浅析重型胎盘早剥致子宫切除临床观察

发表时间:2018/4/17   来源:《健康世界》2018年3期   作者:朱凤青
[导读] 研究分析重型胎盘早剥导致子宫切除的临床特点。

黑龙江省鸡西市精神病防治院  鸡西市铁路地区中心医院  158100
摘要:目的:研究分析重型胎盘早剥导致子宫切除的临床特点。方法:此次研究的对象是选择我院2014年1月—2017年12月收治的41例因重型胎盘早剥行子宫切除产妇,将其临床资料进行回顾性分析,并对其孕周、相关因素、临床表现、围产儿结局进行回顾性分析,总结其临床特点,探讨防治策略。结果:因重型胎盘早剥致子宫切除者41例,占同期分娩产妇0.072%。平均年龄(32.09±5.43)岁,平均孕次(3.05±0.71)次,经产妇35例(85.37%),41例产妇中,12例(29.27%)行剖宫产,25例(60.98%)行阴道分娩,其余4例(9.75%)中期引产。41例产妇平均孕周为(37.25±4.13)周,多数产妇孕周在36周以上,占46.34%,随着孕周的增加,其重型胎盘早剥致子宫切除率逐渐升高,差异有统计学意义(P<0.05)。34例(82.93%)患者重型胎盘早剥主要因素为妊娠期高血压综合征,显著高于其他因素,差异有统计学意义(P<0.05)。18例(45.59%)患者重型胎盘早剥临床表现以混合表现(≥2种症状)为主。37例围产儿早产(70.27%)、21例转入NICU(56.10%),死亡13例。结论:孕次多、孕周大、合并妊娠期高血压综合征、临床表现复杂的重型胎盘早剥产妇子宫切除风险较高,且易造成围产儿结局不良,针对上述临床特点实施针对性干预有望降低子宫切除率。
关键词:重型胎盘早剥;子宫切除;出血;生育能力
Objective:To study and analyze the clinical features of hysterectomy caused by severe placental abruption. Methods:the subjects of this study is to select 41 cases in our hospital from January 2014 to December 2017 were due to severe placental abruption hysterectomy were retrospective analysis,and the gestational age,related factors,clinical manifestations and perinatal outcome were retrospectively analyzed,summarized the clinical characteristics,prevention and treatment strategy. Results:41 cases of severe placental abruption were caused by hysterectomy,which accounted for 0.072% of the parturient women in the same period. The average age was(32.09 + 5.43)years,the average pregnancy time was(3.05 + 0.71)times,35 cases(85.37%)were parturient,12 cases(29.27%)underwent cesarean section in 41 cases,25 cases(60.98%)received vaginal delivery,and the other 60.98% cases(induced)had mid-term induced labor. The average gestational age of 41 pregnant women was(37.25 + 4.13)weeks,most of the pregnant women were over 36 weeks,accounting for 46.34%. With the increase of gestational age,the rate of hysterectomy caused by severe placental abruption increased gradually,the difference was statistically significant(P<0.05). 34 patients(82.93%)had severe placental abruption,the main factor was hypertensive disorder complicating pregnancy,which was significantly higher than other factors. The difference was statistically significant(P<0.05). 18 cases(45.59%)patients with severe manifestation of placental abruption in mixed performance(more than 2 kinds of symptoms). 37 cases of perinatal premature birth(70.27%),21 cases transferred to NICU(56.10%),and 13 cases of death. Conclusion:severe placental multiple pregnancies,gestational age,pregnancy hypertension syndrome,the clinical manifestations of complex maternal abruption hysterectomy at high risk and cause adverse perinatal outcomes,according to the clinical characteristics of the implementation of targeted interventions to reduce the rate of hysterectomy.
[Key words] severe placental abruption;hysterectomy;bleeding;fertility

 
        胎盘早剥的含义为妊娠20周后至分娩期胎儿娩出前,胎盘由正常位置部分或完全剥离子宫壁,具有病情危急、发展迅速等特点,是妊娠晚期严重的并发症之一,其发病率约为0.46%~2.10%,围产儿病死率达25.00%[1]。胎盘剥离面超过1/3即称为重型胎盘早剥,产妇常伴有出血性休克、子宫胎盘卒中等并发症,若未得到及时救治,发生弥散性血管内凝血(DIC)、肾功能衰竭及产后出血等严重并发症可对母儿生命造成严重威胁[2]。作为一种针对产科严重出血的有效治疗措施,子宫切除可有效抢救产妇生命,但该方案对产妇生育能力与心理状态的不良影响极为明显,且有研究表明,子宫切除后女性心血管疾病发病率显著上升[3]。因此,本研究分析胎盘早剥原因,希望尽可能降低子宫切除率。
        1 资料与方法
        1.1 选取标准
        整理我院2014年1月—2017年12月分娩产妇资料,以41例因重型胎盘早剥行子宫切除的产妇为研究对象,进行回顾性分析。选取标准:1)胎盘剥离面超过1/3或合并子宫胎盘卒中、休克、DIC等并发症[4];2)产后出血经积极保守治疗无效,行子宫切除术。排除病史、临床表现、围产儿结局等临床资料不完整者。
        1.2 分析指标
        本研究分析指标包括孕周、胎盘早剥相关因素、临床表现及围产儿结局,其中孕周以28~32周、33~36周、>36周分界;胎盘早剥相关因素包括妊娠期高血压综合征、胎膜早破、缩宫素使用、外伤及用力不当、脐带因素、羊水过多等;临床表现包括腹痛腹胀、阴道流血、血性羊水、胎心异常、自发早产、子宫压痛等;围产儿结局包括早产、出生体质量、重度窒息、转入新生儿重症监护室(NICU)及死亡[5]。
        1.3 统计学分析
        对本临床研究的所有数据采用SPSS18.0进行分析,计数资料以(n/%)表示,并采用χ2检验,满足正态分布且方差齐性则采用独立样本t检验或F检验,若方差不齐,则采用校正t检验,以P<0.05为有统计学意义。
        2 结果
        2014年1月—2017年12月,共有57252例产妇于我院分娩,因重型胎盘早剥致子宫切除者41例,占0.072%。


