基层严重产后出血影响因素分析
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摘要
【背景】严重产后出血是产科严重并发症,与失血性休克、弥漫性血管内凝血、产褥感染、产后贫血、席汉氏综合征、孕产妇死亡密切相关,是我国孕产妇死亡的首位原因。因产后出血导致的孕产妇死亡病例数的80.0%以上发生在基层,占全国孕产妇死亡总数的28%。严重产后出血发生原因复杂,不仅有病理生理因素,还与医疗保健等因素有关。深入探讨基层严重产后出血的影响因素,有利于针对基层医疗服务中存在的问题制定防范措施提供科学依据,以提高基层产科服务质量。
【目的】研究基层严重产后出血影响因素,探讨减少基层严重产后出血发生的防治措施,以降低严重产后出血的发生率,改善母婴结局,降低基层地区孕产妇死亡率。
【方法】采用病例对照研究方法,在河南省选取郏县所有能够开展助产技术服务的县级医疗保健机构,抽取2006年1月1日至2007年12月31日所有住院分娩符合严重产后出血诊断标准的病例作为病例组,以1:1的比例选取同期住院分娩符合条件的病例作为对照组。采用自行设计的产后出血病历调查表,从研究对象的病历中收集相关信息,调查内容包括对孕产妇的基本情况、孕期保健服务利用情况、本次分娩情况、产后出血抢救措施、妊娠结局等。采用Epidata3.1进行数据录入,使用SPSS for Windows 11.5统计软件包进行数据分析。采用平均值、中位数、构成比、率等进行描述性分析。不同组间均值的比较应用两独立样本t检验(Independen-Samples T Test);各影响因素在病例组与对照组的构成比用χ~2检验;通过非条件多因素Logistic回归分析方法探讨各相关因素与严重产后出血的作用关系。
【结果】4所县级医院分娩产妇总数21654例,严重产后出血的发生率为0.42%,由严重产后出血导致子宫切除率是0.16%,是国外报道0.053%的3.0倍;由严重产后出血导致孕产妇死亡数占孕产妇死亡总数的53.9%。对孕前、孕期病理生理因素及医疗保健因素统计分析显示:年龄≥35岁、流产次数≥2次、妊娠合并中重度贫血、胎盘异常、产前检查次数≤4次、引产、产前应用宫缩剂、不良的产程干预、宫口开全后的剖宫产术、产后出血处理时机(出血量≥500ml)、不规范治疗产后出血等因素与基层严重产后出血发生相关;合理的产后预防应用缩宫素是严重产后出血的保护因素。多因素Logistic回归分析显示:产前应用宫缩剂(OR=14.293)、流产≥2次(OR=11.374)、胎盘异常(OR=7.081)、剖宫产(OR=5.389)是严重产后出血的危险因素。产后出血诊断明确后应用欣母沛(OR=0.026)对严重产后出血的发生有保护作用。
【结论】本研究揭示与基层严重产后出血发生有关的一些孕前、孕期、产时、产后的影响因素,为制定基层严重产后出血防治措施提供了科学依据。
【Background】Severe postpartum hemorrhage is the main reason of causing severe obstetrical complication,hemorrhagic shock,disseminated intravascular coagulation(DIC),postpartum infection,Sheehan's syndrome and maternal mortality.80%maternal death caused by severe postpartum hemorrhage occurs in grass-roots areas in China,which accurate for 28%of all national cases of maternal death.The reasons of severe postpartum hemorrhage are complicated, which was affected by pathological,physiological and health care factors.In order to provide scientific evidence to prevent the problem and improve the rural health care quality,Analyzing and investigating the influencing factors of severe postpartum hemorrhage is needed.
【Object】To analyze the influencing factors of severe postpartum hemorrhage,and to explore prevent measurement of reducing the severe postpartum hemorrhage inorde to improve of maternal and infant outcome and reduce the incidence of maternal morbidity and mortality rate (MMR) in rural area.
