子宫压迫缝合术在产后出血治疗中的应用

产后出血导致的子宫切除率为0．14％，其中48．9％为前置胎盘、29．8％为宫缩乏力、8．5％为宫颈撕裂、12．8％为其他原因；经产妇子宫切除者中58．8％源于胎盘因素，初产妇69．2％源于宫缩乏力。近几年来，在产后出血处理方面的研究进展主要集中在降低产后出血死亡率的同时，降低子宫切除率以保持器宫完整性。对于产后出血，在用宫缩剂无效情况下，临床常用的方法有：宫腔纱布填塞、子宫动脉结扎、髂内动脉结扎、高选择性动脉栓塞以及子宫切除术等，但以上方法存在操作复杂、效果不佳或造成患者丧失生育功能等缺陷，故寻求一种简便、高效、易于推广的方法显得尤为迫切，这也是产科工作者一直都很关注的课题。子宫压迫缝合术（uterine compression suture）是20世纪90年代后期兴起的用于产后出血治疗的一系列新方法，现综述如下。     

浅谈产后出血的急救、预防与护理

在产科，产后出血导致产妇死亡的比例较高，因此，必须重视产后出血的观察。出血多发生在胎儿娩出后，胎盘未剥离、宫缩乏力或凝血功能障碍时，所以，在这期间一定要严密观察，认真了解产妇有无孕期高血压、产程进展、分娩机制及胎盘娩出后出血量、产后子宫收缩情况，熟练掌握出血的抢救原则，一旦发生，及时准确地针对病因给予止血.     

宫缩剂不敏感宫缩乏力性产后出血的诊治

产后出血是分娩期主要并发症,发生率为4％～6％,是我国孕产妇死亡的四大原因之一.其中子宫收缩乏力是产后出血的主要原因,占产后出血的70％～75％. 1 宫缩剂不敏感的宫缩乏力性产后出血的诊断 在正常情况下,胎盘娩出后子宫肌纤维的收缩和缩复使胎盘剥离面内开放的血窦闭合,形成血栓而止血.故一切影响子宫正常收缩和缩复功能的因素均可引起产后出血.有宫缩乏力的危险因素并排除胎盘因素(主要是前置胎盘和胎盘粘连、植入和穿透)、产道损伤和凝血功能障碍,即可诊断为宫缩乏力性产后出血.     

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。     

缩宫素配伍米索前列醇预防产后出血的临床应用

产后出血是分娩期严重并发症，居我国产妇死亡原因的首位。子宫收缩乏力为产后出血最常见的原因之一．约占50％-51．6％。为防治子宫收缩乏力所致的产后出血，我院自．2004年1月-2005年1月应用缩宫素配伍米索前列醇以增强子宫收缩，防治产后出血，收到显著临床效果，现总结报道如下。     

难治性产后出血围产期急症子宫切除术19例临床分析

目的探讨难治性产后出血围产期急症子宫切除术的原因、时机、术后并发症及孕产妇结局。方法回顾性分析2016年7月至2019年12月本院收治的因难治性产后出血行急诊子宫切除术19例患者的临床资料。结果 19例患者平均年龄(33.4±4.2)岁,平均孕次(2.8±1.2)次,平均孕周(36.4±4.4)周。子宫切除术原因为胎盘因素7例,宫缩乏力为5例,宫缩乏力合并边缘性胎盘产前出血2例,软产道损伤形成大血肿2例,羊水栓塞2例,晚期产后出血合并感染1例。子宫切除术前平均出血量(4 697.2±1 868.5)ml,平均血红蛋白(56.3±21.7)g/L。除1例羊水栓塞患者死亡外,18例患者痊愈出院。结论围产期急症子宫切除是治疗难治性产后出血的重要措施,胎盘异常及宫缩乏力是两大主要原因。     

产时产后出血子宫切除15例临床分析

目的 分析产时、产后子宫切除的发生率、手术指征、并发症及经验教训。方法 采用回顾性资料分析方法，对我院1990年4月～2004年6月因产科出血切除子宫的15例临床资料整理分析。结果 14年中我院分娩总数11556例，15例行子宫切除术，发生率约为1．3‰。胎盘因素10例，其中胎盘植入8例，前置胎盘2例；产后宫缩乏力3例；羊水栓塞1例；子宫破裂1例。结论 产时产后出血，胎盘因素为子宫切除主要因素，子宫切除为产科出血救治的措施和手段。     

33例重度产后出血的临床原因分析

目的分析重度产后出血的临床原因，探讨预防措施。方法对我院1991年1月至2000年12月33例重度产后出血病例进行回顾性分析。结果①试产时间过长，巨大儿，难产手术为宫缩乏力和软产道损伤性重度出血的主要临床原因。②前置胎盘为剖宫产时急性出血的高危原因。③部分严重出血因发生缓慢易为临床疏忽。结论针对产妇选择适宜的分娩方式，避免产程过长，提高识别、处理难产的水平和手术质量，加强产后监护，是减少重度产后出血的关键。     