该组产妇年龄20~42岁,平均(32.09±5.43)岁,孕次1~8次,平均(3.05±0.71)次,初产妇7例,占17.07%,经产妇35例,占85.37%,41例产妇中,12例(29.27%)行剖宫产,25例(60.98%)行阴道分娩,其余4例(9.75%)中期引产。患者临床表现包括腹痛腹胀、阴道流血、血性羊水、子宫压痛等,多数患者出现混合表现(≥2种症状)。37例围产儿早产(70.27%)、21例转入NICU(56.10%),死亡13例。
        41例产妇平均孕周为(37.25±4.13)周,28~32周10例(24.39%)、33~36周12例(29.27%)、36周以上19例(46.34%),随着孕周的增加,其重型胎盘早剥致子宫切除率逐渐升高,差异有统计学意义(F=6.439,P<0.05)。
        34例(82.93%)患者重型胎盘早剥主要因素为妊娠期高血压综合征,胎膜早破4例(9.76%)、缩宫素使用过量、外伤及用力不当、羊水过多各1例,妊娠期高血压综合征导致早剥显著高于其他因素,差异有统计学意义(P<0.05)。
        3 讨论
        胎盘早剥是产科常见危急重症,对母儿预后影响极大。根据病理改变的不同,胎盘早剥可分为显性剥离、隐形剥离与混合型剥离三种类型,重型胎盘早剥多为混合型剥离,剥离面出血较难控制,出血量大,子宫切除风险较高[6]。
        目前临床对于胎盘早剥的病因与发病机制尚无明确阐释,多数研究认为,子宫胎盘血管病变、子宫压力变化、宫腔感染等多种因素在胎盘早剥的发生发展中均扮演着一定角色[7]。本研究结果示,34例(82.93%)患者胎盘早剥主要因素为妊娠期高血压综合征,显著高于其他因素。妊娠期高血压综合征可引发底蜕膜螺旋小动脉痉挛或硬化,继而引发远端毛细血管坏死、破裂出血及血肿形成,致胎盘发生早剥[8]。本组患者随着孕周延长,其子宫切除率呈上升趋势。轻度胎盘早剥剥离面积较小、症状及体征不典型,其早期确诊率不足50%,且临床顾虑围产儿早产风险,处理时不果断,故病程拖延至孕周>36周时往往已进展至重型胎盘早剥[9-10]。一般而言,多数因重型胎盘早剥致子宫切除的产妇以混合表现为主,胎盘早剥确诊后应迅速终止妊娠,保证胎儿存活率。
        通过分析41例产妇重型胎盘早剥致子宫切除的原因、表现与结局,笔者将该病的早期防范策略总结如下:1)落实产前检查,加强产前宣教,增强产妇对妊娠期异常症状的认识,提高其早期就诊率[11];2)强调血压监测,在B超检查的基础上,定期监测产妇血压水平,早期发现血管病变导致的局部血肿、胎盘位置变化并实施对症治疗,避免病情进展[12-13];3)细化病史调查,为临床重型胎盘早剥的风险判断提供参考,亦可于症状出现时结合病史资料准确做出判断;4)胎膜早破、缩宫素使用亦在重型胎盘致子宫切除中占据了一定地位,故应密切观察产程、规范使用缩宫素[14-16];5)随着孕周的延长,子宫体积逐渐增大,对下腔静脉的压迫亦有所增加,可能加剧胎盘早剥,使产妇子宫切除风险增加,故应嘱产妇孕晚期采取侧卧位,保证盆腔、下腔静脉血液回流顺畅,避免胎盘蜕膜静脉床大量充血引发的早剥[17]。
        重型胎盘早剥致子宫切除的发生率虽然不高,但其对母儿预后的影响十分严重,在积极预防的基础上,应做到胎盘早剥的早发现、早治疗,尽可能降低子宫切除率,争取胎儿存活。

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