探讨手术治疗剖宫产术后难治性产后出血(IPPH)患者治疗效果。

选择中国知网数据库、万方数据知识服务平台、维普中文期刊服务平台、中国生物医学文献数据库、PubMed、Embase、Web of Science等数据库中，关于手术治疗剖宫产术后IPPH患者疗效研究的临床研究文献为研究对象。以"剖宫产""难治性产后出血""cesarean section""refractory postpartum hemorrhage"等为中、英文关键词，筛选符合本研究纳入与排除标准，并且文献质量符合要求的临床研究文献，检索时限为2000年1月1日至2024年6月1日。采用RevMan 5.3软件对所得数据进行分析，先使用Cochrane-Q检验对纳入文献的异质性进行检测，并根据异质性检测结果采用随机效应或固定效应模型进行Meta分析。对本研究采用的疗效评价指标产后出血(PPH)量，采用标准化均数差(SMD)作为效应量，并计算其95%CI；采用漏斗图评价纳入文献发表偏倚。

按照本研究设定的文献检索策略，共计纳入关于手术治疗剖宫产术后IPPH患者疗效研究文献为17篇，文献质量均为B级，文献异质性较大；涉及775例采用手术治疗剖宫产术后IPPH患者，共计采用8种手术治疗方法，以PPH量为疗效指标的SMD分别如下。改良B-Lynch缝合术＋双侧子宫动脉上行支结扎术疗效的SMD为－2.07(95%CI：－3.14~－1.00，P<0.001)；改良B-Lynch缝合术疗效的SMD为－0.59(95%CI：－0.84~－0.34，P<0.001)；双侧子宫动脉上行支结扎术疗效的SMD为－2.77(95%CI：－4.91~－0.64，P<0.001)；子宫动脉结扎＋宫腔水囊压迫疗效的SMD为－1.27(95%CI：－1.76~－0.77，P<0.001)；子宫动脉结扎＋Hayman缝合术疗效的SMD为－5.24(95%CI：－6.01~－4.48，P<0.001)；Bakri球囊宫腔填塞术疗效的SMD为－3.71(95%CI：－4.77~－2.65，P<0.001)；盆腔血管介入栓塞术疗效的SMD为－1.63(95%CI：－1.92~－1.34，P<0.001)；子宫交叉捆绑术疗效的SMD为－4.52(95%CI：－11.26~－2.22，P＝0.190)。8种手术治疗方法疗效的合并效应量，即疗效的总体SMD为－2.46(95%CI：－3.09~－1.82，P<0.001)，研究组(8种方法之一)的疗效优于对照组，并且差异均有统计学意义(P<0.05)。

现有改良B-Lynch缝合术等8种手术方法治疗剖宫产术后IPPH患者均具有确切临床疗效，可以根据患者实际情况选择单独或者联合应用。

To explore the therapeutic effects of surgical treatment for patients with refractory postpartum hemorrhage (IPPH) after cesarean sections.

Clinical research literature on the efficacy of surgical treatment for patients with IPPH after cesarean section was selected from databases including China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, VIP Chinese Journal Service Platform, China Biomedical Literature Database, PubMed, Embase, and Web of Science using computer-based retrieval. Key words in both Chinese and English, such as ＂cesarean section＂ ＂refractory postpartum hemorrhage＂ etc., were employed to screen clinical studies that met the inclusion and exclusion criteria of this research and had acceptable literature quality. The retrieval time frame was from January 1, 2000, to June 1, 2024. RevMan 5.3 software was used to analyze the obtained data. First, the Cochrane-Q test was applied to detect the heterogeneity among the included literature, and a random effects model or a fixed effects model was used for Meta-analysis based on the results. For the efficacy evaluation index postpartum hemorrhage(PPH) volume adopted in this study, the standardized mean difference (SMD) was used as the effect size, and its 95%CI was calculated. A funnel plot was used to evaluate the publication bias of the included literature.

According to the literature retrieval strategy set in this study, a total of 17 pieces of literature on the efficacy of surgical treatment for patients with IPPH after cesarean section were included, all of which were of grade B quality. There was significant heterogeneity among the literature. The studies involved 775 patients with IPPH after cesarean section treated surgically, and a total of eight surgical treatment methods were adopted. The SMD with PPH volume as the efficacy index for 8 methods were as follows, respectively. The SMD for the efficacy of modified B-Lynch suture combined with bilateral ascending uterine artery ligation was -2.07 (95%CI: -3.14--1.00, P<0.001); the SMD for the efficacy of modified B-Lynch suture was -0.59 (95%CI: -0.84--0.34, P<0.001); the SMD for the efficacy of bilateral ascending uterine artery ligation was -2.77 (95%CI: -4.91--0.64, P<0.001); the SMD for the efficacy of uterine artery ligation combined with intrauterine water balloon compression was -1.27 (95%CI: -1.76--0.77, P<0.001); the SMD for the efficacy of uterine artery ligation combined with Hayman suture was -5.24 (95%CI: -6.01--4.48, P<0.001); the SMD for the efficacy of Bakri balloon intrauterine packing was -3.71 (95%CI: -4.77--2.65, P<0.001); the SMD for the efficacy of pelvic vascular interventional embolization was -1.63 (95%CI: -1.92--1.34, P<0.001); and the SMD for the efficacy of uterine cross-ligature was -4.52 (95%CI: -11.26--2.22, P=0.190). The pooled effect size for the efficacy of the eight surgical treatment methods, that is, the overall SMD for efficacy was -2.46 (95%CI: -3.09--1.82, P<0.001). The efficacy of the study group (use one of the eight methods) was superior to that of the control group, and the differences were all statistically significant (P<0.05).

The existing eight surgical treatment methods, such as modified B-Lynch suture etc., have definite clinical efficacy in treating patients with IPPH after cesarean section and can be selected for individual or combined application according to the actual conditions of patients.