郭嚴(yán)
[摘要]目的 探討卡前列素氨丁三醇(欣母沛)聯(lián)合宮頸鉗夾治療宮縮乏力產(chǎn)后出血的臨床效果。方法 選擇2015年1月~2017年1月我院收治的經(jīng)陰道順產(chǎn)后宮縮乏力大出血患者80例作為研究對(duì)象,按照隨機(jī)數(shù)字表法分為兩組,每組各40例。對(duì)照組患者采用單純宮頸鉗夾治療,觀察組患者在對(duì)照組基礎(chǔ)上行欣母沛深部肌肉注射。比較兩組患者治療后2 h及24 h的失血量、止血時(shí)間、凝血功能、并發(fā)癥及預(yù)后情況。結(jié)果 觀察組患者治療后2 h及24 h失血量分別為[(506.5±31.8)ml]和[(565.5±35.1)ml],均顯著少于對(duì)照組[(658.9±45.9)ml,(789.6±58.5)ml],差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組患者的止血時(shí)間[(55.8±9.9)min]短于對(duì)照組[(125.2±18.5)min],差異有統(tǒng)計(jì)學(xué)意義(P<0.05);干預(yù)后觀察組患者凝血功能檢查指標(biāo)中,PT[(13.5±1.1)s]、TT[(11.5±2.4)s]、APTT[(21.6±1.3)s]低于對(duì)照組[(33.6±2.1)s,(21.5±2.5)s,(41.7±3.4)s],觀察組患者的Fib[(1.7±0.3)g/L]高于對(duì)照組[(0.8±0.1)g/L],差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組患者發(fā)生膀胱損傷(2.5%)、宮頸壞死(2.5%)以及失血性休克(2.5%)的概率均顯著低于對(duì)照組(7.5%,7.5%,12.5%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組患者需要進(jìn)行子宮切除的比例(2.5%)顯著低于對(duì)照組(27.5%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論 前列素氨丁三醇聯(lián)合宮頸鉗夾治療宮縮乏力產(chǎn)后出血,臨床止血效果理想,并發(fā)癥少,值得推廣應(yīng)用。
[關(guān)鍵詞]卡前列素氨丁三醇;宮頸鉗夾;宮縮乏力;產(chǎn)后出血
[中圖分類號(hào)] R714.461 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1674-4721(2017)10(a)-0126-03
[Abstract]Objective To investigate the effect of Carboprost Tromethamine (Hemabate) combined with cervical clamp for treatment of postpartum hemorrhage caused by uterine inertia.Methods 80 cases with postpartum hemorrhage caused by uterine inertia of spontaneous vaginal delivery from January 2015 to January 2017 in our hospital were selected as research objects,and they were randomly divided into two groups,each 40 cases.The patients in control group was treated with simple cervical jaws,the patients in observation group was treated with Hemabate deep intramuscular injection in the base of the control group.Then the blood loss after 2 hours and 24 hours,hemostasis time,coagulation function,complications and conditions of prognosis were compared between the two groups.Results The blood loss after 2 hours and 24 hours of patients in observation group were respectively [(506.5±31.8)ml] and [(565.5±35.1)ml],they were significantly less than [(658.9±45.9)ml,(789.6±58.5)ml] of patients in the control group,the differences were statistically significant (P<0.05).The hemostasis time of patients in observation group [(55.8±9.9)min] was shorter than that in the control group [(125.2±18.5)min],the difference was statistically significant (P<0.05).After the intervention,the blood coagulation function index of the patients