74例因产后出血切除子宫的原因分析
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摘要
目的:通过病例分析寻找出具有统计学意义的致产后出血子宫切除的产科因素,使每一位临床医师了解导致其发生的相关因素,并在实践工作中做好围产期预防工作,降低产后异常情况致子宫切除的发生。方法:对抽样调查到的近二十年间74例部分不同级别医院分娩的产妇因产后出血切除子宫病例作回顾性分析。分析内容为产妇的一般情况,产次,既往人流史或剖宫产史,产后出血高危因素,产后出血类型,子宫切除指征等;分析1987年-2006年间不同年代、分娩所在的不同级别医院、不同分娩方式下致产后出血子宫切除的原因;影响产后出血子宫切除原因的因素。应用EXCEL软件进行统计学分析,计算相应的构成比,进一步分析影响产后出血子宫切除的相关因素。结果:(1)致产后出血子宫切除的原因包括:胎盘因素(32.4%),产褥感染(29.7%),子宫收缩乏力(24.3%),DIC(9.5%),子宫破裂(4.1%)。(2)致不同时限产后出血的原因构成比不同。其中致产时出血的原因包括:子宫收缩乏力45.0%,胎盘因素30.0%,DIC 17.5%,子宫破裂5.0%,产褥感染2.5%;致晚期产后出血的原因包括:产褥感染61.8%,胎盘因素35.3%,子宫破裂2.9%。(3)不同年代、不同分娩方式、不同级别分娩医院致产后出血子宫切除的原因构成比不同。①1987-1996年产后出血子宫切除原因顺位:产褥感染(53.8%),胎盘因素(23.1%),子宫破裂(15.4%),子宫收缩乏力(7.7%);1997-2006年产后出血子宫切除原因顺位:胎盘因素(34.4%),子宫收缩乏力(27.9%),产褥感染(24.6%),DIC(11.5%),子宫破裂(1.6%)。②经阴道分娩产后出血子宫切除的原因顺位:胎盘因素(34.3%),子宫收缩乏力(31.4%), DIC(17.1%),产褥感染(11.4%),子宫破裂(5.7%);剖宫产分娩产后出血子宫切除的原因顺位:产褥感染(46.2%),胎盘因素(30.8%),子宫收缩乏力(17.9%), DIC(2.6%),子宫破裂(2.6%)。③产后出血子宫切除原因中,省级医院顺位:产褥感染(50.0%),胎盘因素(50.0%);市(县)级医院顺位:胎盘因素(30.2%),子宫收缩乏力(30.2%),产褥感染(26.4%), DIC(9.4%),子宫破裂(3.8%);镇级医院顺位:胎盘因素(60.0%),子宫收缩乏力(40.0%);个体诊所顺位:产褥感染(66.7%),子宫破裂(16.7%), DIC(16.7%);家中顺位:胎盘因素(50.0%),产褥感染(25.0%), DIC(25.0%)。结论:(1)因产后出血导致子宫切除的原因包括子宫收缩乏力、胎盘因素、子宫破裂、产褥感染、DIC,其中以胎盘因素所占比重最大。(2)不同原因在致不同时限产后出血中所占的比重不同,产时出血的主要原因为子宫收缩乏力,晚期产后出血的主要原因为产褥感染。(3)抽样调查结果显示,1997-2006年较1987-1996年致产后出血子宫切除原因构成比发生明显变化,前十年的主要原因为产褥感染,后十年胎盘因素已成为首要因素。(4)胎盘因素是阴道分娩患者中致产后出血子宫切除的主要原因;产褥感染是剖宫产分娩患者中致产后出血子宫切除的主要原因。(5)基层医院分娩患者,其发生产后出血子宫切除的比例高。(6)经产妇、多胎、有剖宫产史或人流史的患者,产后出血子宫切除的比例高。(7)贯彻落实围产期保健,及时发现高危妊娠;实行计划生育,减少人工流产、引产及多孕多产;严格掌握剖宫产指征;严禁非法接生;提高各级医院尤其是乡镇基层医院产科医务人员的技术水平和责任心,严格操作规范,是降低产后出血导致子宫切除的主要措施。
Emergency obstetric hysterectomy is a procedure that potentially preserves the life of pregnancy and the postpartum bleeding is the direct cause of its indication. It is an indispensable life saving tool for the management of intractable obstetric haemorrhage unresponsive to other treatment. Although obstetric hysterectomy is the most effective process to control obstetric haemorrhage, it also is described as a catastrophic procedure for the surgery ends a women’s reproductive life. The available evidence showed that hysterectomy may impact the life quality of these women more or less after operation. To provide evidence for taking appropriate preventive mearsures and try to reduce the occurring of obstetric hysterectomy is an important problem. The objective is to analyze the relative high risk factors in occurring obstetric hysterectomy. The indications for emergency obstetric hysterectomy should be discussed seriously. These results will make clinicians know about variation of indications for emergency obstetric hysterectomy in order to cut down the incidence of obstetric hysterectomy effectly. The method of sampling survey is used to review 74 cases of the obstetric hysterectomy perform in the past 20 years (1987-2006) and make a retrospective study, The content is comprised of parity, the history of induced abortion or uterine-incision delivery, risk factors and type of postpartum hemorrhage, and operational indications. Comparison of reasons was made among different date including the era, rank of delivery hospital and the delivery manner. All the date come from the records in hospital. Statistical analysis was carried out using EXCEL software package to calculate constituent ratio and the results help us to analysis on the cause of 74 obstetrical bleeding cases treated by suing hysterectomy. Results are manifested:⑴The indications of obstetrical bleeding cases treated by suing hysterectomy are placenta factors(32.4%), uterus ruptures(4.1%), atony of uteres(24.3%), puerperal infection(29.7%) and DIC(9.5%).