中华妇产科杂志
中華婦產科雜誌
중화부산과잡지
CHINESE JOUNAL OF OBSTETRICS AND GYNECOLOGY
2012年
9期
641-645
,共5页
罗方媛%陈锰%张力%余海燕%游泳%曲海波%刘兴会
囉方媛%陳錳%張力%餘海燕%遊泳%麯海波%劉興會
라방원%진맹%장력%여해연%유영%곡해파%류흥회
产后出血%气囊阻塞%结扎术%栓塞,治疗性%治疗失败
產後齣血%氣囊阻塞%結扎術%栓塞,治療性%治療失敗
산후출혈%기낭조새%결찰술%전새,치료성%치료실패
Postpartum hemorrhage%Balloon occlusion%Ligation%Embolization,therapeutic%Treatment failure
目的 探讨5种止血手术治疗难治性产后出血的疗效及止血失败的原因.方法 选择2007年1月至2011年7月四川大学华西第二医院收治的难治性产后出血产妇96例,采取的止血方法及例数:宫腔填塞纱条或球囊(填塞组)35例,盆腔血管结扎(结扎组)12例,盆腔动脉栓塞(介入组)9例,子宫压迫缝合(缝合组)26例及子宫压迫缝合+宫腔填塞(缝合+填塞组)14例.对各组产妇的止血手术中、术后情况及治疗结果进行分析,并对止血失败的原因行多因素分析.结果 (1)96例产妇产后出血量1200～ 91 00 ml.实施以上止血手术后71例产妇止血成功,25例止血失败.(2)术前出血量介入组和填塞组明显多于缝合组,分别比较,差异均有统计学意义(P＜0.05)；术中出血量介入组和缝合组少于结扎组,分别比较,差异均有统计学意义(P＜0.05)；手术时间介入组明显短于结扎组、缝合组和缝合+填塞组,分别比较,差异均有统计学意义(P＜0.05).(3)96例产妇中,出血原因为宫缩乏力者55例,止血成功43例,止血成功率为78％；出血原因为前置胎盘者46例,止血成功39例,止血成功率为85％；出血原因为胎盘植入者33例,止血成功1 3例,止血成功率为39％.出血原因为宫缩乏力及前置胎盘产妇的止血成功率在各组间比较,差异均无统计学意义(P＞0.05)；胎盘植入产妇的止血成功率在介入组中明显高于其他各组,差异均有统计学意义(P＜0.01).(4)对25例止血失败产妇的原因进行多因素分析,结果显示,瘢痕子宫、胎盘植入、术前或术中存在凝血功能障碍是难治性产后出血止血失败的危险因素,OR值分别为2.9(95％ CI为1.1 ～7.6)、17.9(95％ CI为5.6 ～56.3)、16.2(95％CI为3.2～83.5).介入治疗对止血成功具有一定的保护作用(OR =0.9,95％CI为0.8 ～0.9).结论 (1)5种止血手术对于难治性产后出血均有良好的止血效果,但盆腔动脉栓塞介入治疗具有手术时间短、术中出血少的优势,尤其在有胎盘植入的情况下,介入治疗的止血成功率更高；(2)瘢痕子宫、胎盘植入及凝血功能障碍是止血失败的危险因素,对于有以上危险因素的难治性产后出血产妇应根据具体情况选择合适的止血方式.
目的 探討5種止血手術治療難治性產後齣血的療效及止血失敗的原因.方法 選擇2007年1月至2011年7月四川大學華西第二醫院收治的難治性產後齣血產婦96例,採取的止血方法及例數:宮腔填塞紗條或毬囊(填塞組)35例,盆腔血管結扎(結扎組)12例,盆腔動脈栓塞(介入組)9例,子宮壓迫縫閤(縫閤組)26例及子宮壓迫縫閤+宮腔填塞(縫閤+填塞組)14例.對各組產婦的止血手術中、術後情況及治療結果進行分析,併對止血失敗的原因行多因素分析.結果 (1)96例產婦產後齣血量1200～ 91 00 ml.實施以上止血手術後71例產婦止血成功,25例止血失敗.(2)術前齣血量介入組和填塞組明顯多于縫閤組,分彆比較,差異均有統計學意義(P＜0.05)；術中齣血量介入組和縫閤組少于結扎組,分彆比較,差異均有統計學意義(P＜0.05)；手術時間介入組明顯短于結扎組、縫閤組和縫閤+填塞組,分彆比較,差異均有統計學意義(P＜0.05).(3)96例產婦中,齣血原因為宮縮乏力者55例,止血成功43例,止血成功率為78％；齣血原因為前置胎盤者46例,止血成功39例,止血成功率為85％；齣血原因為胎盤植入者33例,止血成功1 3例,止血成功率為39％.齣血原因為宮縮乏力及前置胎盤產婦的止血成功率在各組間比較,差異均無統計學意義(P＞0.05)；胎盤植入產婦的止血成功率在介入組中明顯高于其他各組,差異均有統計學意義(P＜0.01).(4)對25例止血失敗產婦的原因進行多因素分析,結果顯示,瘢痕子宮、胎盤植入、術前或術中存在凝血功能障礙是難治性產後齣血止血失敗的危險因素,OR值分彆為2.9(95％ CI為1.1 ～7.6)、17.9(95％ CI為5.6 ～56.3)、16.2(95％CI為3.2～83.5).介入治療對止血成功具有一定的保護作用(OR =0.9,95％CI為0.8 ～0.9).結論 (1)5種止血手術對于難治性產後齣血均有良好的止血效果,但盆腔動脈栓塞介入治療具有手術時間短、術中齣血少的優勢,尤其在有胎盤植入的情況下,介入治療的止血成功率更高；(2)瘢痕子宮、胎盤植入及凝血功能障礙是止血失敗的危險因素,對于有以上危險因素的難治性產後齣血產婦應根據具體情況選擇閤適的止血方式.
