子宫下段防波堤样缝合术在前置胎盘手术止血中的应用

Application of uterine lower part breakwater-like suture operation in placenta previa

目的探讨子宫下段防波堤样缝合术应用于前置胎盘手术止血中的有效性和安全性。方法收集2016年6月至2017年6月在华中科技大学同济医学院附属协和医院住院的前置胎盘产妇47例，针对胎盘剥离部位的出血，优先采用子宫下段后壁防波堤样缝合术止血方法；并对子宫前壁薄弱、失去正常形态者，同时实施前壁编织状缝合成形术；部分产妇配合宫旁血管缝扎、肌壁血窦压迫缝合、宫腔球囊压迫止血及引流等综合止血措施。对产妇及新生儿的结局及预后进行分析。结果47例前置胎盘产妇，合并胎盘植入、穿透、膀胱侵犯者30例（63.8%，30/47），合并胎盘粘连者17例（36.2%，17/47），有剖宫产史者34例（72.3%，34/47）；其子宫颈管长度为（2.8±0.9）cm；其终止妊娠的孕周为（36.1±1.5）周。采用子宫下段后壁防波堤样缝合1道止血者19例（40.4%，19/47），后壁防波堤样缝合2-3道止血者16例（34.0%，16/47）；后壁防波堤样缝合配合子宫下段前壁编织状缝合者12例（25.5%，12/47）。行宫旁血管缝扎术10例（21.3%，10/47），宫腔球囊压迫子宫下段及内口处渗血面17例（36.2%，17/47）。47例产妇术中的出血量为700（500-1 200）ml，最多者为2 500 ml，术中出血≥1 000 ml者18例（38.3%，18/47）；输血量为450（228-675）ml；术后第1天的恶露量（150±63）ml，术后住院时间为（4.7±1.0）d。无产褥感染和晚期产后出血者；术后随访半年无出现远期并发症者。其新生儿出生体质量为（2 817±492）g；1分钟Apgar评分为（7.8±1.1）分，5分钟评分为（8.9±0.8）分；转新生儿ICU者16例（34.0%，16/47），无新生儿死亡。结论子宫下段后壁防波堤样缝合术是快速、安全的前置胎盘手术止血方法之一。子宫下段前壁编织样缝合成形术可有效止血、恢复子宫下段正常形态；多种止血方法的联合应用可减少产后出血及子宫切除率，改善母儿预后。

ObjectiveTo explore the efficacy and safety of uterine lower posterior wall breakwater-like suture technique in controlling the intraoperative bleeding of placenta previa.MethodsFrom June 2016 to June 2017, 47 patients were diagnosed placenta previa in Union Hospital, Tongji Medical College of Huazhong University of Science and Technology. Posterior wall breakwater-like suture technique was used preferentially, as for cases with poor myometrium layer, lower anterior wall stitch suture was used at the same time. Bilateral descending branches of uterine artery ligation and Cook balloon compression of uterine lower segment was conducted when necessary. The clinic data of the 47 cases were analyzed.ResultsThirty cases （63.8, 30/47） were diagnosed placenta inccreta or percreta by ultrasound or MRI preoperatively. Senventeen cases were diagnosed as placenta accreta （36.2%, 17/47） . Thirty-four cases had the previous history of cesarean section. The average cervical canal length of 47 patients was （2.8±0.9） cm. There were 19 cases （40.4%,19/47） with 1 time posterior wall breakwater-like sutured and 16 cases （34.0%,16/47） with 2 or 3 times posterior wall breakwater-like sutured; 12 cases （25.5%,12/47） were treated with anterior wall stitch suture simultaneously.Ten cases （21.3%, 10/47） underwent uterine artery ligation, 17 cases （36.2%, 17/47） underwent COOK balloon compression on the staxis surface of lower segment. None of them had postpartum hemorrhage or performed internal iliac artery embolization. The median blood loss in the operation was 700 ml, the percentiles 25 was 500 ml, and the percentiles 75 was 1 200 ml. The blood loss ≥1 000 ml in 18 （38.3%, 18/47） patients,and the most serious one was 2 500 ml. The median blood transfusion volume （including allogenetic transfusion and autotransfusion） was 450 ml, the percentiles 25 was 228 ml, and the percentiles 75 was 675 ml. The average vaginal bleeding volume was （150±63） ml first day after operation. The mean hospitalization time was （4.7±1.0） days. The mean gestational weeks of pregnancy termination was （36.1±1.5） weeks, and the mean birth weight of newborns was （2 817±492） g. Apgar score：1-minute 7.8±1.1, 5-minute 8.9±0.8. No neonatal death, 16 cases were transferred to neonatal ICU （34.0%, 16/47） mainly for premature delivery and low birth weight. No complication was found in 6 months post-operation.ConclusionsUterine posterior wall breakwater-like suture technique is a simple, safe and effective way in controlling intraoperative bleeding of placental previa.Lower anterior wall stitch suture could effectively stop bleeding and restore the normal uterine shape. Combined application of various methods could significantly reduce the incidence of postpartum hemorrhage and hysterectomy, and improve maternal and fetal prognosis.