【作者】 戴满花；

【导师】 刘慧姝；

【作者基本信息】 广州医学院 ， 妇产科学， 2011， 硕士

【摘要】 严重产后出血在全世界范围内是孕产妇发病和死亡的主要原因。围产期子宫切除术是一种临床上用于严重产科出血经保守治疗无效,挽救产妇生命的重要的措施之一。子宫切除虽然可以有效控制产科出血,但生育期妇女术后患者生存质量明显下降。子宫切除术后腹腔内持续出血需再次手术止血是临床的一种严重状况;急性肺损伤易发展为成人呼吸窘迫综合症致多器官功能障碍综合征,导致围产期妇女死亡。鉴于目前在产科领域对其的文献报道不多。本研究旨在通过对近11年来广州市重症孕产妇救治中心严重产后出血临床资料回顾性分析,了解现阶段严重产后出血围产期子宫切除、子宫切除术后再次开腹探查术及相关ALI/ARDS患者的相关危险因素,探讨防治措施,有利于降低严重产后出血围产期并发症的发生及孕产妇死亡率。第一章严重产后出血临床资料分析【研究目的】了解严重产后出血的原因、并发症及结局。【资料与方法】收集广州市重症孕产妇救治中心自1999年1月1日至2010年12月31日11年间所有住院待产孕产妇共34623人,严重产后出血患者316例。统计资料包括年龄、孕产次、孕周、出血原因、治疗措施及转归等多项指标。采用SPSS 13.0统计软件进行统计学处理,计量资料符合正态分布者用均数±标准差表示;计数资料用频数和率来表示,采用χ~2检验进行分析;以P<0.05为差异有统计学意义。【结果】1.院内严重产后出血的发生率为0.18%(63/34623),其中阴道分娩17例(0.09%,17/19014),剖宫产分娩46例(0.29%,46/15609)。剖宫产严重产后出血发生率显著高于阴道分娩(P=0.000)。2.严重产后出血原因:凝血功能障碍,占38%(120/316);子宫收缩乏力,占29.7%;胎盘因素,占21.8%;软产道裂伤,占15.5%。3.严重产后出血的处理、并发症及结局3.1保守性手术治疗92例,其中70例(76.1%,70/92)止血成功。3.2主要并发症及结局:失血性休克206例、子宫切除术142例、DIC120例、ALI/ARDS81例,死亡23例。【结论】1.我院严重产后出血的发生率为0.18%,剖宫产严重产后出血发生率明显高于阴道分娩。2.凝血功能障碍是严重产后出血的最主要原因。第二章围产期子宫切除及子宫切除术后再次行腹腔探查术相关因素分析第一节围产期子宫切除相关危险因素分析【研究目的】了解近11年间广州市重症孕产妇救治中心严重产后出血围产期子宫切除的发生率和相关危险因素。【资料与方法】收集1999年1月1日至2010年12月31日11年间广州市重症孕产妇救治中心收治的资料可分析的严重产后出血病例316例,其中142例行围产期子宫切除(子宫切除组),其余174例为非子宫切除患者(对照组)。统计资料包括年龄、流产次数、经产次数、妊娠期各种并发症或合并症、分娩方式、子宫切除方式、子宫切除前后处理等。采用SPSS 13.0统计软件进行统计学处理,计量资料符合正态分布者用均数±标准差表示,采用独立样本t-检验;计数资料用频数和率来表示,采用χ2检验进行分析;相关因素的分析采用二分类多因素Logistic回归分析;P≤0.05表示差异有统计学意义。【结果】1.子宫切除142例患者中院内子宫切除47例,院内子宫切除患者占分娩总数的0.14%(47/34623)。2.单因素分析显示:子宫切除组与对照组患者在年龄≥35岁、孕次≥2次、产次≥2次、产检次数≥5次、胎盘粘连或植入、组织残留、羊水栓塞、子宫破裂、DIC和保守性手术治疗(P=分别为0.000、0.007、0.001、0.000、0.001、0.014、0.000、0.000、0.000和0.000)两组之间差异有统计学意义。3.二分类多因素Logistic回归分析显示:年龄≥35岁(OR 2.560;95%CI 1.187-5.521)、子宫破裂(OR 11.367;95%CI 2.903-44.513)、羊水栓塞(OR 8.808;95%CI 1.859-41.722)、DIC(OR 5.054;95%CI 2.725-9.367)、胎盘粘连或植入(OR 6.805;95%CI 2.998-15.444)是严重产后出血围产期子宫切除的相对独立作用的危险因素;产检次数≥5次(OR 0.013;95%CI 0.237-0.845 )、保守性手术治疗是保护性因素( OR 0.311 ; 95%CI 0.155-0.622)。4.相对独立的多个危险因素作用大小的顺位为:子宫破裂(OR 13.400;95%CI 3.423-52.455)、胎盘粘连或植入(OR 7.337;95%CI 3.273-16.448)、羊水栓塞(OR 6.711;95%CI 1.620-27.800)、DIC(OR 5.178;95%CI 2.804-9.560)、年龄≥35岁(OR 2.916;95%CI 1.412-6.021)。第二节围产期子宫切除术后再次行腹腔探查术相关危险因素分析【研究目的】探讨严重产后出血围产期子宫切除术后再次行腹腔探查术相关危险因素。【资料与方法】收集1999年1月1日至2010年12月31日11年间广州市重症孕产妇救治中心收治的资料可分析的严重产后出血致子宫切除病例142例,其中18例行围产期再次探查手术(再次探查组),其余124例为非再次探查手术患者(对照组)。收集的临床资料包括产妇年龄、妊娠次数、分娩次数、产前检查、妊娠期各种并发症和合并症、子宫切除方式及时机、切除子宫的医院、失血量、处理措施等。采用SPSS 13.0统计软件进行统计学处理,计量资料符合正态分布者用均数±标准差表示,采用独立样本t-检验;计数资料用频数和率来表示,采用χ~2检验进行分析;相关因素的分析采用二分类多因素Logistic回归分析;P≤0.05表示差异有统计学意义。【结果】1. 142例围产期子宫切除患者中再次探查手术者18例,发生率为12.7%(18/142)。2.单因素分析结果显示:再次探查组与对照组患者在产检次数﹤5次、羊水栓塞、DIC、基层医院切除子宫、产后出血量、子宫切除时机和输血量(p=分别为0.047、0.015、0.003、0.034、0.000、0.041和0.000)两组之间差异有统计学意义。3.二分类多因素Logistic回归分析显示:产后出血量(OR 1.000;95%CI 1.000-1.000)和输血量(OR 1.001;95%CI 1.000-1.001)的增加是严重产后出血围产期子宫切除术后再次开腹探查术的相对独立的危险因素。4.相对独立的多个危险因素作用大小的顺位为:产后出血量(OR 1.000;95%CI 1.000-1.001)和输血量(OR 1.000;95%CI 1.000-1.001)相似。【结论】1.年龄≥35岁、子宫破裂、DIC、胎盘粘连或植入及羊水栓塞是严重产后出血围产期子宫切除的主要风险因素;产前检查次数的增加、保守性手术治疗是子宫切除的保护性因素。2.产后出血量和输血量是严重产后出血围产期子宫切除术后再次行腹腔探查术的主要危险因素。第三章ALI/ARDS相关危险因素分析【研究目的】通过分析严重产后出血发生ALI/ARDS患者产前、产后的危险因素,为临床防治严重产后出血发生ALI/ARDS提供借鉴。【资料与方法】收集1999年1月1日至2010年12月31日11年间广州市危重症孕产妇救治中心收治的资料可分析的严重产后出血病例316例,其中81例发生ALI/ARDS(ALI/ARDS组),其余235例严重产后出血患者为对照组。收集的临床资料包括:年龄、孕次、产次、妊娠期各种并发症或合并症、产后出血量、输血量、产时情况及产后处理措施等。采用SPSS 13.0统计软件进行统计学处理,计量资料符合正态分布者用均数±标准差表示,采用独立样本t-检验;计数资料用频数和率来表示,采用χ~2检验进行分析;相关因素的分析采用二分类多因素Logistic回归分析;P≤0.05表示差异有统计学意义。【结果】1. 316例严重产后出血患者中发生ALI/ARDS者81例,发生率为25.6%(81/316)。2.单因素分析结果显示:ALI/ARDS组与对照组患者在产检次数<5次、羊水栓塞、子宫破裂、DIC、失血性休克、产后出血量、子宫切除术、子宫切除术后再次探查术、总输血量、浓缩红细胞输入量、血浆输入量、血小板输入量和冷沉淀输入量的比例(P=分别为0.014、0.000、0.042、0.000、0.000、0.000、0.000、0.000、0.000、0.000、0.000、0.005和0.000)两组之间差异有统计学意义。3.二分类多因素Logistic回归分析显示:子宫切除术( OR 12.988;95%CI3.961-42.581)、子宫切除术后再次探查术(OR 25.547;95%CI 1.843-354.210)是严重产后出血发生ALI/ARDS的相对独立的风险因素。4.相对独立的多个危险因素作用大小的顺位为:子宫切除术后再次探查术( OR 21.266;95%CI7.643-59.169 )、子宫切除术( OR 1.000;95%CI1.000-1.000)。【结论】严重创伤(子宫切除术后再次探查术、子宫切除术)是严重产后出血发生ALI/ARDS的主要危险因素。更多还原