【Methods】The Case-Control Study method was used in this research.The samples were selected from all of county-level hospitals(4 hospitals) in Jia county of Henan Province.Cases of severe postpartum hemorrhage were taken(from January 1st,2006 to December 31th,2007) as research group,and the cases of control-group were selected according to 1:1 ratio at the same period in the same hospitals.The relevant information of postpartum hemorrhage from case record was collected via the questionnaire designed.The contents of questionnaire included survey object's social demographic characteristics,history of prenatal health care, delivery care,emergency care of postpartum hemorrhage and pregnancy outcomes.Epidata 3.1 was used to input data,and applied SPSS 11.5 software to conduct statistical analysis.The mean,median,percentage and ratio were used in data description.T-test andχ~2- test were applied in factors analysis in the two groups.Logistic regression was used to investigate the interaction relationship between those factors and severe postpartum hemorrhage.
【Result】The total number of living-birth in four hospitals is 21,654.The rate of severe postpartum hemorrhage is 0.42%,and rate of hysterectomy causing by severe postpartum hemorrhage is 0.171%,which is 3.2 times higher than that of international data(0.053%). Death caused by severe postpartum hemorrhage is accurate for 53.9%of the total number of maternal death.The single factor analysis showed that:age＞35,times of abortion≥2, pregnancy with middle and severe anemia,placenta abnormity,times of antenatal check≤4, Induce contractions with Oxytocin,Speeding up the labor process,harmful intervention during labor process,having cesarean section after dilatation of cervix with 10cm,delay opportunity of dealing with hemorrhage(bleeding≥500ml),substandard care of postpartum hemorrhage are associated with severe postpartum hemorrhage.Reasonable and preventive application of Oxytocin and using Carboprost Tromethamine timely are the protective factors.The result of multi-factor logistic regression showed that speeding up the labor process with oxytocin (OR=14.293),times of abortion≥2(OR=11.374),abnormal placenta(OR=7.081),cesarean section(OR=5.389) were important indicators of postpartum hemorrhage,and using Carboprost Tromethamine(OR=0.028) was protective indicator.
【Conelusion】This research indicated that the factors exiting in pre-pregnancy,antenatal,labor and delivery period were important impact factors of severe postpartum hemorrhage,and provided scientific evidences for making the strategies of prevention and treatment of severe postpartum hemorrhage.
【目的】研究基层严重产后出血影响因素,探讨减少基层严重产后出血发生的防治措施,以降低严重产后出血的发生率,改善母婴结局,降低基层地区孕产妇死亡率。
【方法】采用病例对照研究方法,在河南省选取郏县所有能够开展助产技术服务的县级医疗保健机构,抽取2006年1月1日至2007年12月31日所有住院分娩符合严重产后出血诊断标准的病例作为病例组,以1:1的比例选取同期住院分娩符合条件的病例作为对照组。采用自行设计的产后出血病历调查表,从研究对象的病历中收集相关信息,调查内容包括对孕产妇的基本情况、孕期保健服务利用情况、本次分娩情况、产后出血抢救措施、妊娠结局等。采用Epidata3.1进行数据录入,使用SPSS for Windows 11.5统计软件包进行数据分析。采用平均值、中位数、构成比、率等进行描述性分析。不同组间均值的比较应用两独立样本t检验(Independen-Samples T Test);各影响因素在病例组与对照组的构成比用χ~2检验;通过非条件多因素Logistic回归分析方法探讨各相关因素与严重产后出血的作用关系。
【结果】4所县级医院分娩产妇总数21654例,严重产后出血的发生率为0.42%,由严重产后出血导致子宫切除率是0.16%,是国外报道0.053%的3.0倍;由严重产后出血导致孕产妇死亡数占孕产妇死亡总数的53.9%。对孕前、孕期病理生理因素及医疗保健因素统计分析显示:年龄≥35岁、流产次数≥2次、妊娠合并中重度贫血、胎盘异常、产前检查次数≤4次、引产、产前应用宫缩剂、不良的产程干预、宫口开全后的剖宫产术、产后出血处理时机(出血量≥500ml)、不规范治疗产后出血等因素与基层严重产后出血发生相关;合理的产后预防应用缩宫素是严重产后出血的保护因素。多因素Logistic回归分析显示:产前应用宫缩剂(OR=14.293)、流产≥2次(OR=11.374)、胎盘异常(OR=7.081)、剖宫产(OR=5.389)是严重产后出血的危险因素。产后出血诊断明确后应用欣母沛(OR=0.026)对严重产后出血的发生有保护作用。
【结论】本研究揭示与基层严重产后出血发生有关的一些孕前、孕期、产时、产后的影响因素,为制定基层严重产后出血防治措施提供了科学依据。
【Background】Severe postpartum hemorrhage is the main reason of causing severe obstetrical complication,hemorrhagic shock,disseminated intravascular coagulation(DIC),postpartum infection,Sheehan's syndrome and maternal mortality.80%maternal death caused by severe postpartum hemorrhage occurs in grass-roots areas in China,which accurate for 28%of all national cases of maternal death.The reasons of severe postpartum hemorrhage are complicated, which was affected by pathological,physiological and health care factors.In order to provide scientific evidence to prevent the problem and improve the rural health care quality,Analyzing and investigating the influencing factors of severe postpartum hemorrhage is needed.
