산과적 출혈 처치에 있어서 응급 자궁적출술 및 경피적 혈관색전술 적용의 임상적 양상과 효과 비교
Emergent hysterectomy and angiographic embolization for the management of obstetrical hemorrhage: 8-year experiences
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목적: 고식적인 방법으로 조절되지 않는 산과적 출혈의 처치에 있어서 응급 자궁적출술 및 경피적 혈관색전술의 임상적 양상과 효과를 비교하고자 하였다. 연구 방법: 1999년 1월부터 2007년 7월까지 본원에서 산과적 출혈로 응급 자궁적출술을 시행한 88명과 경피적 혈관색전술을 시행한 53명의 환자를 대상으로 하였다. 고식적 지혈방법으로 조절되지 않거나 대량출혈이 예상되는 환자에게 응급 자궁적 출술 및 경피적 혈관색전술을 시행하였고, 환자의 의무 기록 검토 및 전화 설문을 통하여 관련 합병증, 추후 월경의 양상과 임신 유무 등의 정보를 조사하였다. 두 군의 비교에는 비모수적 통계방법을 이용하였다. 결과: 연구 기간에 산후출혈의 치료에 경피적 혈관색전술의 이용이 점차 증가하는 추세로 2007년도에는 산과적 출혈의 치료에서 경피적 혈관색전술이 차지하는 분율이 약 4분의 3 정도에 해당하였다. 산과적 출혈의 치료로 자궁적출술을 시행한 군에서 출혈의 가장 흔한 원인으로는 태반 이상 (68.2%)이었고, 자궁이완증 (25.0%)이 다음을 차지하였다. 반면, 경피적 혈관색전술군에서는 자궁이완증이 54.7%로 가장 흔한 원인을 차지하였고 태반이상은 17%을 차지했다. 시술 전 혈색소는 혈관색전술군에서 의미 있게 낮았고, 총 수혈량은 두 군 간의 의미 있는 차이는 없었으며 혈관색전술군에서 입원 기간이 유의하게 짧았다. 혈관색전술의 성공률은 89%였으며, 시술과 관련된 급성 합병증은 발견되지 않았다. 혈관색전술을 시행한 대부분의 환자에서 정상적인 생리가 재개되었다. 결론: 산과적 출혈의 치료에 있어 경피적 혈관색전술이 비침습적이고, 효과적이면서 임신 능력을 보존하는데 유용한 방법이며 최근에 시행이 점차 증가하고 있음을 확인하였다.
Abstract
Objective: To compare the clinical characteristics and outcome of hysterectomy and angiographic embolization in the management of obstetrical hemorrhage unresponsive to conservative management. Methods: We retrospectively analyzed 88 patients who underwent hysterectomy and 53 patients who underwent angiographic embolization for the management of obstetrical hemorrhage from January 1999 to July 2007. We analyzed the maternal characteristics and outcomes by the review of medical records and telephone interview. Nonparametric test was performed for comparison of both groups. Results: Angiographic embolization for the management of obstetrical hemorrhage is on the increase year by year, consisting of about three quarters of total cases in the last year. The most common indication of hysterectomy was abnormal placentation (68.2%) followed by uterine atony (25.0%). For the embolization, the most common indication was uterine atony (54.7%) followed by abnormal placentation (17%). The median pre-operative hemoglobin was significantly lower in embolization group than hysterectomy group [8.3 (3.8~12.7 g/dL) vs. 10.8 (2.4~13.7 g/dL), P<0.001]. There was no difference in the total transfusion amount of packed RBC between the two groups. The median hospital stay was shorter in embolization group [8 (5~57 days) vs. 6 (3~14 days), P<0.001]. Overall success rate of embolization was 89% and procedure-related acute complications were not occurred. Of the total population, there was one maternal death in the hysterectomy group. We found that most women who underwent the embolization resume normal menstruation. Conclusion: Angiographic embolization for the management of obstetrical hemorrhage is more commonly performed in recent years. Angiographic embolization was associated with shorter hospital stay, reasonable success rate, and minimal complication rate.
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