26例难治性产后出血的治疗体会

The treatment experience of 26 cases with intractable postpartum hemorrhage

目的探讨外科手术及介入手术治疗难治性产后出血的结局,为临床医师选择合适的治疗方法提供参考依据。方法回顾性分析山西省运城市中心医院产科2014年1月至2016年1月收治的202例产后出血患者中,难治性产后出血26例﹙12.9%﹚的临床资料。依据不同治疗方法分为2组,采用外科手术的患者称为外科手术组,共12例;采用介入治疗的患者称为介入治疗组,共14例。比较两组患者出血量、治疗休克纠正时间、输血量、住院时间、子宫切除率。结果 (1)12例外科手术组中4例为产后出血急诊子宫切除术后再次腹腔内出血;1例剖宫产剔除肌瘤,1例瘢痕子宫剖宫产,1例剖宫产腹壁血肿,1例产程停滞剖宫产,1例凶险型前置胎盘合并穿透性胎盘植入,1例羊水栓塞;1例阴道壁裂伤至子宫下段,1例产后子宫收缩乏力。14例介入治疗组,剖宫产3例,分别为1例子宫收缩乏力,2例晚期产后出血;阴道分娩11例,分别为2例子宫收缩乏力,1例胎盘植入,8例晚期产后出血。(2)外科手术组与介入治疗组比较,总出血量[(5 600±850)m L vs(2 130±130)m L]、手术时间[(115±12)min vs(54±3)min]、休克纠正时间[(5.32±0.58)h vs(2.12±0.23)h]、输浓缩红细胞[(20.2±2.5)U vs(6.6±2.1)U]、子宫切除率[58.3%vs 0],差异均有统计学意义(P均≤0.001)。结论两种止血手术对于难治性产后出血均有良好的止血效果,但盆腔动脉栓塞介入治疗具有微创、手术时间短、术中出血少的优势;羊水栓塞、剖宫产手术缝合不当、严重弥散性血管凝血(disseminate intravascular coagulation,DIC)生命体征不平稳等难治性产后出血应根据具体情况选择合适的止血方法。

Objective To explore the outcomes of surgical operation and interventional therapy for the treatment of intractable postpartum hemorrhage,thus provide some references for the clinicians to select the appropriate treatment method. Methods The clinical data of 26 patients( 12. 9%) with intractable postpartum hemorrhage among 202 cases of postpartum hemorrhage,who were admitted to the obstetrics department of Yuncheng Central Hospital from January, 2014 to January, 2016 were retrospective analyzed. The patients were divided into surgical operation group( n = 12) and interventional therapy group( n = 14) according to the different treatment methods adopted, determine whether there is statistical significance in comparing the blood volume,the treatment of shock correction time,the amount of blood transfusion,the length of hospital stay,and the rate of hysterectomy of the two groups. Results( 1) In the 12 cases of surgical operation,4 cases were postpartum hemorrhage after emergency hysterectomy; 1 case of cesarean delivery remove fibroids,1 case of scar uterine cesarean delivery,1 case of cesarean delivery abdominal wall hematoma, 1 case of stagnant labor cesarean delivery,1 case of dangerous type of placenta previa merged,penetrating the placenta implants,1 case of amniotic fluid embolism; 1 case of vaginal wall laceration to the lower uterine segment, 1 case of postpartum uterine contraction atony. In the 14 cases of interventional therapy group,3 cases of cesarean delivery,including 1 case of uterine contraction atony and 2 cases of late postpartum hemorrhage; 11 cases of vaginal delivery,including 2 cases of uterine contraction atony,1 case of placenta implantation and 8 cases of late postpartum hemorrhage.( 2) Compared with the surgical operation group and the interventional therapy group,there were significant differences( P≤0. 001) in total blood loss [( 5600 ±850) m L vs( 2130 ± 130) m L],operation time [( 115 ± 12) min vs( 54 ± 3) min],shock correct time [( 5. 32 ± 0. 58) h vs( 2. 12 ± 0. 23) h],lose concentration of red blood cells [( 20. 2 ± 2. 5) u vs( 6. 6± 2. 1) u],and the hysterectomy rate( 58. 3% vs 0). Conclusions Two kinds of hemostasis have good hemostasis effect on intractable postpartum hemorrhage, but pelvic artery embolism has the advantages of minimal invasion, short operation time and less bleeding. In case of amniotic fluid embolism,the suture of cesarean section,and the unstable life condition of the serious DIC,the method of hemostasis should be selected according to the specific situation.