会阴Ⅲ～Ⅳ度裂伤及特殊裂伤的预防和处理

会阴Ⅲ～Ⅳ度裂伤是阴道分娩的严重并发症,由于裂伤累及肛门括约肌复合体和（或）肛门黏膜,又称为产科相关肛门括约肌损伤（OASIS）,是导致产后肛门失禁最常见的原因,严重影响生活质量。阴道分娩后准确评估会阴裂伤程度并及时修复解剖结构对恢复肛门括约肌功能、改善预后至关重要;但临床实践中隐匿性OASIS有时被漏诊,不能及时识别、修复或愈合不良等,可导致会阴-直肠瘘或直肠-阴道瘘。需要加强预防和管理会阴Ⅲ～Ⅳ度裂伤,恰当运用质量管理工具,分析导致OASIS的风险因素和关键环节,从妊娠期和产程管理、助产能力提升、风险评估、预防和治疗等关键环节着手,减少或避免OASIS发生,提升识别和修复OASIS的能力。     

会阴Ⅲ度裂伤13例分析

会阴Ⅲ度裂伤是分娩期的严重并发症,虽经及时修补多能及时愈合,但住院时间延长,且可能伴发肛门括约肌功能不全,故应积极预防其发生。我们回顾分析了会阴Ⅲ度裂伤13例的临床资料,探讨其防治措施。1 临床资料1.1 一般资料 1990年1月至1999年12月共有16 465例孕妇在我院分娩,其中,经阴分娩10 623例,发生会阴Ⅲ度裂伤13例,发生率为0.12%,其中肛门括约肌完全断裂4例,部分断裂7例。另2例肛门括约肌层完整,但直肠前壁破裂。13例均为初产妇头位产,23～31岁,孕周为38～41＋１周,巨大儿5例,正常体重儿8例。1.2 原因分析 会阴Ⅲ度裂伤1…     

会阴Ⅲ度裂伤3例分析

会阴裂伤是产科中最常见的情况之一。本文报告我院1997年1月～2004年12月间因分娩造成会阴Ⅲ度裂伤3例并对其原因及预防措施进行了探讨。     

会阴Ⅲ度裂伤1例临床分析心得

通过分析该产妇会阴Ⅲ度裂伤原因,探讨有效的预防措施。经过分析患者的撕裂情况和成因还有当时护理人员所采取的护理方法是否得当以及护理后的成果能不能达到预期效果,归纳整理出会阴裂伤的成因和治疗会阴Ⅲ度撕裂的关键原因和有效护理方案。如今会阴撕裂的常见因素多为难产、助产人员的专业技术和纯熟程度等。产妇的胎儿大小、胎儿体位也是造成会阴Ⅲ度撕裂的重要因素。通过提前对产妇在孕期做预防护理和与患者进行良好沟通,配合做好心理疏导。同时提高本院助产人员的专业技术,可有效预防会阴Ⅲ度撕裂,在撕裂后做好修补术,在良好护理条件下可愈合良好。加强助产人员在产妇护理中的助产技术,在分娩时可降低会阴Ⅲ度裂伤的发生率,减轻产妇的痛苦,并减少产后并发症的发生。     

英国皇家妇产科医师学会《会阴Ⅲ度和Ⅳ度裂伤处理指南2015版》要点解读

        产妇在阴道分娩过程中,常会出现不同程度的会阴裂伤,不仅会导致产时大出血危及生命,还会发生产伤性肛门括约肌损伤（OASIS）,导致会阴部正常组织结构功能改变,出现肛门失禁等对患者生理功能和生活质量造成严重影响的并发症。OASIS的发生率增长迅速,英国报道的OASIS发生率从2000年的1.8%升至2012年的5.9%,增加了3倍。     

会阴Ⅲ度裂伤17例临床分析

目的:探讨会阴Ⅲ度裂伤的原因及治疗.方法:对我院会阴Ⅲ度裂伤的17例患者的临床资料进行回顾性分析.结果:会阴Ⅲ度裂伤因素中胎儿过大占17.65%,急产占29.41%,梗阻性难产占11.76%,助产不当占41.18%.17例均及时行会阴修补术,5～6天均痊愈出院.结论:胎儿过大、急产、梗阻性难产、助产不当是造成会阴Ⅲ度裂伤的因素,及时行会阴修补术,愈后良好.     

