子(zi)宮(gong)破(po)裂是指子(zi)宮(gong)體部或子(zi)宮(gong)下段于分娩(mian)期或妊娠(shen)期發生(sheng)(sheng)裂傷,為(wei)產(chan)科嚴重(zhong)并(bing)發癥,威脅母兒生(sheng)(sheng)命(ming)。主要死于出血、感染休克。隨(sui)著產(chan)科質量的提高(gao)(gao),城鄉婦幼衛生(sheng)(sheng)保(bao)健網的建立和逐步健全發生(sheng)(sheng)率(lv)(lv)顯著下降。城市醫院已很少見(jian)到(dao),而(er)農村偏(pian)遠地區(qu)時有發生(sheng)(sheng)。子(zi)宮(gong)破(po)裂絕(jue)大多數發生(sheng)(sheng)于妊娠(shen)28周之后(hou),分娩(mian)期最多見(jian),目前發生(sheng)(sheng)率(lv)(lv)控制在(zai)1‰以下,產(chan)婦病死率(lv)(lv)為(wei)5%,嬰兒病死率(lv)(lv)高(gao)(gao)達50%~75%甚至更高(gao)(gao)。
子(zi)宮(gong)破(po)(po)裂(lie)多發(fa)生于難產、高齡(ling)多產和(he)(he)子(zi)宮(gong)曾經(jing)手術(shu)或有過損傷的產婦(fu)。根(gen)據破(po)(po)裂(lie)的原因,可分為(wei)無瘢(ban)(ban)痕子(zi)宮(gong)破(po)(po)裂(lie)和(he)(he)瘢(ban)(ban)痕子(zi)宮(gong)破(po)(po)裂(lie)。
1.梗阻性難產
明(ming)顯的骨盆狹窄(zhai)頭盆不稱,軟產道(dao)畸形(xing)盆腔腫(zhong)瘤和異常胎(tai)位等因素阻(zu)礙(ai)胎(tai)先露(lu)下降(jiang),子(zi)(zi)宮(gong)為克服阻(zu)力加強收縮(suo)子(zi)(zi)宮(gong)下段(duan)被迫拉長變(bian)薄最終發(fa)生子(zi)(zi)宮(gong)破(po)裂(lie)。此種(zhong)子(zi)(zi)宮(gong)破(po)裂(lie)為子(zi)(zi)宮(gong)破(po)裂(lie)中最常見(jian)類型,破(po)裂(lie)處多(duo)發(fa)生于子(zi)(zi)宮(gong)下段(duan)。
2.子宮瘢(ban)痕破裂
造成(cheng)子(zi)(zi)宮(gong)(gong)(gong)(gong)瘢痕(hen)的(de)原因(yin)(yin)主(zhu)要(yao)有剖(pou)宮(gong)(gong)(gong)(gong)產(chan)術(shu),子(zi)(zi)宮(gong)(gong)(gong)(gong)肌(ji)瘤(liu)剝除術(shu),子(zi)(zi)宮(gong)(gong)(gong)(gong)破(po)裂(lie)或穿孔修補術(shu),子(zi)(zi)宮(gong)(gong)(gong)(gong)畸形矯形術(shu)等;造成(cheng)破(po)裂(lie)的(de)原因(yin)(yin)是妊(ren)娠子(zi)(zi)宮(gong)(gong)(gong)(gong)的(de)機械性牽拉導(dao)致瘢痕(hen)處(chu)破(po)裂(lie)或者子(zi)(zi)宮(gong)(gong)(gong)(gong)瘢痕(hen)處(chu)內膜受損,胎盤植(zhi)入,穿透(tou)性胎盤導(dao)致子(zi)(zi)宮(gong)(gong)(gong)(gong)自(zi)發破(po)裂(lie)。近些年剖(pou)宮(gong)(gong)(gong)(gong)產(chan)術(shu)迅速增(zeng)加(jia)子(zi)(zi)宮(gong)(gong)(gong)(gong)體(ti)部縱切口(kou)剖(pou)宮(gong)(gong)(gong)(gong)產(chan)再次妊(ren)娠容易并發子(zi)(zi)宮(gong)(gong)(gong)(gong)破(po)裂(lie),分析原因(yin)(yin)除宮(gong)(gong)(gong)(gong)體(ti)部縱切口(kou)和下(xia)段橫切口(kou)解(jie)剖(pou)性質不同外,還要(yao)考慮(lv)感染(ran)因(yin)(yin)素的(de)作(zuo)用,因(yin)(yin)為目前采(cai)用子(zi)(zi)宮(gong)(gong)(gong)(gong)體(ti)部縱切口(kou)剖(pou)宮(gong)(gong)(gong)(gong)產(chan)的(de)患者通常經(jing)過(guo)了漫長(chang)的(de)產(chan)程,多(duo)次陰道(dao)檢(jian)查(cha),感染(ran)幾(ji)率增(zeng)加(jia)。
3.濫用宮縮劑
此處的(de)(de)宮縮(suo)劑應(ying)該包(bao)括(kuo)各(ge)種刺激子(zi)(zi)宮收縮(suo)的(de)(de)物質包(bao)括(kuo)最(zui)常用的(de)(de)縮(suo)宮素(催產素)和近些年(nian)才應(ying)用的(de)(de)米索(suo)前列醇,報道的(de)(de)米索(suo)前列醇導致子(zi)(zi)宮破(po)裂的(de)(de)病(bing)例越來越多。原因主要包(bao)括(kuo)藥物劑量(liang)過(guo)(guo)大或給藥速(su)度(du)過(guo)(guo)快子(zi)(zi)宮頸不(bu)成熟,胎位(wei)不(bu)正梗阻性難產,用藥期間對(dui)產程觀(guan)察不(bu)仔細(xi)等。
4.陰道助產手術損傷
宮口(kou)未開(kai)全,強行產鉗術或臀牽引術導致子(zi)宮頸嚴重裂傷并(bing)上延到子(zi)宮下段。忽略性橫位(wei)內(nei)倒轉術,毀胎術部(bu)分(fen)人工剝(bo)離胎盤術等由于操作(zuo)不(bu)當,均可以造成(cheng)子(zi)宮破裂。
5.子(zi)(zi)宮畸形和子(zi)(zi)宮壁(bi)發(fa)育不良
最常見的是(shi)雙(shuang)角(jiao)子宮或單(dan)角(jiao)子宮。
6.子宮本(ben)身病變
多(duo)產(chan)(chan)婦(fu)多(duo)次刮宮史、感染性流產(chan)(chan)史宮腔(qiang)感染史、人工剝(bo)離胎盤史、葡萄胎史等。由于上述因素導致子宮內(nei)膜乃至(zhi)肌(ji)壁受損(sun),妊娠后胎盤植入或穿透,最終導致子宮破裂。
