完全性子宫破裂的临床特点分析

doi:10.3877/cma.j.issn.1673-5250.2019.06.006

中华妇幼临床医学杂志(电子版) ›› 2019, Vol. 15 ›› Issue (06) : 639 -645. doi: 10.3877/cma.j.issn.1673-5250.2019.06.006

所属专题：文献；

论著

完全性子宫破裂的临床特点分析

林春容¹, 陈锰¹, 刘兴会¹^,^†(

)

^1. 四川大学华西第二医院妇产科、出生缺陷与相关妇儿疾病教育部重点实验室，成都　610041

收稿日期:2019-10-08 修回日期:2019-11-10 出版日期:2019-12-01
通信作者: 刘兴会

Clinical characteristics of complete uterine rupture

Chunrong Lin¹, Meng Chen¹, Xinghui Liu¹^,^†()

^1. Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China

Received:2019-10-08 Revised:2019-11-10 Published:2019-12-01
Corresponding author: Xinghui Liu
About author:
Corresponding author: Liu Xinghui, Email: xinghuiliu@163.com
Supported by:
The National Key Research & Development Program of Reproductive Health & Major Birth Defects Control and Prevention(2016YFC1000406)

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引用本文：

林春容, 陈锰, 刘兴会. 完全性子宫破裂的临床特点分析[J/OL]. 中华妇幼临床医学杂志(电子版), 2019, 15(06): 639-645.

Chunrong Lin, Meng Chen, Xinghui Liu. Clinical characteristics of complete uterine rupture[J/OL]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2019, 15(06): 639-645.

目的

探讨完全性子宫破裂的发病现状、危险因素、临床特点及其患者妊娠结局。

方法

选择2006年1月至2018年12月，在四川大学华西第二医院住院分娩的106 747例产妇为研究对象。采取回顾性分析法，分析完全性子宫破裂患者的患病率、一般临床资料、临床特征及妊娠结局等。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求。

结果

①本组患者的完全性子宫破裂患病率为0.038%(41/106 747)，其中，2006—2015年为0.035%(26/73 369)，2016—2018年为0.045%(15/33 378)。②41例完全性子宫破裂患者中，瘢痕子宫者为22例(53.7%)，非瘢痕子宫者为19例(46.3%)。最常见的临床症状为持续性下腹部疼痛(48.7%，20/41)，最常见临床体征为腹部及子宫压痛(58.5%，24/41)，胎心异常仅为3例(15.0%，3/20)。③41例完全性子宫破裂患者中，无一例死亡，其中6例(14.6%)发生并发症；33例(80.5%)患者接受子宫修补术，7例(17.1%)接受全子宫切除术或者次全子宫切除术，1例(2.4%)因残角子宫妊娠接受残角子宫切除术。④41例完全性子宫破裂患者共计分娩活产新生儿为27例(61.0%)，死胎为16例(39.0%)。27例活产新生儿中，转入新生儿科治疗为9例(33.3%)，发生新生儿窒息为10例(37.0%)，其中，轻度窒息为8例(29.6%)，重度窒息为2例(7.40%)；另外17例新生儿生后1 min Apgar评分均为良好。

结论

完全性子宫破裂患者最常见的危险因素包括瘢痕子宫、胎盘黏连及植入、宫腔镜手术史。若具有完全性子宫破裂高危因素的产妇出现持续性下腹部疼痛或者胎心异常，应警惕完全性子宫破裂的可能，及时手术治疗可改善母儿结局。

关键词: 子宫破裂, 子宫切除术, 残角子宫妊娠, 瘢痕子宫, 危险因素, 孕妇

Objective

To investigate the current status, clinical features and pregnancy outcome of complete uterine rupture in order to guide the clinical practice.

Methods

From January 2006 to December 2018, a total of 106 747 parturients who gave birth in West China Second University Hospital, Sichuan University were selected into this study. The prevalence rate, general clinical data, clinical features and pregnancy outcomes of patients with complete uterine rupture were analyzed. This study was in line with the World Medical Association Declaration of Helsinki revised in 2013.

