严重产后出血产妇保留子宫的可能性

Possibility of reserving uterus during severe postpartum hemorrhage

目的探讨严重产后出血时产妇保留子宫的可能性。方法回顾性分析2003年1月1日至2009年12月31日138例严重产后出血（出血量≥2000ml）病例资料。结果138例严重产后出血的病例中，子宫收缩乏力所致者占首位（60例，43．48％），其次为胎盘因素（55例，39．86％），出血量2000-10000ml，平均（3004±1473）ml。138例均输血，输血量800～7200ml。其中108例保留子宫病例出血量2000～7500ml，平均（2546±932）ml；30例子宫切除病例，出血量2500-10000ml，平均（4653±1857）ml，差异有统计学意义（t=8．57，P=0．00）。将所有病例分成前后2阶段比较：2003年至2005年子宫切除12例，发生率0．47‰，2006年至2009年子宫切除18例，发生率0．36％0；2组平均出血量分别为（3783±861）ml及（5233±2124）ml，差异有统计学意义（t=2．234，P=0．034）。产后出血达3000ml以上病例中，保留子宫24例，平均出血量（3818±1284）ml；切除子宫27例，平均出血量（4900±1789）ml，2组差异有统计学意义（t=2．453，P=0．018）。2组出血量达3000ml所用时间分别为（160±129）min及（100±67）min，差异有统计学意义（t=2.113，P=0．04）。6例产后出血≥4000ml且成功保留子宫的病例，平均出血量5570ml。138例产妇中2例死亡，皆为羊水栓塞所致。围产儿死亡率3．73％。结论产后出血量及出血速度是决定能否保留子宫的关键。对于具有出血高危因素的人群，应提前预防性应用前列腺素制剂，以减少出血量。宫腔填纱是有效的止血方法，尤其适用于前置胎盘引起的出血。

Objective To investigate the possibility of reserving uterus during severe postpartum hemorrhage. Methods A retrospective analysis was conducted on the clinical data of 138 cases of severe postpartum hemorrhage （blood loss ≥2000 ml） from January 1, 2003 to December 31, 2009. Results Among 138 cases of severe postpartum hemorrhage, uterine atony （n= 60, 43. 38%） was the first cause and the second was placental factor （n= 55, 39.86 %）. The blood loss varied from 2000 ml to 10 000 ml and the mean level was about （3004±1473） ml. The volume of blood transfusion for these patients varied from 800 ml to 7200 ml. Among these patients, the blood loss of 108 cases reserved uteri was from 2000 ml to 7500 ml, with the average of （2564±932） ml; while for 30 cases performed with hysterectomy, the blood loss was about 2500 to 10 000 ml averagly （4653±1857） ml （t=8. 57, P=0. 00）. These patients were divided into two groups according to time series. Twelve cases of hysterectomy were performed during 2003 to 2005, and the hysterectomy rate was 0. 47%0; 18 cases of hysterectomy were performed during 2006 to 2009, and the hysterectomy rate was 0. 360/000. The average blood loss of the above two groups was （3783±861） ml and （5233±2124） ml respectively （t=2. 234, P=0. 034）. Among all the cases with blood loss 3000 ml, uteri were reserved in 24 cases with the average blood loss of （3818 ±1284） ml; while hysterectomy were performed in 27 cases with average blood loss of （4900±1789） ml （t=2. 453, P= 0. 018）. The time for blood loss to 3000 ml in the two groups was （160±129） min and （100±67） min, respectively, and the difference was significant （t=2.113, P= 0.04）. The uteri of six cases with postpartum hemorrhage over 4000 ml were successfully reserved, and average bleeding amount was 5570 ml.Two patients among the 138 women died of amniotic fluid embolism. The perinatal mortality rate was 3.73%. Conclusions The postpartum hemorrhage volume and velocity is the key point to decide whether to reserve the uterus or not. For the population with high risk factors, prophylaxis treatment with pmstaglandins should be initiated to reduce the bleeding volume. Uterine packing might be an effective treatment to stop postpartum hemorrhage, especially for those bleeding due to placenta previa.