妊娠期完全性子宫破裂105例临床分析

Clinical Analysis of 105 Cases with Complete Uterine Rupture during Pregnancy

目的:探讨妊娠期瘢痕子宫和无瘢痕子宫完全性子宫破裂的发生率、病因、临床特征及母儿结局.方法:回顾性分析2004年1月至2017年12月云南省33家医疗单位妊娠期完全性子宫破裂的发生情况.收集105例孕妇的一般临床资料、分娩特征、术中所见以及母儿结局,然后按照子宫有无瘢痕史将其分为瘢痕组(65例)和无瘢痕组(40例),对比分析这些指标,并对符合随访条件的母儿进行随访.结果:①瘢痕组妇女不良孕产史、妊娠期糖尿病、子宫原瘢痕破裂比例高于无瘢痕组(P<0.05).无瘢痕组患者高龄产妇、巨大儿、梗阻性难产和医源性产程加速(缩宫素使用不当)、产程中子宫破裂、失血性休克、胎死宫内的比例显著高于瘢痕组(P<0.05).无瘢痕组中的5例因医源性损伤(3例胎头/胎臀吸引,2例产钳助产)发生完全性子宫破裂.②两组患者常见的临床症状分别是产前剧烈腹痛、胎心异常、失血性休克以及产前阴道流血,且无瘢痕组失血性休克比率高于瘢痕组(P<0.05).③瘢痕组子宫下段累及比例高于无瘢痕组(P<0.05),无瘢痕组子宫颈、子宫角受累的比例高于瘢痕组(P<0.05).④无瘢痕组新生儿5分钟Apgar≤7分和胎死宫内的比例高于瘢痕组(P<0.05).而瘢痕组幸存胎儿后续正常发育的比例高于无瘢痕组(P<0.05).结论:瘢痕子宫破裂的主要原因与剖宫产史和腹腔镜下较大子宫肌瘤剔除史有关,无瘢痕子宫破裂主要原因是梗阻性难产、缩宫素使用不当以及宫内操作不当.子宫破裂后常见的临床症状有产前剧烈腹痛、胎心异常、失血性休克等,其中无瘢痕子宫破裂者组织损伤更重,失血量更多,母儿近远期预后更差.

Objective:To analyze the incidence,etiology,clinical characteristics as well as maternal and fetal outcomes in complete uterine rupture with or without scarred uterus. Methods:The information of complete uterine rupture was investigated retrospectively in 33 medical institutions in Yunnan Province from January 2004 to December 2017. The demographic data,delivery characteristics,intraoperative findings,maternal and neonatal outcomes were all collected from 105 case report forms,and then they were divided into scarred group( 65 cases)and unscarred group( 40 cases) according to the history with or without scarred uterus. These data were compared and analyzed,and mother and infant who met the follow-up requirement were followed up. Results:(1)Compared with unscarred group,the proportion of abnormal pregnant history,GDM and scar rupture in situ were higher in the scarred group( P < 0. 05). However,women with unscarred uterus was older,and uterine rupture was more common in labor due to obstructive dystocia with or without oxytocin augmentation,which resulted in hemorrhagic shock,stillbirth( P < 0. 05). In the unscarred group,5 cases had complete uterine rupture due to iatrogenic injury( 3 cases for vacuum extraction,2 cases for forceps).(2)The common clinical symptoms in the two groups were severe antepartum abdominal pain,abnormal fetal heart beat,hemorrhagic shock and antepartum vaginal bleeding respectively. The rate of hemorrhagic shock was higher in the unscarred group than that in the scarred group( P < 0. 05).(3)The rate of lower uterine segment involvement in scarred group was greater than that in unscarred group( P < 0. 05),and the proportion of involvement in cervix and uterine horn in unscarred group was higher than that in scarred group( P < 0. 05).(4)The rate of Apgar score≤7 at 5 minutes and fetal death in the unscarred group were higher than that in the scarred group( P < 0. 05). The proportion of normal development of the surviving fetus in the scarred group was higher than that in the unscarred group( P < 0. 05). Conclusions:The main causes of scarred uterine rupture were associated with cesarean section and laparoscopic myomectomy with larger leiomyoma,while the main reasons of unscarred uterine rupture were obstructive dystocia,oxytocin augmentation and improperly intrauterine operation. The main clinical symptoms of uterine rupture were severe antepartum abdominal pain,abnormal fetal heart beat,hemorrhagic shock and so on. Tissue damage,blood loss as well as maternal and fetal prognosis were more severe in unscarred group.