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难治性产后出血是指因各种原因导致产后24 h内或者产褥期发生严重出血达1 000 mL以上,经过宫缩剂、按摩子宫等保守治疗无效,需要外科止血方式干预达到止血目的的致命性产后出血,是危及孕产妇生命的一种危重并发症[1-2]。目前,用于难治性产后出血治疗的新干预方法不断涌现,使得一部分严重出血得到有效救治并保留子宫。本文就传统的宫腔纱布填塞、宫腔阴道双球囊压迫止血以及子宫动脉栓塞介入治疗三种方法的应用效果进行分析探讨,为有效治疗难治性产后出血、寻找最佳治疗模式和干预措施提供循证依据。
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止血方式不同的3组以及填塞治疗方式不同的3组的产妇在年龄、孕周、孕次、产次的差异均无统计学意义(P>0.05)(见表 1)。
分组 n 年龄/岁 孕周 孕次 产次 球囊组 25 30.20±5.71 36.40±2.97 2.96±1.43 1.80±0.65 纱布组 35 31.00±4.60 36.89±2.06 3.14±1.85 1.77±0.49 介入组 11 31.91±4.28 35.91±2.66 2.45±1.04 1.82±0.75 F — 0.48 0.72 0.77 0.03 P — > 0.05 > 0.05 > 0.05 > 0.05 MS组内 — 24.781 6.276 2.592 0.352 填塞组 34 29.79±4.45 37.15±2.55 2.79±1.36 1.73±0.57 填塞+介入组 19 32.06±5.87 36.47±1.84 3.82±2.33 1.94±0.75 填塞+子宫切除组 7 31.43±4.83 35.86±1.77 2.86±1.22 1.71±0.49 F — 1.27 1.17 2.18 0.72 P — > 0.05 > 0.05 > 0.05 > 0.05 MS组内 — 24.801 5.164 2.942 0.391 表 1 产妇一般资料的比较(x±s)
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止血方式不同的3组术中出血量、产后24 h出血量以及输注红细胞悬液、血浆量比较差异均无统计学意义(P>0.05)。填塞方式不同的3组的术中出血量、产后24 h出血量以及输注红细胞悬液、血浆量差异均有统计学意义(P < 0.01)。在术中出血量和产后24 h出血量方面,填塞+子宫切除组最多(P < 0.01),填塞+介入组次之(P < 0.01),填塞组最少(P < 0.01和P < 0.05);输注红细胞悬液和血浆量方面,填塞+子宫切除组均高于填塞+介入组和填塞组(P < 0.01),填塞+介入组和填塞组间比较差异均无统计学意义(P>0.05)(见表 2)。
分组 n 术中出血量/mL 产后24 h出血量/mL 输注红细胞悬液量/U 输注血浆量/mL 球囊组 25 1 708.00±564.34 2 291.00±1 229.25 5.74±5.15 390.00±432.77 纱布组 35 1 962.86±1 286.60 2 471.00±1 865.57 6.40±7.40 395.71±657.69 介入组 11 1 590.91±323.90 1 890.45±504.24 4.09±1.55 213.64±240.93 F — 0.84 0.62 0.60 0.52 P — > 0.05 > 0.05 > 0.05 > 0.05 MS组内 — 955 502.476 2 310 880.319 37.094 290 916.739 填塞组 34 1 340.91±301.42 1547.88±297.55 2.96±1.42 148.49±141.14 填塞+介入组 19 1 788.24±329.55* 2 032.65±494.94* 4.52±1.37 214.71±208.98 填塞+子宫切除组 7 3 885.71±1 945.45**△△ 6 145.71±1 708.40**△△ 20.71±9.48**△△ 1 642.86±779.12**△△ F — 36.92 137.21 78.78 72.41 P — < 0.01 < 0.01 < 0.01 < 0.01 MS组内 — 485 292.884 435 839.514 11.220 89 221.963 q检验:与填塞组比较*P < 0.05, **P < 0.01;与填塞+介入组比较△△P < 0.01 表 2 产妇术中情况的比较(x±s)
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止血方式不同的3组的住院时间、术后Hb水平以及使用抗生素时间比较,差异均无统计学意义(P>0.05);术后发热时间比较,纱布组高于球囊组和介入组(P < 0.05), 球囊组和介入组间差异无统计学意义(P>0.05)。术前Hb含量在填塞方式不同的3组之间差异均无统计学意义(P>0.05);住院时间、术后发热时间和抗生素使用时间按填塞组、填塞+介入组、填塞+子宫切除组次序逐渐增加(P < 0.05~P < 0.01)(见表 3)。