in the observation group,such like PT [(13.5±1.1)s],TT [(11.5±2.4)s],APTT [(21.6±1.3)s] were lower than those in the control group [(33.6±2.1)s,(21.5±2.5)s,(41.7±3.4)s],while Fib [(1.7±0.3)g/L] was higher than that in the control group [(0.8±0.1)g/L],the differences were statistically significant (P<0.05).The incidence of bladder injury (2.5%),cervical necrosis (2.5%) and hemorrhagic shock (2.5%) of patients in observation group were significantly lower than those in the control group (7.5%,7.5%,12.5%),the differences were statistically significant (P<0.05).The need for hysterectomy ratio of observation group (2.5%) was significantly lower than that in the control group (27.5%),and the difference was statistically significant (P<0.05).Conclusion The treatment of postpartum hemorrhage caused by uterine inertia by using Carboprost Tromethamine combined with cervical clamp is ideal for the clinical hemostasis effect,with few complications,and it is worth promoting the application.endprint
[Key words]Carboprost Tromethamine;Cervical clamp;Uterine inertia;Postpartum hemorrhage
產(chǎn)后出血指陰道分娩后24 h內(nèi)出血量超過(guò)500 ml或剖宮產(chǎn)后出血超過(guò)1000 ml,屬于圍生期導(dǎo)致孕產(chǎn)婦死亡的最主要原因之一[1-2]。臨床上引起產(chǎn)后出血的原因有很多種,其中宮縮乏力為首要原因,其次有胎盤因素、軟產(chǎn)道損傷及凝血功能障礙[3]。針對(duì)宮縮乏力大出血,緊急情況下需要切除子宮以保全產(chǎn)婦生命,但切除子宮對(duì)育齡期婦女身心健康影響極大[4]。近年來(lái)隨著卡前列素氨丁三醇臨床應(yīng)用的推廣,越來(lái)越多的產(chǎn)后宮縮乏力得以解決。本研究以我院經(jīng)陰道順產(chǎn)者80例作為研究對(duì)象,探討應(yīng)用宮頸鉗夾術(shù)聯(lián)合卡前列素氨丁三醇治療宮縮乏力產(chǎn)后出血的臨床效果,現(xiàn)報(bào)道如下。
1資料與方法
1.1一般資料
選擇2015年1月~2017年1月我院收治的經(jīng)陰道順產(chǎn)者80例,所有入組者均因產(chǎn)后出現(xiàn)宮縮乏力而發(fā)生產(chǎn)后出血,排除分娩前合并凝血功能障礙、分娩時(shí)出現(xiàn)軟產(chǎn)道損傷以及分娩后存在有胎盤植入等因素。本研究經(jīng)我院醫(yī)學(xué)倫理委員會(huì)審核及同意,患者均知曉本研究情況并簽署知情同意書。按照隨機(jī)數(shù)字表法將患者分為兩組,每組各40例。觀察組患者年齡19~35歲,平均年齡(25.3±3.6)歲;孕齡36~42周,平均孕齡(39.6±1.1)周;新生兒體重2500~4000 g,平均體重(3355.5±35.5)g;初產(chǎn)婦35名,經(jīng)產(chǎn)婦5名。對(duì)照組患者年齡20~35歲,平均年齡(25.5±3.5)歲;孕齡37~42周,平均孕齡(39.7±1.0)周;新生兒體重2500~4050 g,平均體重(3355.0±35.0)g;初產(chǎn)婦34名,經(jīng)產(chǎn)婦6名。兩組的年齡、孕齡、新生兒體重及生產(chǎn)史等一般資料比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。
1.2方法
對(duì)照組患者行宮頸鉗夾治療,于胎盤娩出后立即采用陰道拉鉤充分暴露軟產(chǎn)道,仔細(xì)檢查,排除胎盤殘留、軟產(chǎn)道裂傷等原因,針對(duì)子宮下段喇叭狀產(chǎn)婦,大多可見(jiàn)鮮紅色的陰道持續(xù)流血。留置導(dǎo)尿管排空膀胱,操作者左手伸入陰道內(nèi),固定宮頸前后唇,右手采用無(wú)齒的卵圓鉗于截石位宮頸9、12及3點(diǎn)位置對(duì)宮頸直至子宮下段進(jìn)行鉗夾,深度以膀胱腹膜返折下0.5 cm為準(zhǔn),排除對(duì)膀胱組織的意外鉗夾后上鉗1齒,持續(xù)鉗夾30 min后,松開(kāi)卵圓鉗,觀察15 min排除活動(dòng)性陰道流血,如未能有效止血,再采取進(jìn)一步止血措施。觀察組患者在進(jìn)行宮頸鉗夾治療的同時(shí),給予深部肌內(nèi)注射卡前列素氨丁三醇(商品名:欣母沛,阜新蒙藥有限責(zé)任公司,國(guó)藥準(zhǔn)字Z21020386)250 μg,觀察15 min,如仍未能有效止血,再次肌內(nèi)注射卡前列素氨丁三醇250 μg,每15 min可重復(fù)應(yīng)用,最大用量不得超過(guò)8支。