【Object】To analyze the influencing factors of severe postpartum hemorrhage,and to explore prevent measurement of reducing the severe postpartum hemorrhage inorde to improve of maternal and infant outcome and reduce the incidence of maternal morbidity and mortality rate (MMR) in rural area.
【Methods】The Case-Control Study method was used in this research.The samples were selected from all of county-level hospitals(4 hospitals) in Jia county of Henan Province.Cases of severe postpartum hemorrhage were taken(from January 1st,2006 to December 31th,2007) as research group,and the cases of control-group were selected according to 1:1 ratio at the same period in the same hospitals.The relevant information of postpartum hemorrhage from case record was collected via the questionnaire designed.The contents of questionnaire included survey object's social demographic characteristics,history of prenatal health care, delivery care,emergency care of postpartum hemorrhage and pregnancy outcomes.Epidata 3.1 was used to input data,and applied SPSS 11.5 software to conduct statistical analysis.The mean,median,percentage and ratio were used in data description.T-test andχ~2- test were applied in factors analysis in the two groups.Logistic regression was used to investigate the interaction relationship between those factors and severe postpartum hemorrhage.
【Result】The total number of living-birth in four hospitals is 21,654.The rate of severe postpartum hemorrhage is 0.42%,and rate of hysterectomy causing by severe postpartum hemorrhage is 0.171%,which is 3.2 times higher than that of international data(0.053%). Death caused by severe postpartum hemorrhage is accurate for 53.9%of the total number of maternal death.The single factor analysis showed that:age＞35,times of abortion≥2, pregnancy with middle and severe anemia,placenta abnormity,times of antenatal check≤4, Induce contractions with Oxytocin,Speeding up the labor process,harmful intervention during labor process,having cesarean section after dilatation of cervix with 10cm,delay opportunity of dealing with hemorrhage(bleeding≥500ml),substandard care of postpartum hemorrhage are associated with severe postpartum hemorrhage.Reasonable and preventive application of Oxytocin and using Carboprost Tromethamine timely are the protective factors.The result of multi-factor logistic regression showed that speeding up the labor process with oxytocin (OR=14.293),times of abortion≥2(OR=11.374),abnormal placenta(OR=7.081),cesarean section(OR=5.389) were important indicators of postpartum hemorrhage,and using Carboprost Tromethamine(OR=0.028) was protective indicator.
【Conelusion】This research indicated that the factors exiting in pre-pregnancy,antenatal,labor and delivery period were important impact factors of severe postpartum hemorrhage,and provided scientific evidences for making the strategies of prevention and treatment of severe postpartum hemorrhage.
引文
1 2006年全国妇幼卫生监测结果分析报告.妇幼卫生监测暨年报资料汇编.2007,11-12.
2 梁娟,李维敏,王艳萍et al.1996-2000年全国孕产妇死亡率变化趋势分析.中华妇产科杂志,2003,38(5):257-260.
3 王临红,王爱玲.农村地区及基层医院预防和处理产后出血的有关问题.实用妇产科杂志,2003,19(5):266-267.