分组 n 住院时间/d 术前Hb/(g/L) 术后Hb/(g/L) 术后发热时间/d 使用抗生素时间/d 球囊组 25 7.44±1.83 108.76±10.87 92.92±15.23 1.04±0.89 5.08±1.19 纱布组 35 8.57±2.70 98.20±12.18** 86.63±10.84 2.17±1.92* 5.89±1.92 介入组 11 8.09±1.22 104.36±14.50 87.27±10.32 1.82±1.40 4.73±0.95 F — 1.85 5.64 1.96 3.89 3.20 P — > 0.05 < 0.01 > 0.05 < 0.05 < 0.05 MS组内 — 5.053 146.798 156.281 2.411 2.476 填塞组 34 7.03±0.77 105.21±12.38 91.85±12.92 1.55±0.75 4.82±0.92 填塞+介入组 19 8.29±1.96* 99.29±16.41 83.18±12.1* 2.41±2.35 5.82±1.78* 填塞+子宫切除组 7 12.14±4.26**△△ 102.00±5.67 95.71±14.73△ 3.29±1.38** 7.86±2.19**△△ F — 22.14 1.23 3.67 4.78 14.19 P — < 0.01 > 0.05 < 0.05 < 0.05 < 0.05 MS组内 — 3.467 177.155 165.716 2.270 1.995 q检验:与填塞组比较* P < 0.05, ** P < 0.01;与填塞+介入组比较△ P < 0.05, △△ P < 0.01 表 3 不同方法术后情况的比较(x±s)
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多因素logistic回归分析显示,胎盘植入和弥散性血管内凝血(DIC)为难治性产后出血止血失败的危险因素(P < 0.01)(见表 4)。
变量 β SE Wald χ2 P OR 95% CI 年龄≥35岁 -0.105 1.134 0.009 > 0.05 0.900 0.098~8.303 胎盘植入 2.556 0.876 8.518 < 0.01 12.889 2.315~71.747 DIC 4.431 1.265 12.276 < 0.01 84.00 7.045~1 001.628 多胎妊娠 0.916 1.197 0.586 > 0.05 2.500 0.239~26.122 介入治疗 -0.791 0.873 0.821 > 0.05 0.453 0.082~2.511 经产妇 0.054 0.880 0.004 > 0.05 1.056 0.188~5.926 瘢痕子宫 0.290 0.807 0.129 > 0.05 1.337 0.275~6.501 表 4 难治性产后出血产妇止血失败的多因素logistic回归分析
不同止血方法应用于难治性产后出血的效果分析
Effect analysis of different hemostatic methods in refractory postpartum hemorrhage
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摘要:
目的探讨不同止血方法治疗难治性产后出血的有效性以及止血失败的原因。 方法选择71例难治性产后出血产妇作为研究对象,其中行宫腔纱布填塞35例,宫腔阴道球囊压迫25例,子宫动脉栓塞介入治疗11例。将71例产妇按止血方法不同分为纱布填塞组(纱布组)、球囊压迫组(球囊组)和动脉栓塞介入组(介入组),再按填塞治疗(包括纱布填塞和球囊压迫)的方式分为单纯填塞治疗组(填塞组)、填塞联合介入治疗组(填塞+介入组)以及填塞联合子宫切除(填塞+子宫切除组)3组。分别对各组的术中情况,术后发热、术后治疗等结果进行对照分析,并对止血失败的原因进行多因素分析。 结果71例产妇产后出血量1 100~8 000 mL,止血成功64例,止血失败行子宫切除7例。止血方式不同的3组的术中出血量、产后24 h出血量以及输注红细胞悬液、血浆量差异均无统计学意义(P>0.05)。填塞方式不同的3组比较显示,术中出血量和产后24 h出血量均为填塞+子宫切除组最多(P < 0.01),填塞+介入组次之(P < 0.01),填塞组最少(P < 0.01和P < 0.05);输注红细胞悬液和血浆量方面,填塞+子宫切除组均高于填塞+介入组和填塞组(P < 0.01),填塞+介入组和填塞组间差异无统计学意义(P>0.05)。术后情况比较显示,纱布组的术后发热时间高于球囊组和介入组(P < 0.05),球囊组和介入组之间差异无统计学意义(P>0.05);住院时间、术后发热时间和抗生素使用时间按填塞组、填塞+介入组、填塞+子宫切除组次序逐渐增加(P < 0.05~P < 0.01)。对64例止血成功的产妇资料进行多因素分析,发现胎盘植入和弥散性血管内凝血是止血失败的危险因素(P < 0.01)。 结论宫腔纱布填塞止血和球囊压迫止血效果无明显差异,但是球囊压迫止血可减低产褥感染发生率;合并胎盘植入,出现凝血功能异常时,填塞和介入的止血方式多难以奏效,需要尽快切除子宫。 Abstract:ObjectiveTo explore the effectiveness of different hemostatic methods in the treatment of refractory postpartum hemorrhage, and the causes of hemostasis failure. MethodsAmong 71 puerpera with refractory postpartum hemorrhage, 35 cases were treated with intrauterine gauze packing, 25 cases were treated with intrauterine vaginal balloon compression, and 11 cases were treated with uterine artery embolization.According to different hemostatic methods, 71 puerpera were divided into the gauze packing group (gauze group), balloon compression group (balloon group) and arterial embolization intervention group (interventional group). Accordingto the method of tamponade treatment (including gauze tamponade and balloon compression), the patients were divided into the tamponade treatment group (tamponade group), tamponade combined with interventional treatment group (tamponade+interventional group), and tamponade combined with hysterectomy group (tamponade+hysterectomy group).The intraoperative condition, postoperative fever and treatment among all groups were compared, and the causes of hemostatic failure were analyzed using multi-factor method. ResultsThe postpartum blood loss in 71 cases was 1 100~8 000 mL, the successful hemostasis in 64 cases was found, and 7 cases were treated with hysterectomy after hemostasis.There was no statistical significance in intraoperative blood loss, postpartum 24 h blood loss, and transfusion of erythrocyte suspension and plasma among three groups with different hemostatic methods (P>0.05).The comparison results among three groups with different tamponade methods showed that the intraoperative blood loss and postpartum blood loss at 24 h in tamponade+hysterectomy group were the most (P < 0.01), followed by the tamponade + intervention group (P < 0.01), and the least in tamponade group (P < 0.01 and P < 0.05).The infusion of RBC suspension and plasma volume in tamponade+hysterectomy group were higher than those in tamponade + intervention group and tamponade group (P < 0.01), and there was no statistical significance of which between tamponade + intervention group and tamponade group (P>0.05).The results of postoperative conditions showed that the postoperative fever time in gauze group was higher than that in balloon group and interventional group (P < 0.05), but there was no statistical significance between balloon group and interventional group (P>0.05).The length of stay, postoperative fever days and duration of antibiotic use gradually increased according to the order of the tamponade group, tamponade + intervention group, tamponade + hysterectomy group (P < 0.05 to P < 0.01).A multi-factor analysis of 64 cases with successful hemostasis showed that the placental implantation and diffuse intravascular coagulation were the risk factors of hemostasis failure (P < 0.01). ConclusionsThere is no significant difference in the hemostatic effect between intrauterine gauze packing and balloon compression, but the balloon compression hemostasis can reduce the incidence rate of puerperal infection.In combination with placenta implantation, abnormal coagulation function and poor hemostatic effect of tamponade and intervention, and the hysterectomy should be implemented as soon as possible. -
表 1 产妇一般资料的比较(x±s)
分组 n 年龄/岁 孕周 孕次 产次 球囊组 25 30.20±5.71 36.40±2.97 2.96±1.43 1.80±0.65 纱布组 35 31.00±4.60 36.89±2.06 3.14±1.85 1.77±0.49 介入组 11 31.91±4.28 35.91±2.66 2.45±1.04 1.82±0.75 F — 0.48 0.72 0.77 0.03 P — > 0.05 > 0.05 > 0.05 > 0.05 MS组内 — 24.781 6.276 2.592 0.352 填塞组 34 29.79±4.45 37.15±2.55 2.79±1.36 1.73±0.57 填塞+介入组 19 32.06±5.87 36.47±1.84 3.82±2.33 1.94±0.75 填塞+子宫切除组 7 31.43±4.83 35.86±1.77 2.86±1.22 1.71±0.49 F — 1.27 1.17 2.18 0.72 P — > 0.05 > 0.05 > 0.05 > 0.05 MS组内 — 24.801 5.164 2.942 0.391 表 2 产妇术中情况的比较(x±s)
分组 n 术中出血量/mL 产后24 h出血量/mL 输注红细胞悬液量/U 输注血浆量/mL 球囊组 25 1 708.00±564.34 2 291.00±1 229.25 5.74±5.15 390.00±432.77 纱布组 35 1 962.86±1 286.60 2 471.00±1 865.57 6.40±7.40 395.71±657.69 介入组 11 1 590.91±323.90 1 890.45±504.24 4.09±1.55 213.64±240.93 F — 0.84 0.62 0.60 0.52 P — > 0.05 > 0.05 > 0.05 > 0.05 MS组内 — 955 502.476 2 310 880.319 37.094 290 916.739 填塞组 34 1 340.91±301.42 1547.88±297.55 2.96±1.42 148.49±141.14 填塞+介入组 19 1 788.24±329.55* 2 032.65±494.94* 4.52±1.37 214.71±208.98 填塞+子宫切除组 7 3 885.71±1 945.45**△△ 6 145.71±1 708.40**△△ 20.71±9.48**△△ 1 642.86±779.12**△△ F — 36.92 137.21 78.78 72.41 P — < 0.01 < 0.01 < 0.01 < 0.01 MS组内 — 485 292.884 435 839.514 11.220 89 221.963 q检验:与填塞组比较*P < 0.05, **P < 0.01;与填塞+介入组比较△△P < 0.01 表 3 不同方法术后情况的比较(x±s)
分组 n 住院时间/d 术前Hb/(g/L) 术后Hb/(g/L) 术后发热时间/d 使用抗生素时间/d 球囊组 25 7.44±1.83 108.76±10.87 92.92±15.23 1.04±0.89 5.08±1.19 纱布组 35 8.57±2.70 98.20±12.18** 86.63±10.84 2.17±1.92* 5.89±1.92 介入组 11 8.09±1.22 104.36±14.50 87.27±10.32 1.82±1.40 4.73±0.95 F — 1.85 5.64 1.96 3.89 3.20 P — > 0.05 < 0.01 > 0.05 < 0.05 < 0.05 MS组内 — 5.053 146.798 156.281 2.411 2.476 填塞组 34 7.03±0.77 105.21±12.38 91.85±12.92 1.55±0.75 4.82±0.92 填塞+介入组 19 8.29±1.96* 99.29±16.41 83.18±12.1* 2.41±2.35 5.82±1.78* 填塞+子宫切除组 7 12.14±4.26**△△ 102.00±5.67 95.71±14.73△ 3.29±1.38** 7.86±2.19**△△ F — 22.14 1.23 3.67 4.78 14.19 P — < 0.01 > 0.05 < 0.05 < 0.05 < 0.05 MS组内 — 3.467 177.155 165.716 2.270 1.995 q检验:与填塞组比较* P < 0.05, ** P < 0.01;与填塞+介入组比较△ P < 0.05, △△ P < 0.01 表 4 难治性产后出血产妇止血失败的多因素logistic回归分析
变量 β SE Wald χ2 P OR 95% CI 年龄≥35岁 -0.105 1.134 0.009 > 0.05 0.900 0.098~8.303 胎盘植入 2.556 0.876 8.518 < 0.01 12.889 2.315~71.747 DIC 4.431 1.265 12.276 < 0.01 84.00 7.045~1 001.628 多胎妊娠 0.916 1.197 0.586 > 0.05 2.500 0.239~26.122 介入治疗 -0.791 0.873 0.821 > 0.05 0.453 0.082~2.511 经产妇 0.054 0.880 0.004 > 0.05 1.056 0.188~5.926 瘢痕子宫 0.290 0.807 0.129 > 0.05 1.337 0.275~6.501 -
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