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。

Application of embolization of the uterine arteries and hysterectomy in intractable postpartum hemorrhage

Objective To investigate embolization of uterine arteries and obstetric hysterectomy in intractable postpartum hemorrhage.Methods Retrospective review were carried out on 35 women with intractable postpartum hemorrhage,19 of which were treated with selective uterine arteries embolization（SUAE group） and 16 with hysterectomy or subtotal hysterectomy（hysterectomy group） in a teaching hospital in 14 years.Results In the hysterectomy group,10 cases（62.5%） were because of abnormal placenta（7 placenta accreta and 3 placenta abruption）,4（25%） of uterine abnormal（2 of uterine atony,1 broad ligment hemotoma after the Cesarean section and 1 uterine rupture）,2（12.5%） of DIC following fluid embolism.In the SUAE group,3（15.8%） were because of placenta previa,13（68.4%） of uterine atony（4 Cesarean section due to primary uterine atony,4 twin pregnancy,2 precipitate birth,1 macrosomia,2 uterine myoma）,3（15.8%） of complications of Cesarean section（1 broad ligment hemotoma after the cesarean section,1 uterine artery aneurysm,1 late postpartum hemorrhage）.Two cases failed;one underwent hysterectomy and the other one underwent laparotomy for hemotoma.The mean blood loss was more in the hysterectomy group than SUAE group（4 593±2 727）ml vs.（2 601±904）ml,P〈0.05）.More cases in the hysterectomy group presented DIC than the SUAE group（68.7% vs.10.5%,P〈0.05）.ConclusionsBoth hysterectomy and SUAE are effective treatments of severe postpartum hemorrhage.SUAE,as a fertility conservative therapy,should be used timely and could not be used once severe DIC or shock occurs.When the conservative treatment could not take effect in a short time,hysterectomy will be needed in time.