胎盘早剥导致子宫切除23例分析
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摘要
目的：分析产科子宫切除的原因及正确掌握适应证。子宫切除术是抢救孕产妇生命、治疗产科急性子宫出血而采取的一种有效治疗措施,产科子宫切除是临床上用于产科严重出血但经其他方法(如药物、按摩子宫、宫腔填塞纱条、结扎子宫动脉等)治疗无效,抢救孕产妇生命的有效措施。由于孕妇年轻,术后将丧失生育的能力,而失去手术时机又可导致病人死亡,故应严格掌握手术指征及早准确地做出决定适时实施手术。
方法：回顾分析我院10年间23例经积极保守治疗无效的产后出血患者行紧急切除子宫,总结产科子宫切除的具体原因。现将我院1999年1月-2009年6月分娩的16244例,因胎盘早剥行子宫切除23例进行分析,其中在本院分娩的产妇行子宫切除18例,占分娩总数的0.11%,其中剖宫产术5例,占27.78%,阴道分娩11例,占61.11%,中期引产2例,占11.11%。外院急诊因胎盘早剥转入行子宫切除5例。
结果：胎盘因素是造成产后出血而行急症子宫切除术的主要原因。胎盘早剥对母婴预后影响很大,故一经确诊,应积极治疗,纠正休克,及时终止妊娠,争取胎儿存活,减少并发症。分娩方式应根据孕妇病情轻重、产程进展、产式、胎儿宫内状况等决定。如果产妇一般状况好、宫口开大、估计短时间内就能结束分娩,可在严密监护下阴道试产,宫口开大后可尽快阴道助产。对于属于轻型胎盘早剥但已有胎儿窘迫和重型胎盘早剥,短时间内不能结束分娩者,不论胎儿存活与否,均应尽快剖宫产结束分娩,以提高围产儿存活率,避免发生子宫胎盘卒中。早期诊断可以降低子宫胎盘卒中的发生。若已出现,术中取出胎儿、胎盘后立即应用宫缩剂,快速缝合子宫切口保持其完整性,用热生理盐水纱垫湿敷、按摩子宫促使其收缩,减少出血。若子宫色泽转红,出血不多,可保留子宫,如经上述处理,子宫仍呈紫蓝色、袋状不收缩,出血仍多,可在输液、输血抢救休克的同时果断行子宫次全切除术。子宫次全切除术不但符合妇女分泌及心理、生理要求,而且术式简单,止血快、出血少、操作者易掌握,但因手术为急诊,阴道准备不够充分,子宫全切易造成术后感染。但对于子宫破裂累及宫颈、羊水栓塞者应以全子宫切除为宜,由于子宫经常水肿充血,破裂后解剖结构不清楚,术中一定要仔细分离,避免损伤膀胱及输尿管。注意残端应严格消毒缝合,止血更要彻底,切不可以掉以轻心。
结论：积极正确处理产程及产科并发症,严格掌握剖宫产指征,降低剖宫产率,从而减少产科子宫切除的发生。
Objective:Analysis of obstetric hysterectomy and correct the indications of the reasons. Hysterectomy is the treatment of acute obstetric uterine bleeding, rescue the life of pregnant women to take an effective treatment measures, Obstetric hysterectomy is a clinic for severe obstetric hemorrhage through other methods (such as medicines, massage the uterus, uterine artery ligation, uterine packing gauze, etc.) ineffective treatment for life-saving maternal and effective measures. As pregnant women young, after the loss of fertility, while the loss of timing of surgery can also cause deaths, so the need to strictly control surgical indications early and accurate decision on timely implementation of the operation.
Methods:Retrospective analysis of 10 years in our hospital 23 cases of ineffective conservative treatment after a positive patients with postpartum hemorrhage an emergency hysterectomy, sum up the specific reasons for obstetric hysterectomy. Now in our hospital in January 1999 June 2009 delivery of 16,244 cases, because of placental abruption-line analysis of 23 cases of hysterectomy, In which to give birth in our hospital 18 cases of maternal line of hysterectomy, accounting for total number of deliveries of 0.11%,11 cases in which vaginal delivery, accounting for 61.11%, cesarean section in 5 cases, accounting for 27.78 percent, medium-term abortion in 2 cases, accounting for 11.11%.. Outside the hospital emergency hysterectomy due to placental abruption into the line in 5 cases.
