难治性产后出血切除子宫病例的临床特点和危险因素

Clinical charateristcs and high risk factors of intractable postpartum hemorrhage requiring hysterectomy:analysis of 152 patients

目的探讨难治性产后出血子宫切除病例的临床特点和危险因素。方法本研究为回顾性研究。研究对象为2005年1月至2016年3月北京大学第一医院产科诊治的难治性产后出血患者。分析切除与未切除子宫(即切除子宫组与保留子宫组)患者的一般情况、病因和危险因素,以及并发症发生情况和结局。采用t检验、秩和检验和Logistic回归分析等方法,对数据进行统计学分析。结果(1)研究期间共收治152例难治性产后出血病例,占同期住院分娩产妇的0.3%(152/48 694)。其中111例(73.0%)于本院定期行产前检查,41例(27.0%)由外院因高危妊娠转诊。152例产后24 h总出血量1 807(1 027~10 000)ml,输注红细胞6(2~42)U。其中29例(19.1%)切除子宫,总的子宫切除率为0.060%。(2)子宫切除组≥1次剖宫产史的比例[62.1%(18/29)与9.8%(12/123),χ^2=40.541],以及产后24 h总出血量和输注红细胞量均高于保留子宫组[5 145(2 061~10 000)与1 586(1 027~7 350)ml,Z=-7.671;24(6~42)与6(2~40)U,Z=-7.485] (P值均<0.05)。(3)难治性产后出血病因包括宫缩乏力(66例,43.4%),胎盘因素(58例,38.2%),软产道损伤(21例,13.8%)和凝血功能障碍(7例,4.6%)。切除子宫组胎盘因素和凝血功能障碍的比例显著高于保留子宫组[69.0%(20/29)与30.9%(38/123),OR(95%CI)为4.971(2.071~11.912);20.7%(6/29)与0.8%(1/123),OR(95%CI)为31.826(3.654~276.132)],宫缩乏力的比例小于保留子宫组[3.4%(1/29)与52.8%(65/123),OR(95%CI)为0.032(0.001~0.241)](P值均<0.01)。2组软产道损伤的比例差异无统计学意义。(4)152例产妇中,27例(17.8%)收住重症监护病房;24例(15.8%)发生严重并发症。切除子宫组并发症发生率及转重症监护病房的比例均显著高于保留子宫组[65.5%(19/29)与4.1%(5/123),χ^2=72.423;72.4%(21/29)与4.9%(6/123),χ^2=73.273;P值均<0.001]。结论剖宫产史伴胎盘植入是难治性产后出血切除子宫的首要原因。合并凝血功能障碍的产妇发生难治性产后出血时,切除子宫的风险最大。子宫破裂所致的难治性产后出血也不容忽视。虽然宫缩乏力仍然是难治性产后出血的第一位原因,但是在医疗资源充分和技术手段齐备的医院,多可通过保守手术成功保留子宫。

Objective To explore the clinical characteristics and etiology of intractable postpartum hemorrhage requiring hysterectomy.Methods We retrospectively collected 152 patients with intractable postpartum hemorrhage between January 2005 and March 2016 in Department of Obstetrics and Gynecology of Peking University First Hospital. Analysis was conducted to identify the general status, etiology, high risk factors, complications and outcome of patients with or without hysterectomy (hysterectomy group and conservative group). T-test, Rank sum test, and Logistic regression analysis were applied in the statistical analysis.Results (1) Totally 152 patients were identified, accounting for 0.3% of total deliveries during the study period (152/48 694). Among them, 111 cases (73.0%) received routine prenatal care in our hospital; and 41 cases (27.0%) were transferred from other hospitals for high-risk pregnancy. The median blood loss within 24 h after delivery was 1 807(1 027-10 000) ml and 6 (2-42) U of red blood cells was transfused. Totally, uterus was removed in 29 cases (19.1%), with a hysterectomy rate of 0.060% (29/48 694) among all deliveries. (2) The proportion of women with previous cesarean sections [62.1%(18/29) vs 9.8%(12/123), χ^2=40.541], the total amount of blood loss within 24 h postpartum [5 145(2 061-10 000) vs 1 586 (1 027-7 350) ml, Z=-7.671] and of transfused red blood cells [24(6-42) vs 6(2-40) U, Z=-7.485] were all significantly higher in the hysterectomy group than those of the conservative group. (3) The main causes for intractable postpartum hemorrhage were uterine atony (66/152, 43.4%), placental factors (58/152, 38.2%), soft birth canal injury (21/152, 13.8%) and coagulation dysfunction (7/152, 4.6%). The proportions of placenta factors and coagulation dysfunction in hysterectomy group were higher than those of the conservative group [69.0%(20/29) vs 30.9%(38/123), OR(95%CI): 4.971(2.071-11.912); 20.7%(6/29) vs 0.8%(1/123), OR(95%CI): 31.826(3.654-276.132)], while the proportion of uterine atony was lower [3.4%(1/29) and 52.8%(65/123), OR(95%CI): 0.032(0.001-0.241)] (all P<0.01). No statistical difference was shown in the proportion of soft birth canal injury between the two groups. (4) Among the 152 cases, 17.8%(27/152) were admitted into the intensive care unit (ICU) and 15.8%(24/152) experienced severe complications. More postpartum women developed severe complications or being transferred to the ICU in the hysterectomy group than in the conservative group [65.5%(19/29) vs 4.1% (5/123), χ^2=72.423; 72.4%(21/29) vs 4.9%(6/123), χ^2=73.273; all P<0.001].Conclusions For women with intractable postpartum hemorrhage cases requiring hysterectomy, previous cesarean section complicating with placenta accreta, is the major reason, while those complicated with coagulation dysfunction carries the highest risk. Meanwhile, those caused by uterine rupture should not be ignored. Although uterine atony remains the leading cause, uterus may be preserved through conservative surgery in most cases in hospitals with adequate medical resources and techniques.