【作者】 沈宇清；

【导师】 陈敦金；

【作者基本信息】 广州医学院 ， 妇产科学， 2009， 硕士

【摘要】 目的产后出血是指胎儿娩出后24小时内失血量超过500ml,是分娩期严重并发症,为孕产妇死亡最常见的原因,占全世界孕产妇死亡病因的1/4,居导致我国孕产妇死亡原因的首位。严重产后出血常伴有较多并发症及合并症如多脏器功能障碍、产褥感染、产后贫血等,严重威胁孕妇和胎儿安危,有较高的孕产妇和围生儿病死率,是发展中国家导致孕产妇死亡的主要原因。但目前临床上还没有客观量化的评估系统以预测及判断母亲病情危重程度及预后。本研究的目的是建立产后出血预后预测评估系统、评定病情的严重程度、早期判断预后,制定有效的治疗方案,改善预后,并以回顾性资料对新建立的评估系统进行评估。方法1、根据产后出血的特点,参考产前及分娩期产后出血高危因素,参照以往“产后出血预测评分表”参数设置,设定了25项指标(分娩地点、年龄、产次、分娩孕周、刮宫次数、产检次数、疤痕子宫、妊娠合并内科疾病、PLT评分、子宫肌瘤、子痫前期、胎盘早剥、前置胎盘、宫高、巨大胎儿、多胎妊娠、分娩方式、产道裂伤、第一产程异常、第二产程延长、第三产程长度、胎盘粘连、胎盘植入、徒手剥胎盘、宫缩乏力),根据产科临床特点并进行赋值。2、回顾性收集2000年1月-2008年6月8年间广州医学院第三附属医院(广州市重症孕产妇救治中心)产科重症监护病房375例资料完整可分析的产后出血患者资料,应用新建立的预测评估系统对患者进行量化评分,将产后出血量>1500毫升定义为严重产后出血,纪录患者各器官功能障碍、子宫切除及死亡情况。建立严重产后出血风险预测公式、多器官功能障碍风险预测公式、子宫切除风险预测公式。3.分析患者评分分值与严重产后出血、多器官功能障碍、子宫切除及死亡的关系。并从评分与预后的关系初步判断评分对临床治疗的指导意义。4.统计方法:不同评分组间差异比较,计数资料采用卡方检验或Fisher切概率法,计量资料采用方差分析。器官损伤数目与评分递增的关系采用有序分组资料的线性趋势检验。评分系统预后方程的建立采用Logistic回归分析。所有数据的处理使用SPSS for windows13.0软件分析。结果1.新建立了产后出血评分系统由25项指标组成,包括:分娩地点、年龄、产次、分娩孕周、刮宫次数、产检次数、疤痕子宫、妊娠合并内科疾病、PLT评分、子宫肌瘤、子痫前期、胎盘早剥、前置胎盘、宫高、巨大胎儿、多胎妊娠、分娩方式、产道裂伤、第一产程异常、第二产程延长、第三产程、胎盘粘连、胎盘植入、徒手剥胎盘、宫缩乏力,每个指标赋值0-3分,分为产前评分及产后评分,总分43分。严重产后出血风险预测公式log eY/(1-Y)= -7.274+0.858*产前评分+0.821*产后评分,多器官功能障碍风险预测公式log eY/(1-Y)= -7.352+0.594*产前评分+0.651*产后评分,子宫切除风险预测公式log eY/(1-Y)= -7.438+0.675*产前评分+0.696*产后评分。2.回顾性资料对产后出血评分系统的评价显示375例患者随着评分的升高母亲的器官功能障碍和并发症发生的阳性率增加。2个器官功能障碍:评分4分组与1-3分组相比较差异显著(x~2=6.23,P=0.01),3个以上器官功能障碍:评分12分组与1-13分组相比较差异显著(x~2=3.86.1,P=0.02)。评分3分组:心脏功能障碍发生率显著升高(p=0.03),评分7分组:血液系统功能障碍较1-6分组发生率显著升高(x~2=4.35, p=0.02),评分8分组:肾脏系统功能障碍、胃肠系统功能障碍较1-7分组发生率显著升高(p=0.03, x~2=7.64, p=0.006),评分12分组:、呼吸、血液、胃肠道系统功能紊乱发生率显著升高,x~2,p值分别为(x~2=11.42,p=0.000; x~2=5.62,p=0.018; x~2=5.23,p=0.018),评分13分组:神经系统功能紊乱发生率显著升高,x~2,p值分别为(x~2=26.18,p=0.000),评分14分组:肾脏功能、呼吸系统障碍发生率较6-8分组显著升高(p=0.04)。子宫切除术:8分组发生率与1-7分组比较显著升高(x~2=9.04,p=0.003)。死亡:20分组发生率与1-7分组比较显著升高(x~2=7.37,p=0.01)。严重产后出血:评分6分组与1-5分组相比较差异显著(x~2=4.35,P=0.02),评分8分组与6-7分组相比较差异显著(x~2=6.00, p=0.015),评分12分组与8-11分组相比较差异显著(x~2=13.18, p=0.000)。结论1.本课题组首次建立了产后出血预后预测评估系统及严重产后出血、多器官功能障碍、子宫切除的风险预测公式。2.初步得出给予指导临床处理的分值:评分4分患者多器官功能障碍发生率显著增加,应及时转上级医院治疗;评分12分患者3个以上器官功能受损发生率明显升高,可威胁母亲生命,应根据具体情况行生命支持治疗;随着评分的升高,母亲的严重产后出血发生的阳性率增加;评分8分组母亲子宫切除率显著升高,应做好急诊子宫切除术准备;评分20分组母亲死亡率显著升高,应早期召集抢救小组做好复苏准备。3.预计该评估系统可以有效的预测产后出血患者的病情危重程度及预后,进一步评价需大样本量的研究。预期应用该评估系统指导临床处理能够早期判断预后,指导临床处理,制定有效的治疗方案,改善预后。更多还原

【Abstract】 ObjectivePost-partum haemorrhage (PPH) refers to an estimated blood loss in excess of 500 ml after delivery within 24 hours. It is a serious complications of deliver and the most common causes of maternal mortality. Postpartum hemorrhage (PPH) accounts for 25% of maternal deaths reported by the World Health Organization, it is the first most common cause of maternal mortality in China. The ideal solution for most postpartum hemorrhage is prevention, including Prenatal prevention and Production to take active management during labour. However, so far there are no theories offering prediction to the severity of severe post-partum haemorrhage patients systematically and accurately. The purpose of this study is to establish post-partum haemorrhage prognosis evaluation system to