阴道分娩直肠扣眼裂伤48例分析:系统综述

A systematic review of 48 cases of vaginal delivery with rectal buttonhole tears

目的文献复习并总结阴道直肠扣眼裂伤的临床特点及治疗方式。方法采用关键词“直肠撕裂与分娩”“直肠裂伤与分娩”“直肠损伤与分娩”“直肠扣眼裂伤”对中华医学期刊全文数据库、中国知网资源总库、万方数据知识服务平台和维普中文期刊服务平台发表的中文论文进行检索。以关键词“rectal tear and delivery”“rectal laceration and delivery”“rectal lesion and delivery”“rectal buttonhole tear”对PubMed、Embase平台发表的英文论文进行检索。检索日期为建库至2023年11月15日,纳入明确诊断阴道分娩直肠扣眼裂伤的病例。对患者的年龄、产次、孕周、新生儿出生体重、直肠裂伤发现时间、是否会阴切开、是否器械助产、直肠裂伤情况、发现裂伤后的处理方式及预后情况等进行分析。采用描述性统计分析。结果共纳入文献30篇,发表时间自1952年至2023年,阴道分娩直肠扣眼裂伤病例共48例。(1)年龄与产次:患者的中位年龄28.0岁(范围21~44岁),初产妇和经产妇分别占72.5%(29/40)和27.5%(11/40)。(2)孕周:患者分娩时的中位孕周39.0周(范围36.0~41.0周)。(3)新生儿出生体重:新生儿中位出生体重为3595 g(范围2320~4250 g),其中巨大儿(出生体重≥4000 g)4例(在单胎中占比9.5%,4/42)。(4)直肠扣眼裂伤发现时间:胎儿娩出前即发现者占26.7%(12/45),胎儿娩出后发现者占73.3%(33/45)。(5)发生位置:直肠扣眼裂伤最常发生于阴道后壁中线位置(65.6%,21/32),其次为侧切伤口右侧(12.5%,4/32)。(6)直肠扣眼裂伤与分娩方式的关系:阴道自然分娩、会阴切开及阴道器械助产的孕妇均可能发生直肠扣眼裂伤。直肠扣眼裂伤可能发生于第一产程或第二产程中。(7)直肠裂伤的缝合时机及预后:93.4%(45/48)接受了直肠的一期缝合,其中93.3%(42/45)愈合良好,6.7%(3/45)术后出现直肠阴道瘘。结论直肠扣眼裂伤是阴道分娩罕见的并发症,应注意识别。若能及时发现直肠扣眼裂伤并于产后进行一期修补,预后多良好。

ObjectiveTo review the literature and summarize the clinical characteristics and treatment methods of rectal buttonhole tears associated with vaginal delivery.MethodsUsing the keywords"rectal tear and delivery""rectal laceration and delivery""rectal lesion and delivery",and"rectal buttonhole tear",we conducted a search for Chinese-language papers published on the Yiigle,CNKI(China National Knowledge Infrastructure),Wanfang Data Knowledge Service Platform,and VIP Chinese Journal Service Platform.Additionally,using the same keywords in English,we searched for papers published on PubMed and Embase.The search period covers from the establishment of the databases up to November 15,2023.Cases with a clear diagnosis of rectal buttonhole tears associated with vaginal delivery were included.Data on maternal age,parity,gestational weeks,neonatal birth weight,time of rectal tear discovery,whether episiotomy was performed,whether instrumental delivery was used,details of the rectal tear,management after discovering the tear,and prognosis were analyzed.Descriptive statistical analysis was used.ResultsA total of 30 papers were included,published from 1952 to 2023,encompassing 48 cases of vaginal delivery with rectal buttonhole tears.(1)Age and parity:The median age of patients was 28.0 years(range 21-44 years),with primiparas and multiparas accounting for 72.5%(29/40)and 27.5%(11/40),respectively.(2)Gestational weeks:The median gestational age at delivery was 39.0 weeks(range 36.0-41.0 weeks).(3)Neonatal birth weight:The median birth weight of the neonates was 3595 g(range 2320-4250 g),with four cases of macrosomia(birth weight≥4000 g),accounting for 9.5%(4/42)of singleton births.(4)Time at identification of rectal buttonhole tear:Rectal tears were discovered before fetal delivery in 26.7%(12/45)of cases and after delivery in 73.3%(33/45)of cases.(5)Location:Rectal buttonhole tears most commonly occurred at the midline of the posterior vaginal wall(65.6%,21/32),followed by the right side of the episiotomy wound(12.5%,4/32).(6)Relationship between rectal buttonhole tears and delivery mode:Rectal buttonhole tears can occur in spontaneous vaginal delivery,episiotomy,and instrumental vaginal delivery.They may occur during the first or second stage of labor.(7)Timing of rectal tear suturing and prognosis:93.4%(45/48)of patients underwent primary rectal suturing,among whom,93.3%(42/45)had good healing,while 6.7%(3/45)developed rectovaginal fistula postoperatively.ConclusionsRectal buttonhole tear is a rare complication of vaginal delivery and should be recognized.If identified promptly and repaired with primary suturing,the prognosis is generally favorable.