产后出血的预防与护理

目的：产后出血的预防与护理方法：对临床70例产后出血的病例进行分析结果：产后出血的原因：宫缩乏力、软产道损伤、胎盘因素及凝血功能障碍,子宫收缩乏力为主要原因。结论：产后出血是孕产妇死亡的主要原因,做好产后出血的预防至关重要。     

从产后出血早期表现中识别羊水栓塞3例分析

胎儿娩出后羊水栓塞发病者的典型临床表现是产后出血。本文通过作者成功抢救 3例羊水栓塞患者的体会 ,对照产后出血的临床症状 ,结合产妇外周血涂片 ,提出了羊水栓塞识别要点。1　资料与方法1.1　一般资料我院 1997年至 1999年分娩总数 12 19例 ,并发产后出血者 5 0例占 4 1%。其中胎盘因素 (胎盘粘连、残留、前置及巨大胎盘 ) 2 8例 ,妊娠高血压综合征 7例 ,宫缩乏力 5例 ,剖宫产子宫切口裂伤 2例 ,宫颈裂伤、阴道壁血肿各 2例 ,不全子宫破裂 1例 ,羊水栓塞 3例。将上述 5 0例设为观察组。以 1999年 8月至 1999年 10月分娩的无产后出血者 1…     

产后出血急症子宫切除术46例临床资料分析

目的探讨难治性产后出血急症子宫切除术的原因、抢救难治性产后出血中的手术时机及孕产妇结局,为预防和处理产后大出血提供依据。 方法采用回顾性研究方法对2010年至2014年在西北妇女儿童医院分娩的46例因产后出血行急症子宫切除术患者的临床资料进行分析。 结果5年间共住院分娩56 436例,有582例发生了产后出血,产后出血发生率1.03%;其中46例患者经保守治疗出血仍不能控制,实施了急症子宫切除术。产后出血原因为：胎盘因素(43.48%,20/46),宫缩乏力(36.96%,17/46),胎盘因素合并宫缩乏力(10.87%,5/46),羊水栓塞(4.35%,2/46)和晚期产后出血感染(4.35%,2/46)。出血量1 500～4 000 ml,平均(2 783±625)ml。46例患者均行急症子宫切除术后痊愈出院。 结论急症子宫切除术是产后大出血经保守治疗无效时抢救孕产妇生命的有效措施,胎盘因素是急诊子宫切除的主要原因,做好产后出血的预防与处理可以有效地降低围生期子宫切除率。     

B-Lynch sutures for major primary postpartum haemorrhage at caesarean section.

This was a retrospective observational study of 11 consecutive patients of major primary postpartum haemorrhage (PPH) who had the B-Lynch suture at the time of caesarean section, performed between 1 March 2001 and 31 March 2004 at a teaching hospital in Scotland. Case-note review was performed in 123 patients, who had major primary PPH to identify patients who had B-Lynch sutures at the time of caesarean section. The patient's age, parity, gestation of pregnancy at which the B-Lynch suture was performed, the indication for caesarean section and the cause of primary major PPH were recorded. The operative details, intraoperative and immediate postoperative complications and the need for subsequent hysterectomy were noted. The patients were followed-up with clinic visits at 6 weeks and any further hospital referral for late postoperative complications and whether subsequent successful pregnancy was achieved, were documented. The incidence of major PPH in our centre was 0.5% of the total deliveries, of which 11 cases had the B-Lynch suture applied at the time of caesarean section. The patients were aged between 25 and 38 years old (mean 31 years). Parity ranged from 0 to 1 and the gestational age at which the procedure was performed ranged from 34 to 41 weeks (mean 38 weeks). Ten operations (91%) were performed by senior registrars supervised by the consultant on call and one (9%) case was performed by a consultant on call. All cases had the B-Lynch sutures performed for major primary PPH caused by uterine atony at the time of caesarean section. The weight of the babies delivered ranged between 2,110 - 4,820 g (mean 3,500 g). The total blood loss at surgery ranged from 2,000 - 10,000 ml (mean 3,500 ml). Only three patients (28%) required hysterectomy. All the patients made a good postoperative recovery. The hospital stay ranged from 4 - 24 days (mean 8 days). The patient who remained in hospital for 24 days did so because her baby was admitted into the neonatal unit. All the patients were reviewed 6 weeks postnatally. There was no significant morbidity. A subsequent successful pregnancy has been achieved in one patient.     