【Abstract】 Severe postpartum hemorrhage remains a major cause of maternal morbidity and mortality in the world. Peripartum hysterectomy is performed as a life-saving operation that is performed for severe obstetric hemorrhage that is unresponsive to conservative methods.Although hysterectomy is the most effective process to control obstetric hemorrhage,most women undergoing obstetric hysterectomy were child-bearing period patients, hysterectomy may impact the life quality of these women more or less after operation. Re-exploration for internal bleeding after hysterectomy is a serious clinical condition;ALI is readily develop into adult respiratory distress syndrome(ARDS) and multiple organ dysfunction syndrome(MODS),which results in death finally. Currently, the studies about re-exploration after peripartum hysterectomy and ALI/ARDS for severe postpartum hemorrhage are rarely reported.The purpose of this study was to review of all cases of severe postpartum hemorrhage in Obstetric Critical Care Center of Guangzhou from January 1999 to December 2010 to assess the associated high risk factors of hysterectomy and re-exploration after peripartum hysterectomy and ALI/ARDS that were associated with improving outcomes of patients. ChapterⅠAnalysis of the clinical details of severe postpartum hemorrhageObjectiveOur study was to analyse the causes,complications and outcomes of severe postpartum hemorrhage .Material and methodsWe retrospectively reviewed 316 severe postpartum hemorrhage cases in Obstetric Critical Care Center of Guangzhou from January 1999 to December 2010. Main demographic data and clinical details including age, gravidity, parity, gestationa age, the cause of hemorrhage,the measures of treatment and outcomes. The statistical analyses were conducted with the“SPSS 13.0 for windows”package program. The measurement data of normal distribution were used independent sample t- test and were defined as mean±standard deviation.Frequency and rate were compared with the Chi-square test; P<0.05 was considered statistically significant.Results1. The incidence of severe postpartum hemorrhage is 0.18% in our hospital during the past 11 years. The incidence of severe postpartum hemorrhage of cesarean sections was higher than the incidence of vaginal deliveries (46/15609vs17/ 19014, P=0.001).2. The causes of severe postpartum hemorrhage include coagulopathy (38%,120/ 316) ,uterine atony(29.7%),abnormalities of placentation (21.8%)and genital tract laceration(15.5%).3. The treatments, main complications and outcomes of severe postpartum hemorrhage include conservative surgical procedure(92cases),hemorrhagic shock(206cases),hysterectomy(142cases),DIC(120cases),ALI/ARDS(81cases), maternal death(23cases). Conclusions1. The incidence of severe postpartum hemorrhage is 0.18%.The incidence of severe postpartum hemorrhage of cesarean sections was higher than the incidence of vaginal deliveries.2. Coagulopathy is the leading cause of severe postpartum hemorrhage.ChapterⅡRisk factors associated with peripartum hysterectomy and re-exploration