이회복됨에따라다시혈관확장되면서출혈하게되는것이결국동맥색전술의실패요인으로작용할것이라생각해볼수있다. 하지만본연구에서시술전수혈량과환자의활력징후를비교해봤을때성공군과실패군간의차이가없었고, 혈관조영술상출혈부위를확인할수있던경우와그렇지못한경우에서도차이가없었기때문에시술전출혈량이동맥색전술의실패에영향을줄것이라고단정하기힘들다. 비록출혈이많았다하더라도색전술당시의활력징후가어느정도안정되어있고저혈량상태에대한수혈등일차적소생술이적절하게동반될수만있다면산후출혈의경우무엇보다동맥색전술을먼저시도해볼수있으며더불어좋은결과를기대해볼수있을것이다. 정도의차이는있겠지만혈역학적으로안정이이루어지지않은상태에서도성공적인동맥색전술을시행한보고도있었다. 20 그외의실패원인들을생각해보면출혈부위의혈관직경이너무커서색전물이빠져나가버린다거나혈관조영카데터가접근하기어려운혈관분지에서의출혈, 잘못된술기, 출혈부위가한정되지않은경우, 기형혈관을동반하는경

7 대한산부회지제 53 권제 9 호, 2010 우등이있을수있겠으나본연구에서는이에대한기록이부족하여분석을하지못하였다. 30,31 동맥색전술당시출혈부위가확인된경우는혈관조영술결과가있는총 57명의환자중 26명이었고, 한가지특이할만한점은 7명에서가성동맥류가진단된것이다. 7명중 4명이조기산후출혈이었으며 3명은후기산후출혈로발견되었다. 대부분의가성동맥류는지연된가성동맥류의파열에의한대량출혈로발견되며증상이없는경우발견이어렵고반복적비정상자궁출혈이가장흔한증상으로출혈량은다양하다. 32 조기산후출혈 4명은모두자궁이완증에의한산후출혈로혈관조영술시우연히가성동맥류가함께발견되었으며이중한명에서만가성동맥류의출혈을동반하고있었다. 후기산후출혈 3명중 2명은각각자궁이완증, 자궁퇴축부전으로동맥색전술을한경우로파열되지않은가성동맥류가있었으며, 나머지 1명은원인불명의산후출혈로혈관조영술시가성동맥류파열을확인할수있었다. 산후출혈의원인중하나인가성동맥류는임신또는수술적외상후발생하는것으로손상된혈관으로인해인접한조직으로혈액이유출되어생긴박동성혈종이다. 33 가성동맥류의발생률에대한보고는거의없으며, 지연된산후출혈의매우드문원인중의하나로, 외상, 골반수술, 융모성질환, 종양, 감염또는 diethylstilbesterol 등에노출시생길수있다. 32 자궁내가성동맥류의진단은초음파, 자궁경, computed tomography, magnetic resonance imaging, 초음파등이있으며 color doppler 를이용할경우 to and fro 라불리는특징적이파동을볼수있고 34 확진은동맥혈관조영술로한다 년 Soyer 등 35 은가성동맥류파열로인한산후출혈환자 7명에대하여동맥색전술을시행하여성공적으로치료한결과를보고하였다. 그들은몇가지점에서임상적으로가성동맥류를의심할수있다고하였다. 첫째, 자궁이완증이동반되지않은조기산후출혈인경우, 둘째, sulprosotne (prostaglandin E2 analogue) 사용에도출혈이지속되는경우, 셋째, 질열상으로인한출혈시일차봉합술을시행하였음에도출혈이지속되는경우이다. 또다른보고에서는제왕절개술후지연된심한자궁출혈 이있을경우가성동맥류를염두에두고치료시초기단계에동맥혈관조영술을고려해보아야한다고하였다. 32 본연구에서진단된 7명의가성동맥류환자중 1명을제외하고모두동맥색전술을시행하여성공적으로지혈되었다. 따라서임상적으로출혈원인이뚜렷하지않은경우, 예를들면, 자궁수축력은나쁘지않으면서출혈이지속되는경우나자궁수축제에반응하지않는산후출혈, 제왕절개분만후의심한지연성산후출혈환자에서가성동맥류를의심해보아야하며혈관조영술과동맥색전술이우선적으로시도되어야한다. 결론적으로, 산후출혈환자에서동맥색전술은성공률이높고합병증이적은안전한시술방법이다. 따라서환자의활력징후가어느정도안정되어있고저혈량상태에대한수혈등일차적소생술이적절하게동반될수만있다면산후출혈의치료로동맥색전술을먼저시도해야한다. 산후출혈의원인중하나인가성동맥류는드물기는하지만동맥색전술로빠른진단과성공적인치료를할수있기때문에항상염두에두고있어야하겠다. 다만출혈의원인이비정상태반인경우동맥색전술의실패와분명히연관성을가지고있으므로대량출혈로인해환자의활력징후가불안정한상태에서는이를고려하여동맥색전술보다자궁절제술을시행하는것이효과적일수있겠다. 또한동맥색전술의실패는총수혈량과밀접한관계가있으며이는신속하고성공적인동맥색전술이대량수혈을줄일수있는 2차적인효과도가져다줄것이라고생각된다. 본연구는후향적으로의무기록을통해이루어져연구수행이전의산후출혈환자들에대한기록이불충분하여동맥색전술의실패와관련있다고알려진모든요인들과의연관성을파악하는것에는부족한면이있고, 전체증례수에비해실패한증례수가적어통계적검증력이약한제한점이있으나, 산후출혈환자의동맥색전술에서실패인자를예측하는데유용한참고자료가될수있을것으로생각되며이에대해향후더많은대상을통한연구가필요할것이다

8 소경아외 6 인. 산후출혈의치료를위한동맥색전술의실패와관련된인자의분석 참고문헌 1. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367: Mercier FJ, Van de Velde M. Major obstetric hemorrhage. Anesthesiol Clin 2008; 26: 53 66, vi. 3. Kang CS, Park SY, Lee JY, Oh JY, Ju WD, Kim SK, et al. Applicable indications and effectiveness of the selective arterial embolization in the management of obstetrical hemorrhage. Korean J Obstet Gynecol 2004; 47: Kwon JH, Kim GS. Obstetric iatrogenic arterial injuries of the uterus: diagnosis with US and