⑵Different type of postpartum hemorrhage have a different constituent ratio of reasons to perform obstetrical hysterectomy. The reasons of intrapartum hemorrhage are atony of uteres (45.0%),placenta factors (30.0%),DIC(17.5%),uterus ruptures (5.0%),puerperal infection (2.5%);The reasons of late postpartum hemorrhage are puerperal infection(61.8%),placenta factors (35.3%),uterus ruptures (2.9%)。⑶Through the compare of the constituent ratio, we can find that the differences are present between different ear, different delivery manners and different rank of delivery hospitals.①The reasons of obstetric hysterectomy between 1987 to 1996 are puerperal infection(53.8%),placenta factors (23.1%),uterus ruptures (15.4%),atony of uteres (7.7%);The reasons of obstetric hysterectomy between 1997 to 2006 are placenta factors (34.4%),atony of uteres (27.9%),puerperal infection (24.6%),DIC(11.5%), uterus ruptures (1.6%)。②The reasons of obstetric hysterectomy which are in vaginal delivery are:placenta factors (34.3%), atony of uteres (31.4%), DIC(17.1%), puerperal infection (11.4%), uterus ruptures (5.7%); The reasons of obstetric hysterectomy which are in cesarean section delivery are:puerperal infection (46.2%), placenta factors (30.8%), atony of uteres (17.9%), DIC(2.6%), uterus ruptures (2.6%)。③The reasons of obstetric hysterectomy are,in the first rank hospital:puerperal infection (50.0%),placenta factors (50.0%);in the second rank hospital:placenta factors (30.2%),atony of uteres (30.2%), puerperal infection (26.4%), DIC(9.4%), uterus ruptures (3.8%); in the third rank hospital:placenta factors (60.0%), atony of uteres (40.0%); in clinic:puerperal infection (66.7%), uterus ruptures (16.7%), DIC(16.7%); in home:placenta factors (50.0%), puerperal infection (25.0%), DIC(25.0%)。The Conclusions are:⑴The major indications of obstetrical bleeding cases treated by suing hysterectomy are placenta factors, uterus ruptures , atony of uteres, puerperal infection and DIC, especially placenta factors.⑵The major cause of intrapartum hemorrhage is atony of uteres and that of late postpartum hemorrhage is puerperal infection.⑶The sample drawing investigation is demonstrated that the constituent ratio of obstetrical emergency hysterectomy make a great change, the leading cause from 1987 to 1996 is puerperal infection and from 1997 to 2006 is placenta factors.⑷Comparing the causes of hysterectomy between the groups of uterine-incision delivery and vaginal delivery, the former is puerperal infection and the latter is placenta factors.⑸The proportion of obstetrical emergency hysterectomy is higher, which have a close relationship with patient's condition and antenatal care and the treatment of gestational complications.⑹There is a high proportion among the multiparas and superfoetations,⑺The valid path that we lower the obstetrical emergency hysterectomy ratio is to carry out perinatal care and discover high risk pregnancy in time, to perform birth control and reduce artificial abortion and induced labor , to grasp indications of uterine-incision delivery , to strictly forbid illegal midwifery and to improve technical leve and responsibility of medical staff.