Results:Placental factor is the build-line post-partum bleeding, emergency hysterectomy in the main indications. A great impact on maternal and infant prognosis of placental abruption, so, once diagnosed, should be actively treated, correct shock, and timely termination of pregnancy, fetal survival fight and reduce complications. Mode of delivery should be based on the severity of maternal illness, fetal status, birth process, production type, and so decided to. If the mothers in general in good condition, cervix, estimated to bring an end to birth a short time, could in the intensive care under the vaginal trial production, opening its mouth as soon as the Palace of vaginal delivery. For this stage a light but there are fetal distress, placental abruption and severe placental abruption, a short time can not be the end of maternity leave, regardless of whether the fetus to survive, should be give cesarean section delivery as soon as possible in order to improve perinatal survival, in order to avoid uteroplacental apo-plexy. Early diagnosis can reduce the incidence of uteroplacental apoplexy. If it has occurred, surgery to remove the baby, placenta im-mediately after application of contraction agents, quickly suture the uterine incision in order to maintain its integrity, with hot saline gauze wet packing, massage the uterus to promote contraction, reduce bleeding. If the uterus color to red, bleeding much, it can keep the uterus, if after the above treatment, the uterus continued to show a purple blue, pocket does not shrink more than the amount of bleeding should be transfusion, blood transfusion to save shock at the same time decisive line of hysterectomy surgery. Hysterectomy surgery is not only consistent with secretion and women's physical, psychological demands, but also surgical simple, fast bleeding, less bleed-ing, the operator easy to master, and due to emergency surgery, vaginal preparations inadequate hysterectomy easily lead to postoperative infection. But for amniotic fluid embolism, uterine rupture involving the cervix were in full hysterectomy is appropriate, Congestion and edema are often due to uterine rupture after the anatomical structures is unclear, surgery should be carefully separated, Ureter and bladder to avoid injury, pay attention to rigorous disinfection of stump suture, hemostasis should be thorough and must not be taken lightly.
Conclusions:Birth process and obstetrics complication were treated correctly,the rate of cesarean section were reduced effectively,all this can help to decrease the incidence of obstetric hysterectomy.
方法：回顾分析我院10年间23例经积极保守治疗无效的产后出血患者行紧急切除子宫,总结产科子宫切除的具体原因。现将我院1999年1月-2009年6月分娩的16244例,因胎盘早剥行子宫切除23例进行分析,其中在本院分娩的产妇行子宫切除18例,占分娩总数的0.11%,其中剖宫产术5例,占27.78%,阴道分娩11例,占61.11%,中期引产2例,占11.11%。外院急诊因胎盘早剥转入行子宫切除5例。
结果：胎盘因素是造成产后出血而行急症子宫切除术的主要原因。胎盘早剥对母婴预后影响很大,故一经确诊,应积极治疗,纠正休克,及时终止妊娠,争取胎儿存活,减少并发症。分娩方式应根据孕妇病情轻重、产程进展、产式、胎儿宫内状况等决定。如果产妇一般状况好、宫口开大、估计短时间内就能结束分娩,可在严密监护下阴道试产,宫口开大后可尽快阴道助产。对于属于轻型胎盘早剥但已有胎儿窘迫和重型胎盘早剥,短时间内不能结束分娩者,不论胎儿存活与否,均应尽快剖宫产结束分娩,以提高围产儿存活率,避免发生子宫胎盘卒中。早期诊断可以降低子宫胎盘卒中的发生。若已出现,术中取出胎儿、胎盘后立即应用宫缩剂,快速缝合子宫切口保持其完整性,用热生理盐水纱垫湿敷、按摩子宫促使其收缩,减少出血。若子宫色泽转红,出血不多,可保留子宫,如经上述处理,子宫仍呈紫蓝色、袋状不收缩,出血仍多,可在输液、输血抢救休克的同时果断行子宫次全切除术。子宫次全切除术不但符合妇女分泌及心理、生理要求,而且术式简单,止血快、出血少、操作者易掌握,但因手术为急诊,阴道准备不够充分,子宫全切易造成术后感染。但对于子宫破裂累及宫颈、羊水栓塞者应以全子宫切除为宜,由于子宫经常水肿充血,破裂后解剖结构不清楚,术中一定要仔细分离,避免损伤膀胱及输尿管。注意残端应严格消毒缝合,止血更要彻底,切不可以掉以轻心。
结论：积极正确处理产程及产科并发症,严格掌握剖宫产指征,降低剖宫产率,从而减少产科子宫切除的发生。
Objective:Analysis of obstetric hysterectomy and correct the indications of the reasons. Hysterectomy is the treatment of acute obstetric uterine bleeding, rescue the life of pregnant women to take an effective treatment measures, Obstetric hysterectomy is a clinic for severe obstetric hemorrhage through other methods (such as medicines, massage the uterus, uterine artery ligation, uterine packing gauze, etc.) ineffective treatment for life-saving maternal and effective measures. As pregnant women young, after the loss of fertility, while the loss of timing of surgery can also cause deaths, so the need to strictly control surgical indications early and accurate decision on timely implementation of the operation.