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。     

Internal iliac artery ligation for arresting postpartum haemorrhage

OBJECTIVE: To study the role of internal iliac artery ligation (IIAL) in arresting and preventing postpartum haemorrhage (PPH). DESIGN: Retrospective chart review of women undergoing therapeutic IIAL for PPH or prophylactic IIAL for risk of PPH. SETTING: Tertiary care hospital in Pune, India. SAMPLE: Women admitted to King Edward Memorial (KEM) Hospital, Pune, India, who underwent IIAL to control or prevent PPH. METHODS: Bilateral IIAL was performed in all women. MAIN OUTCOME MEASURES: Need for re-laparotomy or hysterectomy to control haemorrhage, complications of the procedure. RESULTS: Out of 110 women who underwent IIAL, 88 had therapeutic IIAL for PPH from atony (36), genital tract injury (23), placenta praevia (21), placental abruption (4), uterine inversion (3) or coagulopathy (1). Hysterectomy was performed after IIAL failed to arrest haemorrhage in 33 (39.3%) of 84 women (excluding 4 with vaginal lacerations). Hysterectomy was more likely with uterine rupture (79%) than with nontraumatic PPH (up to 27%). Failure to control haemorrhage by IIAL was evident immediately, and bleeding arrested by IIAL did not recur to require later laparotomy in any woman. Out of 22 women at high risk for PPH undergoing prophylactic IIAL at caesarean section, none had subsequent haemorrhage. One woman had an iliac vein injury that was repaired with no further morbidity. There were no ischaemic complications either during inpatient stay or up to 6 weeks. CONCLUSIONS: IIAL is useful in the treatment and prevention of PPH from any cause. Early resort to IIAL effectively prevents hysterectomy in women with atonic PPH. In traumatic PPH, IIAL facilitates hysterectomy or repair as indicated and prevents reactionary haemorrhage.     

Peripartum hysterectomy in a teaching hospital in the eastern region of Turkey

OBJECTIVES: The aim of this study was to find the incidence and clinical implications of peripartum hysterectomy in our hospital at the Eastern region of Anatolia. STUDY DESIGN: We analyzed retrospectively all cases of peripartum hysterectomy performed at YYU Medical Faculty Hospital between January 1995 and April 2003. Emergency peripartum hysterectomy was performed for hemorrhage which cannot be controlled with other conventional treatments within 24h of a delivery. There were 24 cases of emergency peripartum hysterectomy performed. RESULTS: The incidence of emergency peripartum hysterectomy was 5.09 per 1000 deliveries. Half of the hysterectomies followed cesarean section. Eleven patients were referred to our clinics from other hospitals. Uterine atony (45.8%) was the most common indication and placenta accreta (25.0%) was the second most common. Eighteen patients (75%) had subtotal hysterectomy. Bladder injury was seen in three cases. Re-exploration was performed in three cases (12.5%). Seventeen patients stayed in hospital over 7 days. There were four (16.7%) maternal deaths all of whom were referred from other hospitals. CONCLUSION: The mortality and morbidity of performing a peripartum hysterectomy is elevated, especially if performed in critical patients referred from other hospitals.     

Indication of emergency peripartum hysterectomy: review of 17 cases

OBJECTIVES: The objectives were to determine the incidence, indications, associated risk factors and complications with emergency peripartum hysterectomy at King Abdulaziz University Hospital, Saudi Arabia. METHODS: This is a retrospective analysis of 17 cases of emergency peripartum hysterectomy done from January 1, 1991 to December 31, 2002. RESULTS: Seventeen patients of emergency peripartum hysterectomy were identified among 34,379 deliveries and the incidence rate was 0.5 per 1,000. Uterine atony 11 (64.7%, 9 without previa and 2 with previa) and followed by morbid adherent placenta with previa 6 (35.3%, 1 complete placenta accreta and 5 partial adherent placenta) was the most common indication of hysterectomy. Of the atonic group, 3 were primigravidae, 2 of 3 induced and 1 placenta previa. In morbid adherent placenta group the gravidity, previous abortions and prior cesarean deliveries were higher compared to the atonic group and were statistically significant. Conservative surgery performed in 6 (35.3%) patients before proceeding to hysterectomies, 3 (17.7%) patients had uterine artery ligation and 3 (17.7%) internal iliac ligation. Eight (47.1%) hysterectomies were subtotal. Nine (53%) patients developed disseminated intravascular coagulopathy (DIC) and one case (6%) had bilateral ureteric ligation and bladder injury. No maternal deaths occurred. CONCLUSION: Uterine atony still is the leading cause of primary postpartum hemorrhage and the main indications of emergency peripartum hysterectomy. The combination of high parity, cesarean section, prior cesarean delivery and current placenta previa were identified as risk factors, and should alert the obstetrician that an emergency peripartum hysterectomy may needed. Although no maternal mortality occurred morbidity remained high.     

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.

Intrauterine Bakri Balloon and Vaginal Tamponade Combined with Abdominal Compression for the Management of Postpartum Hemorrhage

Objective

This study sought to investigate the effect of Bakri balloon use and vaginal tamponade combined with abdominal compression for the management of postpartum hemorrhage (PPH).