treatment with transcatheter arterial embolization. Radiographics 2002; 22: Shin WK, Kim DJ, Kim HM, Park SH, Jun HA, Lee KY. A case of angiography and transarterial embolization in arteriovenous malformation of uterus after a cesarean section episode. Korean J Obstet Gynecol 2007; 50: Oliver JA Jr, Lance JS. Selective embolization to control massive hemorrhage following pelvic surgery. Am J Obstet Gynecol 1979; 135: Heaston DK, Mineau DE, Brown BJ, Miller FJ Jr. Transcatheter arterial embolization for control of persistent massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation. AJR Am J Roentgenol 1979; 133: Chow TW, Nwosu EC, Gould DA, Richmond DH. Pregnancy following successful embolisation of a uterine vascular malformation. Br J Obstet Gynaecol 1995; 102: Shin SJ, Lee BS, Jeong CJ, Cho EJ, Cha DH, Lee K. A case taken total abdominal hysterectomy after failure of transarterial embolization in arteriovenous malformation of the uterus. Korean J Obstet Gynecol 1993; 36: Combs CA, Murphy EL, Laros RK Jr. Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991; 77: ACOG educational bulletin. Postpartum hemorrhage. Number 243, January 1998 (replaces No. 143, July 1990). American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1998; 61: Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 77: Mason BA. Postpartum hemorrhage and arterial embolization. Curr Opin Obstet Gynecol 1998; 10: Gilbert WM, Moore TR, Resnik R, Doemeny J, Chin H, Bookstein JJ. Angiographic embolization in the management of hemorrhagic complications of pregnancy. Am J Obstet Gynecol 1992; 166: Bakri YN, Linjawi T. Angiographic embolization for control of pelvic genital tract hemorrhage. Report of 14 cases. Acta Obstet Gynecol Scand 1992; 71: Sieber PR. Bladder necrosis secondary to pelvic artery embolization: case report and literature review. J Urol 1994; 151: Greenwood LH, Glickman MG, Schwartz PE, Morse SS, Denny DF. Obstetric and nonmalignant gynecologic bleeding: treatment with angiographic embolization. Radiology 1987; 164: Hare WS, Holland CJ. Paresis following internal iliac artery embolization. Radiology 1983; 146: Pirard C, Squifflet J, Gilles A, Donnez J. Uterine necrosis and sepsis after vascular embolization and surgical ligation in a patient with postpartum hemorrhage. Fertil Steril 2002; 78: Deux JF, Bazot M, Le Blanche AF, Tassart M, Khalil A, Berkane N, et al. Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage? AJR Am J Roentgenol 2001; 177: Zelop CM, Harlow BL, Frigoletto FD Jr, Safon LE, Saltzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993; 168: Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert P. Serious primary post partum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases. Hum Reprod 2008; 23: Kim JR, Cho YK, Kim HM, Choi EJ, Kim DW, Seo YS, et al. Angiographic findings and effect of superselective embolization for early and late postpartum bleeding. Korean J Obstet Gynecol 2009; 52: Harvey MP, Greenfield TP, Sugrue ME, Rosenfeld D. Massive blood transfusion in a tertiary referral hospital. Clinical outcomes and haemostatic complications. Med J Aust 1995; 163: Lee MK, Kim HO, Hong SG, Kwon OH, Kim JJ. Massive transfusion in Severance hospital. Korean J Blood Transfus 1993; 4: Sawyer PR, Harrison CR. Massive transfusion in adults. Diagnoses, survival and blood bank support. Vox Sang 1990; 58: Wilson RF, Dulchavsky SA, Soullier G, Beckman B. Problems with 20 or more blood transfusions in 24 hours. Am Surg 1987; 53: Leslie SD, Toy PT. Laboratory hemostatic abnormalities in massively transfused patients given red blood cells and crystalloid. Am J Clin Pathol 1991; 96: Kozhura VL, Novoderzhkina IS, Kirsanova AK. Acute and massive hemorrhage: mechanisms of compensation and damage. Anesteziol Reanimatol 2002: Rosenthal DM, Colapinto R. Angiographic arterial embolization in the management of postoperative vaginal hemorrhage. Am J Obstet Gynecol 1985; 151: Poppe W, Van Assche FA, Wilms G, Favril A, Baert A. Pregnancy after transcatheter embolization of a uterine arteriovenous malformation. Am J Obstet Gynecol 1987; 156: Kim MJ, Park CH, Kwen I, Lee HJ, Hur SY, Kim EJ, et al. An uncommon cause of postpartum hemorrhage after cesarean section treated with selective arterial embolization: Pseudoaneurysm of the uterine pedicle. Korean J Obstet Gynecol 2004; 47: Lee JT, Jung HG, Park BD, Hur JS, Hwang JS, Lee DJ, et al. Failed two cases analysis of eight Transarterial embolization therapy for Pseudoaneurysm followed by D&C. Korean J Obstet Gynecol 2000; 43: Mitchell DG, Needleman L, Bezzi M, Goldberg BB, Kurtz AB, Pennell RG, et al. Femoral artery pseudoaneurysm: diagnosis with conventional duplex and color Doppler US. Radiology 1987; 165: Soyer P, Fargeaudou Y, Morel O, Boudiaf M, Le Dref O, Rymer R. Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization. Eur Radiol 2008; 18:

9 대한산부회지제 53 권제 9 호, 2010 = 국문초록 = 목적 : 산후출혈로동맥색전술을시행한환자들을분석하여동맥색전술의실패의원인과관련된인자들에대하여알아보고자하였다. 연구방법 : 2004년부터 2008년까지고려대학교의료원에서산후출혈로동맥색전술을시행한 60명의환자의진료기록과동맥조영술결과를후향적으로분석하여성공군과실패군을비교하였다. 결과 : 동맥색전술의전체성공률은 88.3% (53/60명) 였고실패한경우는 11.7% (7/60명) 였다. 색전술의실패는비정상태반인경우통계적으로유의하게높았으며 (P=0.034), 특히태반유착이동반된전치태반의경우에서더욱그러하였다 (P=0.009). 각대상군의나이, 분만력, 분만방법, 출혈시기, 전원여부, 시술전수술여부, 시술시활력징후, 시술전혈색소수치, 분만후색전술까지시간, 중환자실치료여부등은차이가없었다. 결론 : 산후출혈환자에서동맥색전술은성공률이높고합병증이적은안전한시술방법이나출혈의원인이비정상태반인경우동맥색전술이실패할가능성이높다. 중심단어 : 산후출혈, 동맥색전술, 비정상태반

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding