难治性产后出血的高危因素分析及治疗分析

目的：探讨难治性产后出血的高危因素,为各种高危因素的预防及治疗提出有效的措施。方法：回顾性分析我院2011年12月至2013年12月接诊的难治性产后出血产妇100例,总结出难治性产后出血的高危因素,并分析临床处理和治疗方法。结果：难治性产后出血的原因分别为宫缩乏力（58例）、软产道损伤（12例）、产程异常（11例）、胎盘因素（8例）、凝血功能障碍（6例）、新生儿畸形（3例）、妊娠合并症（2例）,治疗方法：行改良B—Lynch缝合术（36例）、结扎盆腔血管或子宫动脉栓塞,宫腔内纱布填塞（24例）、手取胎盘或钳刮术（13例）、软产道修补缝合（11例）、行子宫切除（9例）、输血治疗（7例）。结论：导致患者难治性产后高危因素众多,最主要是宫缩乏力;医护人员要根据患者具体情况采用合适的治疗方法。     

选择性子宫动脉栓塞术治疗难治性产后出血13例临床分析

目的探讨子宫动脉栓塞术治疗难治性产后出血的时机、疗效及并发症。方法对北京大学人民医院13例难治性产后出血患者,利用数字减影造影（DSA）技术选择子宫动脉及其分支行栓塞治疗。结果 13例产后出血患者分娩时出血量为150～4000ml,平均出血量1200（1200±1215）ml。产后出血总量870～4000ml,平均2555（2555±995）ml。13例患者栓塞前均行按摩子宫,卡孕栓肛塞及欣母沛宫体注射促进子宫收缩,2例剖宫产术中出血患者已行子宫动脉上行支结扎、B-Lynch缝合以及宫腔填纱止血,效果均不佳,经子宫动脉栓塞后12例均成功止血,仅1例未能止血而行全子宫切除术。13例产后出血行子宫动脉栓塞术前存在不同程度的凝血功能异常,在积极纠正凝血功能异常同时行栓塞术。栓塞术后无严重并发症发生,发热为最为常见并发症,但应警惕感染。结论凝血功能障碍并非子宫动脉栓塞术的禁忌证,只要把握好子宫动脉栓塞的时机,子宫动脉栓塞术能有效治疗产后出血,并且并发症少。     

双侧子宫动脉栓塞术治疗难治性产后出血21例分析

目的探讨双侧子宫动脉栓塞术治疗难治性产后出血的疗效及安全性。方法于2003年4月至2005年9月采用Seldinger技术行双侧子宫动脉栓塞术,治疗东莞市厚街医院各种原因导致难治性产后出血21例。其中胎盘早剥合并DIC10例,部分性胎盘植入8例,子宫下段裂伤3例。结果21例患者平均手术时间(40±5)min,栓塞术后平均止血时间(10.0±3.2)min。均抢救成功并保留了子宫,近期无明显并发症。结论双侧子宫动脉栓塞术治疗难治性产后出血具有止血快,且能保留子宫等优点。     

难治性产后出血干预性治疗方法的对比研究

目的探讨难治性产后出血的各种干预性措施在抢救过程中的合理应用及应用价值。方法分析1998年1月至2003年8月间，采用宫腔填塞纱布(塞纱)、盆腔动脉结扎、经导管动脉栓塞术等干预性措施的88例难治性产后出血病人的临床资料。结果全部抢救成功，其中18例宫腔塞纱者成功12例(66．7％)，12例盆腔动脉结扎中成功4例(33．3％)，30例经导管动脉栓塞术(TAE)治疗全部成功(100％)，42例一次开腹行全子宫切除术或加盆腔塞纱者成功36例(85．7％)。结论宫腔塞纱可压迫止血。TAE可替代子宫切除术。当子宫成为凝血功能障碍的病因时，主张行子宫切除．     

难治性产科出血时子宫切除术和子宫动脉栓塞术的临床分析

目的探讨产科急性出血性疾病治疗过程中进行子宫切除术和动脉栓塞术的临床特点以及选择时机。方法回顾性分析35例产科出血因素行子宫切除或者动脉栓塞病例的临床资料。结果16例子宫切除的患者中,胎盘因素10例,占62.5%（前置胎盘/胎盘植入7例,胎盘早剥伴有凝血功能障碍3例）,子宫异常4例（子宫收缩乏力2例、子宫切口延裂致阔韧带血肿和子宫破裂各1例）占25%;羊水栓塞致DIC后切除子宫2例占12.5%。19例行子宫动脉栓塞术中,前置胎盘3例,占15.8%,子宫收缩异常13例（原发性宫缩乏力产程中剖宫产4例、双胎4例,急产产后出血2例,巨大儿1例,巨大子宫肌瘤2例）占68.4%,剖宫产并发症3例（子宫切口延裂致阔韧带血肿和子宫动脉瘤各1例,剖宫产术后晚期产后出血1例）占15.8%,其中2例栓塞失败,分别行子宫切除术和开腹探查血肿清除术。子宫切除术平均出血量（4 593±2 727）ml,子宫动脉栓塞术时平均出血量（2 601±904）ml,两组比较差异有统计学意义（P〈0.05）。子宫切除组有11例出现了DIC表现占68.7%。行子宫动脉栓塞术时发生DIC1例,占10.5%,差异有统计学意义（P〈0.05）。结论二者均为治疗产后出血的有效手段,但是栓塞术作为保守治疗可以保留生育功能,对于改善患者的预后具有重要的意义,要求尽早采用,一旦发生了严重的DIC和休克,则失去了机会。而保守治疗不能短时间见效,应果断行子宫切除术。     

重组激活型Ⅶ因子治疗产后大出血的应用进展

产后出血是临床常见且严重的产后并发症,是导致我国产妇死亡的首位原因.产后出血发生突然,常导致患者出现严重并发症,甚至死亡[1-2].目前,治疗产后出血主要采取保守治疗,但经保守治疗后一些难治性产后大出血仍无法控制,重症患者需要进行干预性治疗[3],如子宫动脉栓塞,甚至需切除子宫.     

重组激活型Ⅶ因子治疗产后大出血的应用进展

产后出血是临床常见且严重的产后并发症,是导致我国产妇死亡的首位原因.产后出血发生突然,常导致患者出现严重并发症,甚至死亡[1-2].目前,治疗产后出血主要采取保守治疗,但经保守治疗后一些难治性产后大出血仍无法控制,重症患者需要进行干预性治疗[3],如子宫动脉栓塞,甚至需切除子宫.     

重组激活型Ⅶ因子治疗产后大出血的应用进展

产后出血是临床常见且严重的产后并发症,是导致我国产妇死亡的首位原因.产后出血发生突然,常导致患者出现严重并发症,甚至死亡[1-2].目前,治疗产后出血主要采取保守治疗,但经保守治疗后一些难治性产后大出血仍无法控制,重症患者需要进行干预性治疗[3],如子宫动脉栓塞,甚至需切除子宫.     

导管动脉栓塞术在难治性产后出血中的应用

目的　探讨经导管动脉栓塞术（TAE）在难治性产后出血中的应用价值。方法　以Seldinger技术对14例难治性产后出血患者,行经皮双髂内动脉前干或子宫动脉超选择插管术,应用数字减影血管造影（DSA）技术明确出血部位后灌注抗生素(头孢噻甲羧肟),并以明胶海绵颗粒栓塞。结果　（1）14例经保守治疗无效的难治性产后出血患者,经TAE治疗后一次性止血成功,止血时间3～10min,平均时间(6.1±3.6)min,手术时间30～50min,平均（41.8±6.4）min;（2）应用DSA发现,出血均来源于单侧或双侧子宫动脉,表现为宫腔内弥漫性、局灶性出血或单侧子宫动脉分支出血;（3）随访2～60个月,14例患者均恢复规律月经,无严重并发症发生。结论　应用TAE治疗难治性产后出血有较好的临床效果,具有止血快、并发症少的特点。     

产后出血介入栓塞治疗24例临床分析

产后出血是产科的主要并发症和产妇的主要死亡原因之一,占我国产妇死亡人数的49.9%。产后出血超过1 000m l或合并休克者为重度产后出血,如不能及时止血,常危及患者生命,我们对于经保守治疗无效的产后出血采用髂内动脉结扎术,甚至子宫切除术。子宫切除,虽然可以达到止血的目的,但是以器官的丢失作为代价。年轻女性切除子宫势必引起一系列生理、心理上的变化,影响患者的生活质量。介入栓塞治疗产后大出血,为临床治疗产后出血提供了一种创伤小,止血快而且彻底,可保留子宫等优点的方法。2000年8月至2005年8月我们为24例产后出血患者施行介入栓塞…     

Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.     

Preventing postpartum hemorrhage in low-resource settings.

OBJECTIVES: To review the literature to determine the most effective methods for preventing postpartum hemorrhage (PPH), the single most important cause of maternal death worldwide. METHODS: Systematic review of published randomized controlled trials and relevant reviews. RESULTS: Review of the literature confirms that active management of the third stage of labor, especially the administration of uterotonic drugs, reduces the risk of PPH due to uterine atony without increasing the incidence of retained placenta or other serious complications. Oxytocin is the preferred uterotonic drug compared with syntometrine, but misoprostol also can be used to prevent hemorrhage in situations where parenteral medications are not available (e.g. at home births in developing countries). CONCLUSIONS: The use of active management of the third stage of labor to prevent PPH due to uterine atony should be expanded, especially in developing country settings.     

Routine postpartum ultrasonography in the prediction of puerperal uterine complications.

OBJECTIVES: To determine whether there is a relationship between the findings of routine postpartum ultrasonographic scanning and puerperal uterine complications such as heavy delayed postpartum hemorrhage, retained products of conception, and need for uterine curettage; and to estimate the value of both routine ultrasonographic scanning and clinical data in the prediction of these complications. METHODS: In this cohort study 265 women were examined ultrasonographically on postpartum Days 1, 14, 42 following uncomplicated vaginal or cesarean deliveries. They were divided into a low-risk (n=149) and a high-risk (n=116) group according to predefined risk factors for puerperal uterine complications. The ultrasonographic findings were dichotomized into no masses (endometrial strip, endometrial fluid, or hyperechoic foci) or a definite intrauterine echogenic/heterogeneous mass (IUM, >15 mm in diameter). RESULTS: The presence of risk factor(s) was significantly associated with uterine subinvolution, IUM, heavy delayed postpartum hemorrhage (PPH), and a need for uterine curettage. Multivariable logistic regression analysis for the risk factor(s) that can predict the occurrence of heavy delayed PPH showed that the presence of an IUM was the most predictive variable. The presence of an IUM and heavy delayed PPH predicted uterine curettage in 61.3% and 37.5% of patients, respectively. CONCLUSION: Routine uterine scanning on Day 1 and Day 14 postpartum is an easy, inexpensive, valuable method that can be offered to women at high risk for delayed PPH due to subinvolution or the presence of an IUM. Accordingly, it may be predicted which women will benefit from uterine curettage in up to two-thirds of cases.     

B-Lynch suture: a case series

OBJECTIVE: To report an 8-year institutional experience in the use of the B-Lynch Suture for the management of postpartum hemorrhage (PPH). STUDY DESIGN: Cases with B-Lynch suture utilization for severe postpartum hemorrhage were identified, from March 1997 to March 2005, at White Memorial Medical Center. Case charts were reviewed, and postoperative follow-up after hospital discharge was conducted by telephone interview and outpatient clinic chart review. Historical characteristics and outcome of these patients are described. RESULTS: B-Lynch suture was performed on 22 patients, between March 1997 and March 2005, to control intractable PPH at cesarean section that did not respond to uterotonic agents. In 12 instances, the B-Lynch suture was the only intervention, whereas in 10 it was combined with vessel ligation. The procedure resulted in control of bleeding with uterine preservation in 77% of the cases. In those cases where the etiology of PPH was uterine atony, the B-Lynch suture was successful in 85% of the cases. Hysterectomy was avoided in 17/22 cases. CONCLUSION: The B-Lynch suture is an alternative surgical procedure for uterine preservation that may be used to control postpartum hemorrhage from uterine atony.     