목적 탐토5충지혈수술치료난치성산후출혈적료효급지혈실패적원인.방법 선택2007년1월지2011년7월사천대학화서제이의원수치적난치성산후출혈산부96례,채취적지혈방법급례수:궁강전새사조혹구낭(전새조)35례,분강혈관결찰(결찰조)12례,분강동맥전새(개입조)9례,자궁압박봉합(봉합조)26례급자궁압박봉합+궁강전새(봉합+전새조)14례.대각조산부적지혈수술중、술후정황급치료결과진행분석,병대지혈실패적원인행다인소분석.결과 (1)96례산부산후출혈량1200～ 91 00 ml.실시이상지혈수술후71례산부지혈성공,25례지혈실패.(2)술전출혈량개입조화전새조명현다우봉합조,분별비교,차이균유통계학의의(P＜0.05)；술중출혈량개입조화봉합조소우결찰조,분별비교,차이균유통계학의의(P＜0.05)；수술시간개입조명현단우결찰조、봉합조화봉합+전새조,분별비교,차이균유통계학의의(P＜0.05).(3)96례산부중,출혈원인위궁축핍력자55례,지혈성공43례,지혈성공솔위78％；출혈원인위전치태반자46례,지혈성공39례,지혈성공솔위85％；출혈원인위태반식입자33례,지혈성공1 3례,지혈성공솔위39％.출혈원인위궁축핍력급전치태반산부적지혈성공솔재각조간비교,차이균무통계학의의(P＞0.05)；태반식입산부적지혈성공솔재개입조중명현고우기타각조,차이균유통계학의의(P＜0.01).(4)대25례지혈실패산부적원인진행다인소분석,결과현시,반흔자궁、태반식입、술전혹술중존재응혈공능장애시난치성산후출혈지혈실패적위험인소,OR치분별위2.9(95％ CI위1.1 ～7.6)、17.9(95％ CI위5.6 ～56.3)、16.2(95％CI위3.2～83.5).개입치료대지혈성공구유일정적보호작용(OR =0.9,95％CI위0.8 ～0.9).결론 (1)5충지혈수술대우난치성산후출혈균유량호적지혈효과,단분강동맥전새개입치료구유수술시간단、술중출혈소적우세,우기재유태반식입적정황하,개입치료적지혈성공솔경고；(2)반흔자궁、태반식입급응혈공능장애시지혈실패적위험인소,대우유이상위험인소적난치성산후출혈산부응근거구체정황선택합괄적지혈방식.
Objective To study the different clinical effects of using 5 kinds of hemostatic surgeries to manage the intractable postpartum hemorrhage and analyse the risk factors of failed hemostasis.Methods From Jan.2007 to Jul.2011,96 patients with intractable postpartum hemorrhage were studied retrospectively and grouped by the first step surgical treatment.The hemostatic surgeries included uterine tamponade (tamponade group ), pelvic blood vessels ligation (ligation group), pelvical arterial embolization (embolization group), uterine compression sutures (sutures group) and uterine compression sutures combining tamponade (combined group).The intraoperative and postoperation datum were compared among groups,so dose the treatment outcomes.Multivariate analysis were used for failed hemostasis.Results ( 1 ) The blood loss of 96 patients ranged from 1200 to 9100 ml,and 71 patients had a succeed hemoatasis after employing these surgeries and 25 failed.(2) The blood loss before hemostasis surgeries in tamponade group and embolization group was statisically greater than in sutures group ( P ＜ 0.05 ).Blood loss during the hemostasis surgeries in ligation group was statistically greater than in embolization and sutures groups ( P ＜0.05).The operating time of embolization group was statistically shorter than ligation group,sutures group and the combined group (P ＜ 0.05 ).(3) Fine of 96 patients had uterine atony and 43 had a successful hemostasis with the success rate about 78％.Forty-six had placenta previa and 39 success with success rate 85％.Thirty-three had placenta accrete and 13 of which succeed in hemostasis with success rate about 39％.In patients with uterine atony and placenta previa,the difference of hemostasis rate in groups had no statistically significant ( P ＞ 0.05 ).In patients with placenta accrete,the hemostasis rate in embolization group was higher than in others groups (P ＜ 0.01 ). (4) The multivariate analysis found that scar uterus,placenta accrete and coagulation defects were the risk factors of failed hemotasis.The OR value respectively was 2.9 (95 ％ CI:1.1 - 7.6 ),17.9 ( 95 ％ CI:5.6 - 56.3 ) and 16.2 ( 95 ％ CI:3.2 - 83.5 ).Embolization had some extent of protective effection ( OR =0.9,95 ％ CI:0.8 - 0.9 ).Conclusions ( 1 ) Five kinds of hemostatic surgeries were all effective.Though the success rate among groups did show statistical difference,pelvical arterial embolization has the comparative advantage of shorter operating time,less operating blood loss and higher success rate in placenta accrete.(2) Since scar uterus,placenta accrete and coagulation defects were the risk factors of failed hemostasis,sufficient preparation should be made for patients with these risk factors and the hemostatic surgeries should be choosed individually.