Methods:Retrospective analysis of 10 years in our hospital 23 cases of ineffective conservative treatment after a positive patients with postpartum hemorrhage an emergency hysterectomy, sum up the specific reasons for obstetric hysterectomy. Now in our hospital in January 1999 June 2009 delivery of 16,244 cases, because of placental abruption-line analysis of 23 cases of hysterectomy, In which to give birth in our hospital 18 cases of maternal line of hysterectomy, accounting for total number of deliveries of 0.11%,11 cases in which vaginal delivery, accounting for 61.11%, cesarean section in 5 cases, accounting for 27.78 percent, medium-term abortion in 2 cases, accounting for 11.11%.. Outside the hospital emergency hysterectomy due to placental abruption into the line in 5 cases.
Results:Placental factor is the build-line post-partum bleeding, emergency hysterectomy in the main indications. A great impact on maternal and infant prognosis of placental abruption, so, once diagnosed, should be actively treated, correct shock, and timely termination of pregnancy, fetal survival fight and reduce complications. Mode of delivery should be based on the severity of maternal illness, fetal status, birth process, production type, and so decided to. If the mothers in general in good condition, cervix, estimated to bring an end to birth a short time, could in the intensive care under the vaginal trial production, opening its mouth as soon as the Palace of vaginal delivery. For this stage a light but there are fetal distress, placental abruption and severe placental abruption, a short time can not be the end of maternity leave, regardless of whether the fetus to survive, should be give cesarean section delivery as soon as possible in order to improve perinatal survival, in order to avoid uteroplacental apo-plexy. Early diagnosis can reduce the incidence of uteroplacental apoplexy. If it has occurred, surgery to remove the baby, placenta im-mediately after application of contraction agents, quickly suture the uterine incision in order to maintain its integrity, with hot saline gauze wet packing, massage the uterus to promote contraction, reduce bleeding. If the uterus color to red, bleeding much, it can keep the uterus, if after the above treatment, the uterus continued to show a purple blue, pocket does not shrink more than the amount of bleeding should be transfusion, blood transfusion to save shock at the same time decisive line of hysterectomy surgery. Hysterectomy surgery is not only consistent with secretion and women's physical, psychological demands, but also surgical simple, fast bleeding, less bleed-ing, the operator easy to master, and due to emergency surgery, vaginal preparations inadequate hysterectomy easily lead to postoperative infection. But for amniotic fluid embolism, uterine rupture involving the cervix were in full hysterectomy is appropriate, Congestion and edema are often due to uterine rupture after the anatomical structures is unclear, surgery should be carefully separated, Ureter and bladder to avoid injury, pay attention to rigorous disinfection of stump suture, hemostasis should be thorough and must not be taken lightly.
Conclusions:Birth process and obstetrics complication were treated correctly,the rate of cesarean section were reduced effectively,all this can help to decrease the incidence of obstetric hysterectomy.
引文
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