Emergency obstetric hysterectomy is a procedure that potentially preserves the life of pregnancy and the postpartum bleeding is the direct cause of its indication. It is an indispensable life saving tool for the management of intractable obstetric haemorrhage unresponsive to other treatment. Although obstetric hysterectomy is the most effective process to control obstetric haemorrhage, it also is described as a catastrophic procedure for the surgery ends a women’s reproductive life. The available evidence showed that hysterectomy may impact the life quality of these women more or less after operation. To provide evidence for taking appropriate preventive mearsures and try to reduce the occurring of obstetric hysterectomy is an important problem. The objective is to analyze the relative high risk factors in occurring obstetric hysterectomy. The indications for emergency obstetric hysterectomy should be discussed seriously. These results will make clinicians know about variation of indications for emergency obstetric hysterectomy in order to cut down the incidence of obstetric hysterectomy effectly. The method of sampling survey is used to review 74 cases of the obstetric hysterectomy perform in the past 20 years (1987-2006) and make a retrospective study, The content is comprised of parity, the history of induced abortion or uterine-incision delivery, risk factors and type of postpartum hemorrhage, and operational indications. Comparison of reasons was made among different date including the era, rank of delivery hospital and the delivery manner. All the date come from the records in hospital. Statistical analysis was carried out using EXCEL software package to calculate constituent ratio and the results help us to analysis on the cause of 74 obstetrical bleeding cases treated by suing hysterectomy. Results are manifested:⑴The indications of obstetrical bleeding cases treated by suing hysterectomy are placenta factors(32.4%), uterus ruptures(4.1%), atony of uteres(24.3%), puerperal infection(29.7%) and DIC(9.5%).⑵Different type of postpartum hemorrhage have a different constituent ratio of reasons to perform obstetrical hysterectomy. The reasons of intrapartum hemorrhage are atony of uteres (45.0%),placenta factors (30.0%),DIC(17.5%),uterus ruptures (5.0%),puerperal infection (2.5%);The reasons of late postpartum hemorrhage are puerperal infection(61.8%),placenta factors (35.3%),uterus ruptures (2.9%)。⑶Through the compare of the constituent ratio, we can find that the differences are present between different ear, different delivery manners and different rank of delivery hospitals.①The reasons of obstetric hysterectomy between 1987 to 1996 are puerperal infection(53.8%),placenta factors (23.1%),uterus ruptures (15.4%),atony of uteres (7.7%);The reasons of obstetric hysterectomy between 1997 to 2006 are placenta factors (34.4%),atony of uteres (27.9%),puerperal infection (24.6%),DIC(11.5%), uterus ruptures (1.6%)。②The reasons of obstetric hysterectomy which are in vaginal delivery are:placenta factors (34.3%), atony of uteres (31.4%), DIC(17.1%), puerperal infection (11.4%), uterus ruptures (5.7%); The reasons of obstetric hysterectomy which are in cesarean section delivery are:puerperal infection (46.2%), placenta factors (30.8%), atony of uteres (17.9%), DIC(2.6%), uterus ruptures (2.6%)。③The reasons of obstetric hysterectomy are,in the first rank hospital:puerperal infection (50.0%),placenta factors (50.0%);in the second rank hospital:placenta factors (30.2%),atony of uteres (30.2%), puerperal infection (26.4%), DIC(9.4%), uterus ruptures (3.8%); in the third rank hospital:placenta factors (60.0%), atony of uteres (40.0%); in clinic:puerperal infection (66.7%), uterus ruptures (16.7%), DIC(16.7%); in home:placenta factors (50.0%), puerperal infection (25.0%), DIC(25.0%)。The Conclusions are:⑴The major indications of obstetrical bleeding cases treated by suing hysterectomy are placenta factors, uterus ruptures , atony of uteres, puerperal infection and DIC, especially placenta factors.⑵The major cause of intrapartum hemorrhage is atony of uteres and that of late postpartum hemorrhage is puerperal infection.⑶The sample drawing investigation is demonstrated that the constituent ratio of obstetrical emergency hysterectomy make a great change, the leading cause from 1987 to 1996 is puerperal infection and from 1997 to 2006 is placenta factors.⑷Comparing the causes of hysterectomy between the groups of uterine-incision delivery and vaginal delivery, the former is puerperal infection and the latter is placenta factors.⑸The proportion of obstetrical emergency hysterectomy is higher, which have a close relationship with patient's condition and antenatal care and the treatment of gestational complications.⑹There is a high proportion among the multiparas and superfoetations,⑺The valid path that we lower the obstetrical emergency hysterectomy ratio is to carry out perinatal care and discover high risk pregnancy in time, to perform birth control and reduce artificial abortion and induced labor , to grasp indications of uterine-incision delivery , to strictly forbid illegal midwifery and to improve technical leve and responsibility of medical staff.