after hysterectomySectionⅠRisk factors associated with peripartum hysterectomy ObjectiveOur study was to estimate the incidence and risk factors associated with peripartum hysterectomy for severe postpartum hemorrhage.Material and methodsWe retrospectively reviewed 142 peripartum hysterectomy cases in Obstetric Critical Care Center of Guangzhou from January 1999 to December 2010. Main demographic data and clinical details including age, gravidity, parity, prenatal care, number of abortion, pathological pregnancy, mode of delivery, method of hysterectomy, the measures of treatment . The statistical analyses were conducted with the“SPSS 13.0 for windows”package program. The measurement data of normal distribution were used independent sample t- test for comparing the differences between hysterectomy and control groups and were defined as mean±standard deviation. Frequency and rate were compared with the Chi-square test.The correlative factors were analyzed by binary logistic regression. P<0.05 was considered statistically significant. Results1. The incidence of peripartum hysterectomy is 0.14% (47/34623) in our hospital during the past 11 years.2. Single factor analysis showed that age≥35years, gravidity, parity, prenatal care,placenta increta or accreta, tissue residue, amniotic fluid embolism,uterine rupture,DIC and conservative surgical procedure were significantly increased in the hysterectomy group(p=0.000,0.007,0.001,0.000,0.001,0.014, 0.000,0.000, 0.000 and 0.000,respectively) as compared with the control group.3. Binary logistic regression analysis showed that age age≥35years ( OR 2.560,95%CI 1.187-5.521), uterine rupture(OR 11.367,95%CI 2.903-44.513), amniotic fluid embolism ( OR 8.808,95%CI 1.859-41.722 ) ,DIC ( OR 5.054,95%CI 2.725-9.367) and placenta increta or accreta(OR 6.805,95%CI 2.998-15.444) were the main risk factors of peripartum hysterectomy. Conservative surgical procedure OR 0.311,95%CI 0.155-0.622) and prenatal care (OR 0.013,95%CI 0.237-0.845)were protect factors.4. The following are risk factors causing peripartum hysterectomy in the order : uterine rupture(OR 13.400,95%CI 3.423-52.455), placenta increta or accreta(OR 7.337,95%CI 3.273-16.448), amniotic fluid embolism(OR 6.711,95%CI 1.620-27.800),DIC(OR 5.178,95%CI 2.804-9.560), age≥35years(OR 2.916,95%CI 1.412-6.021).SectionⅡRisk factors associated with re-exploration after peripartum hysterectomyObjectiveOur study was to estimate the risk factors associated with re-exploration after peripartum hysterectomy for severe postpartum hemorrhage.Material and methodsThe clinical data of 142 obstetric patients who underwent peripartum hysterectomy for severe postpartum hemorrhage in Obstetric Critical Care Center of Guangzhou from January 1999 to December 2010 were retrospectively analyzed. Among them, 18 cases underwent re-exploration after peripartum hysterectomy.Main demographic data and clinical details including age, gravidity, parity, prenatal care, pathological pregnancy, time and method of hysterectomy, hosptial of hysterectomy, blood loss ,the measures of treatment . The statistical analyses were conducted with the“SPSS 13.0 for windows”package program. The measurement data of normal distribution were used independent sample t- test for comparing the differences between re-exploration and control groups and were defined as mean±standard deviation. Frequency and rate were compared with the Chi-square test.The correlative factors were analyzed by binary logistic