瘢痕子宫女性再次剖宫产产后出血的相关因素分析

Analysis of factors associated with postpartum hemorrhage after recurrent cesarean section in women with scarred uterus

目的探讨瘢痕子宫女性再次妊娠并剖宫产终止妊娠产后出血的相关因素。方法回顾性分析2012年1月至2019年6月在上海交通大学医学院附属瑞金医院收治的瘢痕子宫再妊娠剖宫产分娩及同期非瘢痕子宫剖宫产分娩的患者临床数据,分析两组间产后出血发生率及相关因素的差异。又将瘢痕子宫组分为产后出血组和非产后出血组,通过建立logistic回归模型分析瘢痕子宫剖宫产分娩产后出血的高危因素。结果研究共纳入瘢痕子宫组1289例与非瘢痕子宫组2666例,发现瘢痕子宫组产后出血发生率高(P<0.05),既往流产次数多、术前超声显示胎盘前置、术中发现胎盘植入比例高(P<0.05);但术后血红蛋白下降≥25 g/L且红细胞比容下降≥20%(忽略性产后出血)发生率在对照组反而更高(P=0.026)。瘢痕子宫组患者共纳入产后出血(包括忽略性产后出血)组55例,对照组1203例,发现产后出血组既往流产次数、剖宫产次数多,术前超声显示胎盘前置、胎盘低置、术中发现胎盘植入、应用欣母沛、产后清宫比例均显著高于非产后出血对照组(P<0.05);logistic回归模型分析显示既往流产次数、胎盘正常位置、胎盘植入是影响产后出血的前三大因素,其中胎盘正常位置为保护性因素。结论瘢痕子宫患者再次剖宫产术前需充分评估胎盘位置,做出相应的防治预案,同时需提高所有剖宫产孕妇产后,尤其是返回病房后的产后出血的观察及准确评估。

Objective To investigate the factors associated with postpartum hemorrhage in women with scarred uterus who had re-pregnancy terminated with cesarean section.Methods The clinical data of patients undergoing re-pregnancy cesarean delivery with scarred uterus and patients undergoing re-pregnancy cesarean delivery with non-scarred uterus during the same period who were admitted to Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2012 to June 2019 was retrospectively analyzed.The differences in the incidence of postpartum hemorrhage and related factors between the two groups were analyzed.The group with scarred uterus was further divided into the group with postpartum hemorrhage and the group with non-postpartum hemorrhage.A logistic regression model was established to analyze the high-risk factors for postpartum hemorrhage in cesarean delivery with scarred uterus.Results A total of 1289 patients were included in the group with scarred uterus,and 2666 patients were included in the group with non-scarred uterus.It was found that the group with scarred uterus had higher incidence of postpartum hemorrhage(P<0.05),higher number of previous miscarriages,as well as higher proportion of placenta previa found by preoperative ultrasound and intraoperative placenta implantation(P<0.05).However,the incidence in the content of hemoglobin decreased by≥25 g/L and in the erythrocyte volume decreased by≥20%after operation was higher in the control group(neglected postpartum hemorrhage)(P=0.026).A total of 55 patients from the group with scarred uterus were included in the group with postpartum hemorrhage(including neglected postpartum hemorrhage)and 1203 patients were included in the control group.It was found that the number of previous miscarriages and cesarean deliveries,and the proportions of placenta previa found by preoperative ultrasound,placenta hypoplasia,intraoperative detection of placenta implantation,application of hemabate and postpartum clearance in the group with postpartum hemorrhage were all significantly higher than those in the non postpartum hemorrhage control group(P<0.05).Logistic regression model analysis showed that the number of previous miscarriages,normal placental position,and placenta implantation were the top three factors affecting postpartum hemorrhage,among which normal placental position was a protective factor.Conclusion For patients with scarred uterus who require recurrent cesarean section,it is necessary to adequately evaluate the placenta position before the operation,and make corresponding prevention and control plans,as well as to enhance the observation and accurate evaluation of postpartum hemorrhage in all pregnant women with cesarean section,especially after returning to the ward.