引文
1. Plauche W. Peripartal hysterectomy. Obstet Gynecol Clin North Am,1988,15:783–95.
2. Radeka G,Milasinovic L,Vejnovic T,et al. Cesarean hysterectomy in modern obstetrical practice from 1968 to 1993. Med Pregl,1997,50(9-10) : 375.
3. 王莹. 围产期子宫切除 32 例分析. 实用妇产科杂志,2002, 18(3):168-9.
4. 马永清,边旭明,郎景和. 产科临床中的子宫切除术. 中国实用妇科与产科杂志,2001,17 (1) : 39-41.
5. 高云荷. 产后出血原因及高危因素分析. 实用妇产科杂志. 2003,19 (5): 258-60.
6. 全国孕产妇死亡监测协作组. 全国孕产妇死亡监测结果分析. 中华妇产科杂志. 1999,34 (11) : 645.
7. 蔡斐茜,孙宝洁,韩克. 绝经前切除子宫对妇女健康的影响. 实用妇科与产科杂志,1991,7 (2) :79.
8. 蔡斐茜.子宫良性病变手术时卵巢去留问题. 中华妇产科杂志,1984,19 (2) :116.
9. 任庆艳. 产科急症子宫次全切除术指征探讨. 河北医药,2004,26(4):338.
10.Bakshi S,Meyer BA. Indication for and outcomes of emergency peripartum hysterectomy: A five-year review. J Reprod Med,2000,45:733–7.
11.Combs CA,Murphy EL,Laros RK.Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol,1991,77:77–82.
12.Gilbert WM,Danielsen B. Amniotic fluid embolism: decreased moryality in a population based study. Obstet Gynecol,1999, 93 :93.
13.Carey MJ,Rodgers GM. Disse minated intravascular coagulation :clinical andlaboratory aspects. Am J He matol,1998,59 (1) :65.
14.彭家俊,杨梦庚,施德大. 130 年产科子宫切除的经验. 中华妇产科杂志,1991,26(6) :367.
15.乐杰. 妇产科学. 第6 版. 北京:人民卫生出版社,2004,121.
16.杨剑秋,盖铭英. 剖宫产术后晚期出血的原因. 实用妇产科杂志, 2001,17 (3) : 125-6.
17.周齐,张文敏,李虹. 子宫切除术治疗产科出血51 例分析. 实用妇产科杂志,2001,17 (3) :149.
18.郑平,黄醒华,王淑珍. 35 年剖宫产率及适应症的变化. 中华妇产科杂志,1996,31(31):134-7.
19.Oguz Yucel,Ismail Ozdemir,Nese Yucel Asl?. Emergency peripartum hysterectomy: a 9-year review. Arch Gynecol Obstet,2006,124.
20.Loraine K,Endres,Kurt Barnhart. Spontaneous second trimester uterine rupture after classical cesarean . Obstetrics & Gynecology,2000,96(5):806-8.
21.林仙芝 ,李长华. 产科子宫切除术适应证的探讨. 苏州医学院学报,1994,14(1):7.
22.傅莉,崔满华,陈军. 影响剖宫产率与剖宫产指征的因素分析. 中国实用妇科与产科杂志,2003,19(7):15-7.
23.Thonet RGN. Obstetric hysterectomy - an 11 - year experience BrJobstat Gynecol,1996,93 (8) :794 -8.
24.Wai Yoong,Nadine Massiah,Ade Oluwu. Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population. Arch Gynecol Obstet,2006,274: 37-40.
25.马庭元. 剖宫产围手术期预防性用抗生素与术后病率. 中国实用妇科与产科杂志,1990,6 (1) :9.
26.Jennifer Kacmar,Lisa Bhimani,Mary Boyd. Route of delivery as a risk factor for emergent peripartum hysterectomy: a case–control study.Obstetrics & Gynecology,2003,102(1):141-5.
27. 袁 淑 玉 . 331 例 产 后 出 血 相 关 因 素 临 床 分 析 . 实 用 预 防 医学,2004,11(3):572-3.
28.John C. The effect of magnesium sulfate on fetal heart rate variability and uterine activity. Am J Obstet Gynecol,1980,140 :702.
29.Jeffrey MB,Frank HB,Allen PK. Induced abortion : a risk factor placenta previa. Am J Obstet Gynecol,1981 ,141 (2) :769.
30.阮长耿. 血栓与出血——现代理论和临床实践. 南京:江苏科技出版社,1994,11:331.
31.Cunningham FG,Grant NF,Gilstrap LC. Williams obstetrics. 21st edn.McGraw-Hill, 2001.
32.曹泽毅. 中华妇产科学. 北京:人民卫生出版社,1999,835 -6.
