探讨瘢痕子宫患者妊娠后，孕期发生子宫破裂的临床特点及高危因素。

选择2016年1月至2019年12月，成都市妇女儿童中心医院收治的瘢痕子宫患者妊娠后，孕期发生子宫破裂的106例患者为研究对象。其中，由于既往剖宫产术导致瘢痕子宫患者再次妊娠后，孕期发生子宫破裂者为95例(89.6%)；由于非剖宫产术(子宫穿孔术、子宫角楔形切除术、子宫肌瘤剔除术)导致瘢痕子宫患者妊娠后子宫破裂者为11例(10.4%)。采取回顾性分析法，将95例剖宫产术后瘢痕子宫患者，按照再次妊娠后，孕期发生子宫破裂类型，将其分别纳入完全性子宫破裂(CRU)组(n＝17)和不全性子宫破裂(ICRU)组(n＝78)。采取Mann-Whitney U检验、χ²检验或连续性校正χ²检验，对CRU组与ICRU组患者的临床病例资料进行统计学比较。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。

①孕期瘢痕子宫破裂发生率：2016年1月至2019年12月，本院瘢痕子宫患者孕期子宫破裂发生率为0.129%(106/82 157)；每年瘢痕子宫患者孕期子宫破裂发生率总体比较，差异有统计学意义(χ²＝26.490，P<0.001)。②临床特点分析：本组106例患者的年龄为32岁(19～40岁)；104例(98.1%)瘢痕子宫破裂发生在晚孕期(≥28孕周)，2例发生在中孕期(20～27^＋6孕周)；74例(69.8%)破裂者无典型子宫破裂症状，32例(30.2%)有典型子宫破裂症状。在11例非剖宫产术后瘢痕子宫患者中，发生严重不良妊娠结局为8例，包括死胎、新生儿窒息、失血性休克及子宫切除术各为3、5、3及2例。③CRU组与ICRU组比较：孕次、产次、既往剖宫产术分娩次数构成比比较，差异均无统计学意义(P>0.05)；CRU组患者年龄、孕龄、本次妊娠距离前次剖宫产术分娩间隔时间及临产率，均大于、小于、短于及高于ICRU组，并且差异均有统计学意义(Z＝14.323、P<0.001，Z＝-32.578、P<0.001，Z＝-7.268、P<0.001，χ²＝4.720、P＝0.030)。④治疗与随访结果：本组106例患者中，3例接受子宫切除术，18例于剖宫产术中接受双侧输卵管结扎术及子宫修补术，85例接受剖宫产术分娩及子宫修补术。对其中保留生育功能的85例患者随访5～52个月，无一例再次妊娠。

瘢痕子宫患者妊娠，是导致孕期子宫破裂的高危因素，剖宫产术后瘢痕子宫患者最为常见。剖宫产术后瘢痕子宫患者再次妊娠时，其发生CRU与本次妊娠距离前次剖宫术分娩间隔时间密切相关。对于非剖宫产术后瘢痕子宫患者妊娠时，若其发生子宫破裂，则后果往往更严重。

To analyze clinical characteristics and high risk factors of scarred uterus with uterine rupture during pregnancy.

From January 2016 to December 2019, a total of 106 scarred uterine pregnant women with uterine rupture during pregnancy in Chengdu Women′s and Children′s Central Hospital were selected as research subjects. There were 95 cases (89.6%) uterine rupture during re-pregnancy in scarred uterine pregnant women after cesarean section, and 11 cases (10.4%) patients with uterine rupture during pregnancy in scarred uterine pregnant women after non-cesarean section, such as uterine perforation, uterine horn wedge resection, and uterine myomectomy usually. According to types of uterine rupture after cesarean section during re-pregnancy, 95 cases scarred uterine pregnant women with uterine rupture after cesarean section during re-pregnancy were divided into complete uterine rupture (CRU) group (n=27) and incomplete uterine rupture (ICRU) group (n=79). Clinical data of CRU group and ICRU group were compared by Mann-Whitney U test, chi-square test or continuous correction chi-square test. The procedures followed in this study were in line with the requirements of World Medical Association Declaration of Helsinki revised in 2013.

①The rate of uterine rupture in scarred uterine pregnant women during pregnancy was 0.129% (106/82 157) from January 2016 to December 2019 in our hospital. There were statistically different in rates of uterine rupture among these four years by overall comparison (χ²=26.490, P<0.001). ②The average age of 106 patients was 32 years old (19-40 years), and 104 cases (98.1%) pregnant women whose uterine ruptures happened in third trimester (≥28 gestational weeks) and 2 cases (1.9%) in second trimester (20-27^{+ 6} gestational weeks). Uterine ruptures among these 106 pregnant women, 74 cases (69.8%) had no any typical clinical manifestations, and the other 32 cases (30.2%) had typical clinical manifestation. Among 11 patients with scarred uterine after non-cesarean section, 8 cases had serious adverse pregnancy outcomes, including stillbirth, neonatal asphyxia, hemorrhagic shock and hysterectomy in 3, 5, 3 and 2 cases, respectively. ③There were no statistical differences among gravidity, parity, and times of previous cesarean delivery between CUR group and ICUR group (P>0.05). The age of pregnant women in CUR group was significantly older than that of ICUR group (Z=14.323, P<0.001). The gestational age in CUR group was significantly smaller than that of ICUR group (Z=-32.578, P<0.001). The pregnancy interval in CUR group was significantly shorter than that of ICUR group (Z=-7.268, P<0.001). The parturient attack rate in CUR group was significantly higher than that of ICUR group (χ²=4.720, P=0.030). ④The treatment methods of 106 pregnant women included hysterectomy in 3 cases, bilateral tubal ligation and hysterorrhaphy during cesarean section in 18 cases, and just hysterorrhaphy during cesarean section in 85 cases. And 85 patients with retained fertility were followed up for 5 to 52 months, and none of them got pregnant again.

Scarred uterus in pregnant women is a primary risk factor for uterine rupture during pregnancy. The main cause of scarred uterus is cesarean section. CUR is closely related to pregnancy interval in re-pregnant women with scarred uterine after cesarean section. Uterine rupture of scarred uterus caused by non-cesarean section leads to more serious clinical complications.