子宫体双侧弓形动脉缝扎术用于剖宫产 术中子宫收缩乏力性出血的临床研究

李巨,于月新,郑莉彦,等.子宫体双侧弓形动脉缝扎术用于剖宫产术中子宫收缩乏力性出血的临床研究[J].中华妇产科杂志,2013,48(3):165-170.

剖宫产术 知识脉络 子宫出血 知识脉络 宫缩乏力 知识脉络 止血,手术 知识脉络 动脉 知识脉络 结扎术

李巨 于月新 郑莉彦 杨丽娜 孙春燕 陈震宇

110812 沈阳,解放军第二○二医院妇产科

2013

165-170

万方

目的 探讨子宫体双侧弓形动脉缝扎术(简称:止血术)在处理剖宫产术中子宫收缩乏力性出血的止血效果及其对产后子宫血管及血循环的影响.方法 选择2009年5月至2011年12月,在解放军第二○二医院行剖宫产术中因子宫收缩乏力性出血,经保守治疗无效的127例患者,采用无创1号可吸收缝线距子宫下段剖宫产切口上缘及宫体外侧缘2 cm交汇处,贯穿子宫前、后壁环绕宫体并于宫底略前方拉紧、打结,为止血术组.另选同期23例经保守治疗和其他止血方式无效改行止血术者为其他+止血术组；62例患者在剖宫产术中确认子宫体收缩乏力性出血,在给予促宫缩药物的同时立即行止血术为药物+止血术组.止血术时,计算各组出血量、手术时间、即刻止血率及止血总有效率.产后6～12个月行阴道彩超检查双侧子宫动脉阻抗指数(RI)及收缩期峰值与舒张末期血流速度(S/D)比值；并以64排增强CT检查患者双侧子宫动脉显影情况及测量子宫动脉直径.结果 (1)药物+止血术组患者出血量、手术时间及即刻止血率分别为(532 ±28) ml、(34±3) min及97％ (60/62),止血术组出血量为(1150 ±43) ml,手术时间为(61±4)min,即刻止血率为95％(120/127),但两组比较,差异无统计学意义(P＞0.05)；其他+止血术组经保守治疗和其他手术方式止血均无效后采用止血术,出血量、手术时间、即刻止血率分别为(1379 ±95) ml、(79±15) min及78％(18/23),与止血术组和药物+止血术组分别比较,差异均有统计学意义(P＜0.01),但3组患者止血总有效率分别比较,差异无统计学意义(P＞0.05).(2)产后6 ～12个月阴道彩超测量3组患者双侧子宫动脉RI及S/D比值,3组患者左、右侧子宫动脉的RI及S/D比值分别比较,差异均无统计学意义(P＞0.05).(3)3组各有部分患者在术后6 ～12个月行盆腔64排增强CT检查,其他+止血术组患者左侧子宫动脉显影率(13/15)明显低于止血术组(97％,28/29)和药物+止血术组(95％,20/21),两者比较,差异有统计学意义(P＜0.05)；后两组患者左、右侧子宫动脉显影率及子宫动脉直径分别比较,差异均无统计学意义(P＞0.05).结论 止血术用于剖宫产术中子宫收缩乏力性出血,具有操作简单迅速、止血效果确切等优点,对患者术后子宫及卵巢的血管及血循环也无明显影响,是一种值得推广的新术式. Objectives To investigate the effect of bilateral arcuate artery suture hemostasis of corpus uteri (haemostasia) for postpartum hemorrhage due to uterine inertia during caesarean section,and to explore the change of blood vessels and blood flow of the uterus after surgery.Methods From May 2009 to Dec.2011,the 212 patients in No.202 People's Liberation Army Hospital received bilateral arcuate artery suture hemostasis of corpus uteri for postpartum hemorrhage due to uterine inertia during caesarean section.Among them,127 patients who failed to respond to conservative management and received haemostasia were defined as the ‘ haemostasia' group.23 patients who received the suture after they failed to respond to conservative management and other conventional surgical hemostasis were defined as the ‘ other +haemostasia' group.62 patients who received the suture simultaneously with conservative management were defined as the ‘ drug + haemostasia' group.The suture was done by the following steps:(1) The uterus should be exteriorised,and the fundus of uterus should be towards the head.(2)Transfix the anterior and posterior wall of corpus uteri with big blunt round needle and absorbable suture.The entry point was 2 cm above the uterine incision and 2 cm to lateral border of corpus uteri.The suture spanned the fundus of uterus,and was stretched tightly in front of the fundus,then tied knots were made.Bleeding volume,prompt hemostatic rate,effect rate,total effect rate and operation time were recorded.The resistance index (RI) of uterine artery,systolic/ diastolic blood pressure (S/D),the visualization ratio of uterine artery and the mean value of artery diameter were obtained through color Doppler ultrasonography and enhancement CT 6-12 months after the surgery.Results (1) In the ‘ drug + haemostasia' group,the bleeding volume was (532 ±28) ml.The operation time was (34 ± 3) min,and the prompt hemostatic rate was 97％.While the ‘ haemostasia' group had more bleeding volume,longer operation time and lower prompt hemostatic rate than the ‘ drug + haemostasia' group,with no statistically significant difference (P ＞ 0.05).In ‘ other + haemostasia' group,the bleeding volume was (1379 ± 95) ml.The operation time was (79 ± 15) min,and the prompt hemostatic rate was 78％.The differences were significant when compared to the other groups (P ＜ 0.01).There was no statistically significant difference on total effect rate among the three groups (P ＞ 0.05).(2) There was no statistically significant difference on the RI and S/D of bilateral uterine artery among all the groups 6-12 months after the surgery.(3)The visualization ratio of left uterine artery of the ‘ other + haemostasia' group was lower (87％) than the ‘ haemostasia' group (97％) and the ‘ drug +haemostasia' group (95％,P ＜ 0.05).There was no statistically significant difference between the ‘ haemostasia' group and the ‘ drug + haemostasia' group on the visualization ratio of bilateral uterine artery and the mean value of bilateral uterine artery diameter (P ＞ 0.05).Conclusions The bilateral arcuate artery suture hemostasis of corpus uteri is a simple,rapid,effective and safe method to control postpartum hemorrhage due to uterine inertia during caesarean section.The ovary and uterine blood flow are not affected after the surgery.