1.3觀察指標(biāo)
比較兩組患者治療后2 h及24 h的失血量、止血時(shí)間、凝血功能、并發(fā)癥及預(yù)后情況。凝血功能檢查通過(guò)Sysmex CA-1500型全自動(dòng)血凝儀,測(cè)定值中凝血酶原時(shí)間(PT)參考范圍11~13 s,活化部分凝血活酶時(shí)間(APTT)參考范圍男性:31.5~43.5 s,女性32~43 s,凝血酶時(shí)間(TT)參考范圍16~18 s,纖維蛋白原(Fib)參考范圍1.75~5.54 g/L。
1.4統(tǒng)計(jì)學(xué)方法
采用SPSS 13.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析,計(jì)量資料用均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,兩組間比較采用t檢驗(yàn);計(jì)數(shù)資料采用率表示,組間比較采用χ2檢驗(yàn),以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2結(jié)果
2.1兩組患者治療后2 h、24 h失血量及止血時(shí)間的比較
觀察組患者治療后2 h、24 h失血量顯均著少于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);止血時(shí)間短于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表1)。
2.2干預(yù)后兩組患者凝血功能檢測(cè)結(jié)果的比較
干預(yù)后觀察組患者凝血功能檢查指標(biāo)中PT、TT、APTT值低于對(duì)照組,F(xiàn)ib高于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)(表2)。
2.3兩組患者并發(fā)癥及預(yù)后情況的比較
觀察組患者膀胱損傷、宮頸壞死以及失血性休克發(fā)生率均顯著低于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察組患者需要進(jìn)行子宮切除的比例顯著低于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表3)。
3討論
針對(duì)初產(chǎn)婦尤其是合并有產(chǎn)后出血高危因素者,如羊水過(guò)多、多胎妊娠、巨大兒、前置胎盤、胎盤早剝以及合并妊娠期高血壓病、糖尿病等[5],均需提高臨床重視,有效預(yù)防和減少產(chǎn)后宮縮乏力導(dǎo)致的產(chǎn)后大出血。本研究針對(duì)確診宮縮乏力導(dǎo)致產(chǎn)后出血的所有患者均使用宮頸鉗對(duì)宮頸進(jìn)行鉗夾治療,通過(guò)對(duì)宮頸機(jī)械性刺激,刺激其反射性出現(xiàn)子宮的強(qiáng)直性收縮[6],達(dá)到局部壓迫子宮下段血管封閉子宮下段血竇而止血的目的[7-8]。但仍有超過(guò)50%的產(chǎn)婦通過(guò)單純的宮頸鉗夾,無(wú)法達(dá)到有效的止血[9]。故本研究觀察組患者聯(lián)合深部肌肉注射卡前列素氨丁三醇治療,以達(dá)到迅速止血,挽救患者生命的目的。
本研究結(jié)果提示,觀察組患者治療后2 h及24 h失血量顯著少于對(duì)照組,止血時(shí)間短于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。且干預(yù)后觀察組患者凝血功能檢查指標(biāo)中PT、TT、APTT低于對(duì)照組,F(xiàn)ib高于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。深部肌肉注射卡前列素氨丁三醇后,臨床起效快,且半衰期長(zhǎng),生物活性顯著增強(qiáng),能持續(xù)高效地刺激子宮平滑肌收縮[10]。作為一種鈣離子通道載體,顯著提高了子宮平滑肌內(nèi)鈣離子的濃度,達(dá)到抑制腺苷酸環(huán)化酶、阻斷環(huán)磷酸腺苷形成的目的,最終促使細(xì)胞漿內(nèi)鈣離子增加[11],從而觸發(fā)肌原纖維收縮,刺激子宮平滑肌縫隙的連接形成[12-13],達(dá)到促進(jìn)子宮平滑肌出現(xiàn)協(xié)調(diào)性收縮、減少和制止產(chǎn)后宮縮乏力引起出血的目的。故本研究中,對(duì)照組需要進(jìn)行子宮切除的患者顯著少于對(duì)照組。在并發(fā)癥方面,觀察組發(fā)生膀胱損傷、宮頸壞死以及失血性休克的整體比例均顯著低于對(duì)照組??赡苁且?yàn)閷?duì)照組患者止血效果不理想情況下,操作者存在急躁心理,反復(fù)對(duì)宮頸進(jìn)行鉗夾,同時(shí)采用多點(diǎn)鉗夾,故對(duì)照組宮頸壞死率增高,且發(fā)生膀胱損傷的比例增加[14-15]。endprint
綜上所述,卡前列素氨丁三醇聯(lián)合宮頸鉗夾治療宮縮乏力所致的產(chǎn)后出血,有效的提高了子宮肌肉的縮復(fù)作用,達(dá)到封閉子宮下段血管和血竇的目的,臨床止血效果理想,并發(fā)癥少,值得推廣應(yīng)用。
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(收稿日期:2017-07-29 本文編輯:孟慶卿)endprint