Results

① The prevalence rate of complete uterine rupture was 0.038% (41/106 747), of which 0.035% (26/73 369) in 2006-2015 and 0.045% (15/33 378) in 2016-2018. ② Among 41 patients with complete uterine rupture, 22 patients (53.7%) had scar uterus and 19 patients (46.3%) had non-scar uterus. The most common clinical symptom was persistent lower abdominal pain (48.7%, 20/41), the most common clinical signs was abdominal and uterine tenderness (58.5%, 24/41), and fetal heart abnormalities was found in 15.0% (3/20) of patients. ③ All the mothers survived and 6 of them developed complications (14.6%). Hysterorrhaphy was performed in 33 cases (80.5%), total hysterectomy or subtotal hysterectomy was performed in 7 cases (17.1%), removal of rudimentary uterine horn was performed in 1 case (2.4%). ④ In 41 cases of complete rupture of uterus, 27 cases (61.0%) were born alive and 16 cases (39.0%) were stillborn. Among 27 live births, 9 (33.3%) were transferred to pediatrics, 10 (37.0%) had neonatal asphyxia, 8 (29.6%) had mild asphyxia, 2 (7.40%) had severe asphyxia, and 17 had good Apgar scores (1 min after birth).

Conclusions

The most common risk factors of complete uterine rupture include scarred uterus, placental accreta and increta, history of hysteroscopic surgery. In pregnant women with high-risk factors of complete uterine rupture, persistent abdominal pain or abnormal fetal heart monitoring should be aware of the possibility of uterine rupture, and prompt surgical treatment can improve maternal and infant outcomes.

Key words: Uterine rupture, Hysterectomy, Residual uterine pregnancy, Scar uterus, Risk factors, Pregnant women

图1 2006-2018年于四川大学华西第二医院住院分娩孕妇完全性子宫破裂患病率折线图

表1 2006-2018年于四川大学华西第二医院住院分娩孕妇完全性子宫破裂患病率

年份(年)	分娩总例数	患病率[例数(%)]
2006	4 058	1(0.025)
2007	5 363	4(0.075)
2008	5 453	1(0.018)
2009	5 272	4(0.076)
2010	6 359	2(0.031)
2011	7 276	3(0.041)
2012	9 267	5(0.054)
2013	8 722	4(0.048)
2014	10 733	1(0.009)
2015	10 866	1(0.009)
2016	11 755	4(0.034)
2017	9 961	7(0.070)
2018	11 662	4(0.034)
合计	106 747	41(0.038)

表1 2006-2018年于四川大学华西第二医院住院分娩孕妇完全性子宫破裂患病率

年份(年)	分娩总例数	患病率[例数(%)]
2006	4 058	1(0.025)
2007	5 363	4(0.075)
2008	5 453	1(0.018)
2009	5 272	4(0.076)
2010	6 359	2(0.031)
2011	7 276	3(0.041)
2012	9 267	5(0.054)
2013	8 722	4(0.048)
2014	10 733	1(0.009)
2015	10 866	1(0.009)
2016	11 755	4(0.034)
2017	9 961	7(0.070)
2018	11 662	4(0.034)
合计	106 747	41(0.038)

表2 本组41例完全性子宫破裂患者的一般临床资料

项目		例数(%)
年龄(岁)		?
?	<35	25(61.0)
?	≥35	16(39.0)
产次(次)		?
?	<3	36(87.8)
?	≥3	5(12.2)
子宫破裂时孕龄(周)		?
?	0～13^＋6	1(2.4)
?	14^＋1～27^＋6	9(22.0)
?	≥28	31(75.6)
胎数		?
?	单胎妊娠	39(95.1)
?	双胎妊娠	2(4.9)
产前检查		?
?	本院	19(46.3)
?	外院及未产检者	22(53.7)

表2 本组41例完全性子宫破裂患者的一般临床资料

项目		例数(%)
年龄(岁)		?
?	<35	25(61.0)
?	≥35	16(39.0)
产次(次)		?
?	<3	36(87.8)
?	≥3	5(12.2)
子宫破裂时孕龄(周)		?
?	0～13^＋6	1(2.4)
?	14^＋1～27^＋6	9(22.0)
?	≥28	31(75.6)
胎数		?
?	单胎妊娠	39(95.1)
?	双胎妊娠	2(4.9)
产前检查		?
?	本院	19(46.3)
?	外院及未产检者	22(53.7)

表3 本组41例完全性子宫破裂患者的临床特征[例数(%)]