Effects of Heat and Cold on the Perineum after Episiotomy/Laceration

The Redness Edema Ecchymosis Discharge Approximation (REEDA) tool, devised to evaluate postpartum healing of the perineum following an episiotomy/laceration, was used to evaluate the effects of heat and cold on the perineum during the first 24 hours after delivery. Ninety patients were randomly assigned to one of three treatment groups. Treatment consisted of 30 subjects applying a warm perineal pack, 30 applying a cold perineal pack, and 30 taking a warm sitz bath. Analysis of variance indicated no difference in the REEDA score before or two hours after treatment. A Pearson r correlation indicated the REEDA score was associated with a laceration and not with infant weight. Although these findings do not support assumptions from the literature, this study provides baseline data and trends for future study.     

异位妊娠保守治疗138例分析

目的:探讨保守治疗早期异位妊娠的几种方案。方法:将138例早期异位妊娠患者,根据不同治疗方案分4组治疗,比较各组治疗效果。结果:MTX组53例成功(96.4%),其中8例行第2次注射MTX(14.5%)。MTX+米非司酮(RU486)组42例成功(97.7%),其中8例行第2次注射MTX(18.6%)。介入组21例,均一次注射成功(100%),期待治疗组19例,成功率100%。血β-HCG水平>2000U/L者,第2次用药率高达37.5%。MTX组和MTX+RU486组疗效比较,差异无显著性(P>0.05)。结论:4种保守治疗方案对早期异位妊娠患者均有效;对血β-HCG水平在1000U/L以下且继续下降,包块<3cm者,可在医院密切观察暂不用药。血β-HCG水平>2000U/L者需第2次注射MTX的患者增多。     

Laparoscopic Bowel Injuries: Forty Litigated Gynaecological Cases in Canada

Objective: To review the clinical circumstances and the clinical and legal outcomes of 40 laparoscopic bowel injuries that were litigated in Canada.Design: Retrospective review of 40 litigated cases of laparoscopic bowel injury, from 1990 to the end of 1998, provided by the Canadian Medical Protective Association (CMPA).Measurements and Main Results: The laparoscopy was performed for diagnosis (n = 13), tubal occlusion (n = 15), and as an operative therapeutic procedure (n = 12). Injuries were related to the initial peritoneal entry in 22 (55%) women (19 during the closed technique and 3 with the open technique). Of these, the injury was due to the primary trocar (n = 17), scalpel (n = 1), Veress needle (n = 1),Veress needle or undetermined (n = 2), and fascial suture (n = 1). The small bowel was injured in 9 of 11 entries by the trocar during diagnostic laparoscopy and in 6 of 14 tubal occlusions. Five injuries in the tubal occlusion group were attributed to “cautery.” The injury was recognized intra-operatively in 55% of cases. The clinical outcome was uncomplicated in 85% of patients. There was no difference in clinical outcome between small versus large bowel injuries and between intra-operative versus post-operative diagnosis of the injury. The litigation outcome was favourable to the physician in 75% of cases. Recognition was delayed in 45% of cases and this was associated with 67% of the litigation outcomes unfavourable to physicians.Conclusions: (1) The initial laparoscopic entry into the peritoneal cavity remains the major contributor to bowel injury in laparoscopic surgery. (2) The open (Hasson) technique does not prevent bowel injuries. (3) Delayed recognition was a major factor in assessment of liability.     

子宫内膜异位囊肿合并不孕腹腔镜手术治疗38例分析

应用电视腹腔镜手术治疗卵巢子宫内膜异位囊肿合并不孕症患者38例,所有病例均行子宫内膜异位囊肿剔出术,无一例中转开腹,无严重并发症发生.术后随访6～40个月,术后妊娠率为47.4%.说明电视腹腔镜手术诊治子宫内膜异位囊肿,能完成剖腹手术所能进行的手术操作并达到相应疗效,且具有损伤小、术后病人恢复快的优点,对于不孕患者可达到与剖腹手术相同的治疗效果.     