assess the severity of the disease, early prognosis, develop of effective treatment programs to improve the prognosis, and to review information on the new assessment system for evaluation.Methods1. Set 25 indexs(birth place, age,prity, gestational weeks, the number curettage, seized the number of births, uterine scar, medical disease in pregnancy, PLT score, uterine fibroids, pre-eclampsia, placental abruption, placenta previa, palace high, fetal macrosomia, multiple pregnancy, delivery mode, cleft birth canal injury, abnormal first stage of labor, the extension of the second stage of labor, length of third stage of labor, placental adhesion, placenta accreta, stripping bare placenta, uterine atony), and assignment. in accordance with the characteristics of postpartum hemorrhage and risk factors for postpartum hemorrhage and with reference to the classic“post-partum haemorrhage score prediction table”parameter settings, and then assignment.2.a retrospective collection from January 2000 to June 2008 in the third Affiliated Hospital of Guangzhou Medical College (Guangzhou City for treatment of severe maternal Center) obstetric intensive care unit may be 375 cases of complete information on the analysis of data of patients with post-partum haemorrhage, Major haemorrhage is defined as an estimated blood loss of more than 1500 ml. And establish the Postpartum Hemorrhage Prediction scoring system.3. The scores depending on the system were calculated, the relationship between the score and the maternal outcomes (organ dysfunction, hysterectomy and death) were analyzed, And to determine the initial score of the guide clinical treatment, to analyse the forecasting system to guide the clinical treatment of the impact on prognosis from the relationship between score and prognosis .4.Statistical analysis: Results were compared by means of Student’s t test ,Mann-Whitney U-test , chi-square test and Fisher’s exact test as appropriate , the relationship between the severe preeclampsia -eclampsia scores and multiple organ dysfunction were evaluated by Kruskal-Wallis nonparametric analysis. A multivariate logistic regression model was applied for choosing appropriate variables to the equation of mortality prediction.Results1. New post-partum bleeding score system is composed of 25 variables, including: birth place, age, production times, delivery gestational age, the number curettage, seized the number of births, uterine scar, medical disease in pregnancy, PLT score, uterine leiomyoma, pre-eclampsia, placental abruption, placenta previa, palace high, fetal macrosomia, multiple pregnancy, childbirth methods, canal laceration, abnormal first stage of labor, the extension of the second stage of labor, the third stage of labor, placental adhesion, placenta accreta, fitness stripping the placenta, uterine atony, The score of each variable is 0 to 3 and the maximum possible score is 43. the risk of the prediction formula[0] of Severe postpartum hemorrhage is as follows:log eY / (1-Y) = -7.274 +0.858 * score +0.821 * prenatal postpartum score.2. Retrospective information