2. Radeka G,Milasinovic L,Vejnovic T,et al. Cesarean hysterectomy in modern obstetrical practice from 1968 to 1993. Med Pregl,1997,50(9-10) : 375.
3. 王莹. 围产期子宫切除 32 例分析. 实用妇产科杂志,2002, 18(3):168-9.
4. 马永清,边旭明,郎景和. 产科临床中的子宫切除术. 中国实用妇科与产科杂志,2001,17 (1) : 39-41.
5. 高云荷. 产后出血原因及高危因素分析. 实用妇产科杂志. 2003,19 (5): 258-60.
6. 全国孕产妇死亡监测协作组. 全国孕产妇死亡监测结果分析. 中华妇产科杂志. 1999,34 (11) : 645.
7. 蔡斐茜,孙宝洁,韩克. 绝经前切除子宫对妇女健康的影响. 实用妇科与产科杂志,1991,7 (2) :79.
8. 蔡斐茜.子宫良性病变手术时卵巢去留问题. 中华妇产科杂志,1984,19 (2) :116.
9. 任庆艳. 产科急症子宫次全切除术指征探讨. 河北医药,2004,26(4):338.
10.Bakshi S,Meyer BA. Indication for and outcomes of emergency peripartum hysterectomy: A five-year review. J Reprod Med,2000,45:733–7.
11.Combs CA,Murphy EL,Laros RK.Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol,1991,77:77–82.
12.Gilbert WM,Danielsen B. Amniotic fluid embolism: decreased moryality in a population based study. Obstet Gynecol,1999, 93 :93.
13.Carey MJ,Rodgers GM. Disse minated intravascular coagulation :clinical andlaboratory aspects. Am J He matol,1998,59 (1) :65.
14.彭家俊,杨梦庚,施德大. 130 年产科子宫切除的经验. 中华妇产科杂志,1991,26(6) :367.
15.乐杰. 妇产科学. 第6 版. 北京:人民卫生出版社,2004,121.
16.杨剑秋,盖铭英. 剖宫产术后晚期出血的原因. 实用妇产科杂志, 2001,17 (3) : 125-6.
17.周齐,张文敏,李虹. 子宫切除术治疗产科出血51 例分析. 实用妇产科杂志,2001,17 (3) :149.
18.郑平,黄醒华,王淑珍. 35 年剖宫产率及适应症的变化. 中华妇产科杂志,1996,31(31):134-7.
19.Oguz Yucel,Ismail Ozdemir,Nese Yucel Asl?. Emergency peripartum hysterectomy: a 9-year review. Arch Gynecol Obstet,2006,124.
20.Loraine K,Endres,Kurt Barnhart. Spontaneous second trimester uterine rupture after classical cesarean . Obstetrics & Gynecology,2000,96(5):806-8.
21.林仙芝 ,李长华. 产科子宫切除术适应证的探讨. 苏州医学院学报,1994,14(1):7.
22.傅莉,崔满华,陈军. 影响剖宫产率与剖宫产指征的因素分析. 中国实用妇科与产科杂志,2003,19(7):15-7.
23.Thonet RGN. Obstetric hysterectomy - an 11 - year experience BrJobstat Gynecol,1996,93 (8) :794 -8.
24.Wai Yoong,Nadine Massiah,Ade Oluwu. Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population. Arch Gynecol Obstet,2006,274: 37-40.
25.马庭元. 剖宫产围手术期预防性用抗生素与术后病率. 中国实用妇科与产科杂志,1990,6 (1) :9.
26.Jennifer Kacmar,Lisa Bhimani,Mary Boyd. Route of delivery as a risk factor for emergent peripartum hysterectomy: a case–control study.Obstetrics & Gynecology,2003,102(1):141-5.
27. 袁 淑 玉 . 331 例 产 后 出 血 相 关 因 素 临 床 分 析 . 实 用 预 防 医学,2004,11(3):572-3.
28.John C. The effect of magnesium sulfate on fetal heart rate variability and uterine activity. Am J Obstet Gynecol,1980,140 :702.
29.Jeffrey MB,Frank HB,Allen PK. Induced abortion : a risk factor placenta previa. Am J Obstet Gynecol,1981 ,141 (2) :769.
30.阮长耿. 血栓与出血——现代理论和临床实践. 南京:江苏科技出版社,1994,11:331.
31.Cunningham FG,Grant NF,Gilstrap LC. Williams obstetrics. 21st edn.McGraw-Hill, 2001.
32.曹泽毅. 中华妇产科学. 北京:人民卫生出版社,1999,835 -6.