4 中国孕产妇与儿童生存策略研究 北京 2006,50.
5 段涛,丰有吉,狄文主译.威廉姆斯产科学.第21版济南:山东科学技术出版社,2006,561.
6 RoySton E and Armstrong S.(1989) Preventing maternal deaths.Geneva,World Health Organisation.
7 上海产后出血研究协作组.上海市5365例阴道分娩产后出血的剂量研究.上海医学,2001,24(6)327-331.
8 上海产后出血研究协作组.上海市剖宫产出血计量研究.上海医学,2001,24(6)332-335.
9 乐杰.妇产科学.第6版,北京:人民出版社,2005,49.
10 Joupilla P.Postpartum haemorrhage.Curr Opin Obstet,Gynecol,1995,7:446-450.
11 Stones RW,Paterson CM,Saunders NStG Risk factors for major Obstetric haemorrhage.Eur[J]Obstet Cynecol Reprod Biol,1993,48:15-18.
12 Prithchard JA,Baldwin RM,Dickey JC,Wiggins KM.Blood volume Changes in pregnancy and the puerperium.Am[J]ObStet Cynecol,1962,84:1271-1282.
13 Combs CA,Murphy EL,Lars RK Jr Factors associated with postpartum haemorrhage with vaginal Birth[J].Obstet Gynecol,1991,77:74-76.
14 Nordstr ML,Fogelstam K,Fridman G,et al.Routine Oxytocin in third stage of labour:a placebo controlled randomized thal[J].Br J Obstet Gynecol,1997,104:781-786.
15 M.A.IJAIYA,A.P.ABOYEJI and D.ABUBAKAR.Analysis of 348consecutive cases of primary postpartum haemorrhage at a tertiary hospital in Nigeria.Journal of Obstetrics and Gynaecology 2003,23(4):374-377.
16 D.O.Selo-ojeme.Primary postpartum haemorrhage.Journal of Obstetrics and Gynaecology,2002,22(5):463-469.
17 冯洁,戴钟英,吴氢凯等.阴道分娩产后出血量的精确测定与血液指标的关系研究.实用妇产科杂志,2003,19(5):281-283.
18 Prithchard JA.Changes in the blood volume during Pregnancy and delivery.Anesthesiology,1965,26:293.
19 张伟峰,王山米.不同年代产后出血346例临床特点分析.中国妇产科临床杂志,2006,7(5):336-337.
20 凌红.影响产后出血的相关因素探讨.中国妇幼保健,2006,21(6):745.
21 谢芳,赵庆国,田丰莲等.刮宫术和胎盘粘连及相关因素与产后出血的关系.中国妇幼保健,2006,21(10):1325-1326.
22 MazorM,Hershkovitz R,Bash ri Aet al.meconium stained ammiotic fliudin preterm delivery is an independent risk factor for perinatal complications.Eur.J Obstet Gynecol Reprod Biod,1998,81(1):9
23 Ceminski A,Dlugolecki F.Relationship between placenta previa and maternal age,parity and casarean deliveries.Ginekol Pol,2005,76(4):284-289.
24 南京市围产期保健协作组1999年南京市剖宫产术后出血情况分析.中华妇产科杂志,2001,36(10):731.
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32 Dildy,Gary A.Postpartum hemorrhage:new management options.Clin Obstet Gynecol,2002,45(2):330.
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3 Lars H(?)j, Placido C, Birgitte B N, et al. Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial[J].BMJ,2005,331(7519):723.
4 Oboro V. Intrauterine misoprostol for refractorg postpartum hemorrhage[J].Int J Gynaecol Obstet.2003,80(1):67.
5 Lamont R F, Morgan D J, Logue M,et al .Aprospective randomized trial to compare the efficacy and safety of hemabate and syntometrine for the prevention of primary poslpartum haemorrhage[J].Prostaglandins Other Lipid Mediat,2002,66(3):203.
6 Dildy, Gary A.Postpartum hemorrhage:New management options[J].Clin Obstet Gynecol,2002,45(2):330.
7 Franchini M. Post-partum hemorrhage:New therapeutic options[J].Recenti Prog Med, 2007,98(1):7-11.
8 Wee L, Barron J, Toye R.Management of severe postpartum haemorrhage by uterine artery embolization[J]. BJA:British Journal of Anaesthesia,2004,93(4):591-594.