输尿管子宫内膜异位症的诊治——附3例分析

目的:探讨输尿管子宫内膜异位症诊断和治疗中应注意的问题。方法:总结3例输尿管子宫内膜异位症临床资料和随访结果,复习国内外文献报道,进行分析讨论。结果:1例为混合型输尿管子宫内膜异位症,因梗阻严重行病灶切除输尿管端端吻合术,术后配合内分泌治疗。2例为腔外型,内分泌治疗效可,其中1例配合输尿管支架管置入术。结论:争取早期发现输尿管子宫内膜异位症,在保护肾功能的前提下制订适宜的治疗方案。     

Fertility Treatment in the Forty and Older Woman

Purpose: To determine the outcomes and logical progression of fertility treatment in women forty years and older using their own oocytes. Methods: This was a retrospective study in which 401 completed treatment cycles in 152 women aged forty and older were reviewed. Results: Assisted reproductive technology (ART) cycles (n = 58) were reviewed, comprising both in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). Intrauterine insemination (IUI) cycles (n = 343) were reviewed, consisting of 38 unstimulated natural cycle–IUI (NC-IUI), 194 clomiphene citrate–IUI (CC-IUI), and 111 injectable gonadotropins–IUI (INJ-IUI) cycles.The live birth rate of 15.5% for ART cycles was significantly higher than the live birth rate of 3.2% seen for all IUI cycles (p = 0.0007). There were no differences among treatment groups in spontaneous abortion, preterm delivery, or ectopic pregnancy rates. Conclusions: For women 40 years of age who wish to use their own eggs, ART offers the best chances for conception and delivery.     

左炔诺孕酮T形宫内节育器治疗子宫腺肌病46例分析

目的:探讨宫腔内放置含左炔诺孕酮的T形宫内节育器(曼月乐)治疗子宫腺肌病的疗效。方法:选择46例患子宫腺肌病的已育妇女,选择月经周期第5~8天放置左炔诺孕酮T形宫内节育器。分别在放置前、放置后3个月、12个月观察其月经量、血红蛋白、痛经、子宫体积及血清中FSH、LH、E2水平的变化。结果:放置左炔诺孕酮T形宫内节育器后,患者的月经量较放置前明显减少(P<0.01),18例患者出现时间长短不等的闭经;血红蛋白较放置前无明显增加(P>0.05);痛经明显减轻(P<0.01);子宫体积较放置前明显缩小(P<0.05);血清FSH、LH、E2水平较放置前无明显变化(P>0.05)。结论:宫腔内放置左炔诺孕酮T形宫内节育器能明显减轻患者的临床症状,对卵巢功能无明显影响,能有效地提高患者的生活质量,有很好的临床应用价值。     

新式剖宫产术子宫切口撕裂70例分析

目的 :回顾性分析新式剖宫产术的临床资料 ,解析子宫切口撕裂的原因。方法 :收集施行新式剖宫产术10 6 4例 ,进行统计学分析处理。结果 :子宫切口撕伤共 70例 ,占同期剖宫产术的 6 5 7% ;枕后位发生子宫切口撕裂率占6 2 86 % ,较枕前、枕横位易发生子宫切口撕裂 (两组子宫切口撕裂率分别占 2 6 %和 10 % ) ;70例子宫口撕裂中麻醉效果不佳占 35 % ;体重大于 4 0 0 0g的胎儿 ,子宫切口撕裂率明显增加。结论 :新式剖宫产术具有较多的优点也有缺点。子宫切口撕裂发生率并不低于与传统剖宫产术。术前必须判断麻醉的效果 ,综合胎儿大小、胎方位、先露下降情况等因素 ,如遇困难 ,可采取子宫纵切口或子宫下段横切口加上“⊥”型竖切 ,以避免子宫切口撕裂