on postpartum hemorrhage evaluation scoring system from 375cases of patients showed that the more of the score is, the higher of the positive rate of complications [0]and the mother’s organ dysfunction is. 2 organ dysfunction: score 4 sub-division, compared with 1-3 significant difference (x~2 =6.23, P =0.01), 3 or more organ dysfunction: sub-12 score compared with the difference between 1-13 division significant (x~2=3.86.1, P=0.02). Score 3 sub-groups: the incidence of cardiac dysfunction was significantly higher (p=0.03), score 7 sub-groups: incidence of the blood system dysfunction than the 1-6 division was significantly higher (x~2=4.35, p=0.02), score Eight sub-groups: renal dysfunction, gastrointestinal system dysfunction than the 1-7 division was significantly higher incidence (p=0.03, x~2=7.64, p=0.006), score 12 Packet: the incidence of breathing, blood, gastrointestinal Road system dysfunction significantly increased, x~2 p value, respectively (x~2 =11.42, p=0.000; x~2=5.62, p=0.018; x~2=5.23, p=0.018), score 13 sub-groups: the incidence of nervous system function disorder significantly increased, x~2 p value, respectively (x~2=26.18, p=0.000), score 14 sub-groups: the incidence of renal function respiratory obstacles than 6-8 division significantly increased (p=0.04). Hysterectomy: Packet 8 incidence compared with the 1-7 packet was significantly higher (x~2 = 9.04, p=0.003). Death: The incidence of sub-20 division compared with 1-7 significantly increased (x~2=7.37, p=0.01). Severe postpartum hemorrhage: 6 sub-score compared with the 1-5 subgroup significantly different (x~2=4.35, P=0.02), score 6-7 Packet compared with 8 Packet significant different (x~2=6.00, p=0.015), sub-12 score compared with the 8-11 division significantly different (x~2=13.18, p=0.000).Conclusions1. We have established the Severe Postpartum Hemorrhage Prediction scoring system and the risk of severe postpartum hemorrhage prediction formula.2. Some information was found usefully for management purposes in Prediction scoring system [0] of Severe Postpartum Hemorrhage. The observations were found that the severe Postpartum Hemorrhage score of 4 is a cutpoint score aiding a management purposes decision regarding [0]that severe Postpartum Hemorrhage patients should be transferred from small hospital to large hospital; the score of 12 is a cutpoint scores aiding management purposes decision regarding which severe Postpartum Hemorrhage patients should be transferred to intensive care unit performing appropriate interventions to reduce the fatality rate. The more of the score is, the higher of the positive rate of severe postpartum hemorrhage. the risk of hysterectomy was significantly increased when the score is more than 8 and should be well prepared[0] for emergency hysterectomy. The risk of maternal mortality was significantly high when the score is more than 20 and early recovery rescue team should prepare to do a good job.3. The evaluation system can effectively predict the risk of severe postpartum hemorrhage , but large sample are needed for further study.更多还原