如何规范产后出血的药物治疗

产后出血（postpartum hemorrhage）是导致孕产妇死亡的首要原因。引起产后出血的原因分别为子宫收缩乏力、胎盘因素、软产道裂伤及凝血功能障碍。产后出血的病因治疗是最根本的治疗,是产后出血救治成功的关键。产后出血的药物治疗主要是针对子宫收缩乏力宫缩剂的治疗。缩宫素为一线用药,当单独手法按摩子宫和缩宫素不能达到止血目的时,可以考虑使用卡贝缩宫素、卡前列素氨丁三醇或卡前列酸栓。在没有注射用宫缩剂或注射用宫缩剂使用禁忌时可以考虑使用米索前列醇。当药物加强宫缩治疗无效时应注意不同药物的起效时间及持续时间。此外,一方面要重新核对有无合并其他原因所致产后出血;另一方面应及时采用必要的进一步治疗如宫腔填塞或子宫动脉栓塞等。     

Secondary postpartum hemorrhage due to uterine artery pseudoaneurysm rupture in von Willebrand disease

We here report a case of a 33-year-old woman who experienced secondary postpartum hemorrhage (PPH) due to uterine artery pseudoaneurysm rupture. She had intrauterine balloon tamponade for unexplained primary PPH after spontaneous vaginal delivery, and subsequent angiography showed no abnormal contrast extravasation. However, profuse vaginal bleeding occurred 22 days postpartum. Color Doppler ultrasonography demonstrated an anechoic mass with turbulent flow in the lower uterine segment, corresponding to uterine artery pseudoaneurysm. She was successfully treated with selective uterine arterial embolization. Decreased levels of von Willebrand factor and factor VIII led to the diagnosis of von Willebrand disease. When it is determined that a patient has unexplained PPH or uterine artery pseudoaneurysm, a high index of suspicion and further investigation for underlying bleeding disorders is warranted.     

Outcomes of hypogastric artery ligation and transcatheter uterine artery embolization in women with postpartum hemorrhage

Objective

This study aimed to report our experience of emergent bilateral hypogastric (internal iliac) artery ligation (HAL) in the management of intractable postpartum hemorrhage (PPH) in a tertiary care center.

Impact of simulation and team training on postpartum hemorrhage management in non-academic centers

Objective: Prompt recognition and response to postpartum hemorrhage (PPH) are vital in preventing maternal morbidity and mortality. We conducted a multi-center study to evaluate in situ simulation and team training for PPH among experienced clinical teams in non-academic hospitals in urban and rural communities.

Methods: A longitudinal intervention study was performed in six Oregon community hospitals. All teams responded to an in situ simulated delivery and postpartum hemorrhage using trained actors and an obstetric birthing simulator, followed by a debriefing and training session. The simulation scenario was then repeated in 9–12?months. All sessions were digitally video recorded and independently reviewed by two obstetricians using a structured evaluation form. PPH management including clinical response times were compared before and after team training using Student’s paired t-test and McNemar’s test.

Results: Twenty-two teams completed paired case simulations. Team training significantly improved response times in the management of PPH, including the recognition of PPH, time to administer first medication, performance of uterine massage and time to administer second medication. Medical management (use of three indicated medications) improved after training from 27.3% to 63.6%, p?=?0.01.

Conclusions: Simulation and team training significantly improved postpartum hemorrhage response times among clinically experienced community labor and delivery teams.     

Uterine tamponade using condom catheter balloon in the management of non-traumatic postpartum hemorrhage

Aim: To study the efficacy and complications of uterine tamponade using condom catheter balloon in non-traumatic postpartum hemorrhage (PPH). Material and Methods: This prospective study was conducted in a tertiary care teaching hospital in India. Eighteen patients with non-traumatic PPH not responding to medical management were included in the study. Uterine tamponade was achieved by a condom catheter balloon filled with saline and kept in situ for 8-48?h. The main outcome measures were success rate in controlling hemorrhage, time required to stop bleeding, subsequent morbidity and technical difficulties. Data was analyzed using appropriate statistical methods. Results: The success rate of condom catheter balloon in controlling hemorrhage was 94%. The mean amount of fluid filled in the condom catheter balloon was 409?mL. The average time taken to control bleeding was 6.2?min. The mean duration for which condom catheter balloon was left in situ was 27.5?h. The average amount of blood loss was 1330?mL. Five patients (28%) had infective morbidity. Conclusion: Condom catheter balloon is effective in controlling non-traumatic PPH in 94% cases. It is effective, simple to use, easily available and is a cheap modality to manage non-traumatic postpartum hemorrhage, especially in limited resource settings.