9 Api M, Api O, Yayla M.Fertility after B-Lynch suture and hypogastric artery ligation[J].Fer Til Seril,2005,84(2):509.
10 Descargues G, Mauger T F, Douvrin F, et al.Menses, fertility and pregnancy after arterial embolization for the control of postpartum haemorrhage[J]. Human Reproduction, 2004,19(2):339-343.
2 梁娟,李维敏,王艳萍et al.1996-2000年全国孕产妇死亡率变化趋势分析.中华妇产科杂志,2003,38(5):257-260.
3 王临红,王爱玲.农村地区及基层医院预防和处理产后出血的有关问题.实用妇产科杂志,2003,19(5):266-267.
4 中国孕产妇与儿童生存策略研究 北京 2006,50.
5 段涛,丰有吉,狄文主译.威廉姆斯产科学.第21版济南:山东科学技术出版社,2006,561.
6 RoySton E and Armstrong S.(1989) Preventing maternal deaths.Geneva,World Health Organisation.
7 上海产后出血研究协作组.上海市5365例阴道分娩产后出血的剂量研究.上海医学,2001,24(6)327-331.
8 上海产后出血研究协作组.上海市剖宫产出血计量研究.上海医学,2001,24(6)332-335.
9 乐杰.妇产科学.第6版,北京:人民出版社,2005,49.
10 Joupilla P.Postpartum haemorrhage.Curr Opin Obstet,Gynecol,1995,7:446-450.
11 Stones RW,Paterson CM,Saunders NStG Risk factors for major Obstetric haemorrhage.Eur[J]Obstet Cynecol Reprod Biol,1993,48:15-18.
12 Prithchard JA,Baldwin RM,Dickey JC,Wiggins KM.Blood volume Changes in pregnancy and the puerperium.Am[J]ObStet Cynecol,1962,84:1271-1282.
13 Combs CA,Murphy EL,Lars RK Jr Factors associated with postpartum haemorrhage with vaginal Birth[J].Obstet Gynecol,1991,77:74-76.
14 Nordstr ML,Fogelstam K,Fridman G,et al.Routine Oxytocin in third stage of labour:a placebo controlled randomized thal[J].Br J Obstet Gynecol,1997,104:781-786.
15 M.A.IJAIYA,A.P.ABOYEJI and D.ABUBAKAR.Analysis of 348consecutive cases of primary postpartum haemorrhage at a tertiary hospital in Nigeria.Journal of Obstetrics and Gynaecology 2003,23(4):374-377.
16 D.O.Selo-ojeme.Primary postpartum haemorrhage.Journal of Obstetrics and Gynaecology,2002,22(5):463-469.
17 冯洁,戴钟英,吴氢凯等.阴道分娩产后出血量的精确测定与血液指标的关系研究.实用妇产科杂志,2003,19(5):281-283.
18 Prithchard JA.Changes in the blood volume during Pregnancy and delivery.Anesthesiology,1965,26:293.
19 张伟峰,王山米.不同年代产后出血346例临床特点分析.中国妇产科临床杂志,2006,7(5):336-337.
20 凌红.影响产后出血的相关因素探讨.中国妇幼保健,2006,21(6):745.
21 谢芳,赵庆国,田丰莲等.刮宫术和胎盘粘连及相关因素与产后出血的关系.中国妇幼保健,2006,21(10):1325-1326.
22 MazorM,Hershkovitz R,Bash ri Aet al.meconium stained ammiotic fliudin preterm delivery is an independent risk factor for perinatal complications.Eur.J Obstet Gynecol Reprod Biod,1998,81(1):9
23 Ceminski A,Dlugolecki F.Relationship between placenta previa and maternal age,parity and casarean deliveries.Ginekol Pol,2005,76(4):284-289.
24 南京市围产期保健协作组1999年南京市剖宫产术后出血情况分析.中华妇产科杂志,2001,36(10):731.
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