临床特征		发生率	临床特征		发生率
子宫手术史		27(65.9)	子宫畸形		4(9.7)
?	剖宫产术分娩术	18(66.7)	?	诱因	?
?	子宫腺肌瘤挖除术	3(13.6)	?	如厕	4(9.8)
?	子宫肌瘤挖除术	1(4.6)	?	腹部撞击史	2(4.9)
?	宫腔黏连松解术	3(11.1)	?	无明显诱因	35(85.4)
?	子宫纵膈切除术	2(7.4)	引产		7(17.1)
人工终止妊娠术史		19(46.3)	?	米非司酮＋米索前列醇	4(57.1)
临床表现		?	?	依沙吖啶	1(14.3)
?	持续性下腹部疼痛	20(48.7)	?	其他	2(28.6)
?	阴道流血	9(22.0)	子宫破裂位置		?
?	其他(如心悸、血压下降等)	7(17.1)	?	原瘢痕处	19(46.3)
?	胎心异常	3(15.0)	?	宫角、宫底部	13(31.7)
?	无	9(22.0)	?	其他	9(22.0)

表3 本组41例完全性子宫破裂患者的临床特征[例数(%)]

临床特征		发生率	临床特征		发生率
子宫手术史		27(65.9)	子宫畸形		4(9.7)
?	剖宫产术分娩术	18(66.7)	?	诱因	?
?	子宫腺肌瘤挖除术	3(13.6)	?	如厕	4(9.8)
?	子宫肌瘤挖除术	1(4.6)	?	腹部撞击史	2(4.9)
?	宫腔黏连松解术	3(11.1)	?	无明显诱因	35(85.4)
?	子宫纵膈切除术	2(7.4)	引产		7(17.1)
人工终止妊娠术史		19(46.3)	?	米非司酮＋米索前列醇	4(57.1)
临床表现		?	?	依沙吖啶	1(14.3)
?	持续性下腹部疼痛	20(48.7)	?	其他	2(28.6)
?	阴道流血	9(22.0)	子宫破裂位置		?
?	其他(如心悸、血压下降等)	7(17.1)	?	原瘢痕处	19(46.3)
?	胎心异常	3(15.0)	?	宫角、宫底部	13(31.7)
?	无	9(22.0)	?	其他	9(22.0)

表4 本组41例完全性子宫破裂患者及其分娩新生儿围生期结局[例数(%)]

围生期结局		发生率	围生期结局		发生率
输血情况		?	胎儿结局		?
?	红细胞	23(56.1)	?	存活	27(61.0)
?	新鲜冰冻血浆	12(29.3)	?	胎死宫内	16(39.0)
?	血小板	3(7.3)	新生儿生后1 min Apgar评分		?
?	纤维蛋白原	2(4.9)	?	良好	17(63.0)
?	冷沉淀	2(4.9)	?	轻度窒息	8(29.6)
?	自体血	1(2.4)	?	重度窒息	2(7.4)
孕产妇并发症		6(14.6)	新生儿结局		?
?	膀胱破裂	2(4.8)	?	自行抱回	2(7.4)
?	DIC	1(2.4)	?	转入新生儿科	9(33.3)
?	肠损伤	1(2.4)	手术方式		?
?	肺炎	1(2.4)	?	子宫修补术	33(80.5)
?	败血症	1(2.4)	?	全子宫切除术或次全子宫切除术	7(17.1)
产妇转入ICU		3(7.3)	?	残角子宫切除术	1(2.4)

表4 本组41例完全性子宫破裂患者及其分娩新生儿围生期结局[例数(%)]

围生期结局		发生率	围生期结局		发生率
输血情况		?	胎儿结局		?
?	红细胞	23(56.1)	?	存活	27(61.0)
?	新鲜冰冻血浆	12(29.3)	?	胎死宫内	16(39.0)
?	血小板	3(7.3)	新生儿生后1 min Apgar评分		?
?	纤维蛋白原	2(4.9)	?	良好	17(63.0)
?	冷沉淀	2(4.9)	?	轻度窒息	8(29.6)
?	自体血	1(2.4)	?	重度窒息	2(7.4)
孕产妇并发症		6(14.6)	新生儿结局		?
?	膀胱破裂	2(4.8)	?	自行抱回	2(7.4)
?	DIC	1(2.4)	?	转入新生儿科	9(33.3)
?	肠损伤	1(2.4)	手术方式		?
?	肺炎	1(2.4)	?	子宫修补术	33(80.5)
?	败血症	1(2.4)	?	全子宫切除术或次全子宫切除术	7(17.1)
产妇转入ICU		3(7.3)	?	残角子宫切除术	1(2.4)

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Clinical characteristics of complete uterine rupture

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Clinical characteristics of complete uterine rupture