regression. P<0.05 was considered statistically significant.Results1. The incidence of re-exploration after peripartum hysterectomy is 12.7% (18/142).2. Single factor analysis showed that prenatal care, amniotic fluid embolism,DIC, hosptial of hysterectomy,blood loss , time of hysterectomy and blood transfusion were significantly increased in the re-exploration group (p=0.047,0.015,0.003,0.034,0.000,0.041and 0.000, respectively) as compared with the control group.3. Binary logistic regression analysis showed that blood transfusion(OR 1.001,95%CI 1.000-1.001) and blood loss(OR 1.000,95%CI 1.000-1.000) were the main risk factors of re-exploration after peripartum hysterectomy.4. The following are risk factors causing re-exploration after peripartum hysterectomy in the order : blood transfusion(OR 1.000,95%CI 1.000-1.001) as same as blood loss(OR 1.000,95%CI 1.000-1.001).Conclusions1. Uterine rupture, placenta increta or accreta, age≥35years,DIC, amniotic fluid embolism were the main risk factors of peripartum hysterectomy. conservative surgical procedure and prenatal care were protect factors. 2. Blood transfusion and blood loss were the main risk factors of re-exploration after peripartum hysterectomy.ChapterⅢRisk Factors Associated with ALI/ARDS ObjectiveOur study was to estimate the risk factors associated with ALI/ARDS for severe postpartum hemorrhage,and to provide a learn to prevent and treat ALI/ARDS for severe postpartum hemorrhage.Material and methodsThe clinical data of 316 obstetric patients who underwent severe postpartum hemorrhage in Obstetric Critical Care Center of Guangzhou from January 1999 to December 2010 were retrospectively analyzed. Among them, 81 cases underwent ALI/ARDS.Main demographic data and clinical details including age, gravidity, parity, pathological pregnancy, blood loss , blood transfusion,the measures of treatment.The statistical analyses were conducted with the“SPSS 13.0 for windows”package program. The measurement data of normal distribution were used independent sample t- test for comparing the differences between ALI/ARDS and control groups and were defined as mean±standard deviation. Frequency and rate were compared with the Chi-square test.The correlative factors were analyzed by binary logistic regression. P<0.05 was considered statistically significant.Results1. The incidence of ALI/ARDS for severe postpartum hemorrhage is 25.6% (81/316).2. Single factor analysis showed that prenatal care, amniotic fluid embolism, uterine rupture ,DIC, hemorrhagic shock , blood loss, hysterectomy, re-exploration after peripartum hysterectomy,blood transfusion,packed red blood cells transfusion,plasma transfusion,platelet transfusion and cryoprecipitate transfusion were significantly increased in the ALI/ARDS group (p=0.014,0.000,0.042,0.000,0.000, 0.000, 0.000, 0.000,0.000, 0.000,0.000,0.005 and 0.000, respectively) as compared with the control group.3. Binary logistic regression analysis showed that hysterectomy ( OR 12.988,95%CI3.961-42.581) and re-exploration after peripartum hysterectomy(OR 25.547,95%CI 1.843-354.210) were the main risk factors of ALI/ARDS for severe postpartum hemorrhage.4. The following are risk factors causing ALI/ARDS in the order : re-exploration after peripartum hysterectomy(OR 21.266,95%CI7.643-59.169), hysterectomy(OR 1.000,95%CI1.000-1.000).ConclusionRe-exploration after peripartum hysterectomy, hysterectomy were the main risk factors of ALI/ARDS for severe postpartum hemorrhage.更多还原