1.出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)子(zi)(zi)(zi)宮(gong)(gong)(gong)破(po)裂(lie)通常表現(xian)為大(da)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue),出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)分為內(nei)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)、外(wai)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)或(huo)(huo)(huo)混合出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)。內(nei)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)指出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)積(ji)聚(ju)于闊韌(ren)帶內(nei)或(huo)(huo)(huo)腹腔(qiang)(qiang)內(nei),導致闊韌(ren)帶血(xue)(xue)(xue)(xue)(xue)(xue)(xue)腫或(huo)(huo)(huo)腹腔(qiang)(qiang)積(ji)血(xue)(xue)(xue)(xue)(xue)(xue)(xue);外(wai)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)指出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)自陰(yin)道(dao)(dao)(dao)排出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)。子(zi)(zi)(zi)宮(gong)(gong)(gong)破(po)裂(lie)的(de)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)部位通常包(bao)括子(zi)(zi)(zi)宮(gong)(gong)(gong)及軟(ruan)產道(dao)(dao)(dao)破(po)裂(lie)口和(he)胎盤(pan)(pan)(pan)剝(bo)離(li)面出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue),子(zi)(zi)(zi)宮(gong)(gong)(gong)和(he)軟(ruan)產道(dao)(dao)(dao)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)通常需要(yao)損傷(shang)(shang)所在部位的(de)大(da)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)管,如果(guo)軟(ruan)產道(dao)(dao)(dao)損傷(shang)(shang)未傷(shang)(shang)及大(da)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)管,通常不表現(xian)為大(da)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)或(huo)(huo)(huo)活動(dong)(dong)性出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)。胎盤(pan)(pan)(pan)剝(bo)離(li)面的(de)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)與胎盤(pan)(pan)(pan)剝(bo)離(li)的(de)程度和(he)子(zi)(zi)(zi)宮(gong)(gong)(gong)收(shou)縮強度有關(guan),如果(guo)胎盤(pan)(pan)(pan)未完全(quan)剝(bo)離(li)或(huo)(huo)(huo)剝(bo)離(li)后(hou)未排出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)(gong)腔(qiang)(qiang),影響子(zi)(zi)(zi)宮(gong)(gong)(gong)收(shou)縮,表現(xian)為大(da)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue);反之如果(guo)胎盤(pan)(pan)(pan)完全(quan)剝(bo)離(li)并已經排出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)(gong)腔(qiang)(qiang),子(zi)(zi)(zi)宮(gong)(gong)(gong)收(shou)縮很好,則胎盤(pan)(pan)(pan)剝(bo)離(li)面少量活動(dong)(dong)性出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)。上述出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)指術前出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue),術后(hou)亦可以出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue),原(yuan)因主要(yao)為闊韌(ren)帶血(xue)(xue)(xue)(xue)(xue)(xue)(xue)腫清(qing)除后(hou)創面出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)或(huo)(huo)(huo)DIC出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue),或(huo)(huo)(huo)保守治療子(zi)(zi)(zi)宮(gong)(gong)(gong)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)。出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)除引起(qi)失血(xue)(xue)(xue)(xue)(xue)(xue)(xue)性休克(ke)外(wai),還由于產婦高凝狀態,出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)(xue)過(guo)多(duo),休克(ke)時間過(guo)長,出(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)(chu)現(xian)DIC。
2.感(gan)(gan)(gan)染子(zi)宮(gong)破(po)裂(lie)后(hou)(hou)容(rong)易出(chu)(chu)現感(gan)(gan)(gan)染的(de)(de)部(bu)位主要有(you)(you)盆(pen)腔、腹(fu)(fu)(fu)腔、盆(pen)腔腹(fu)(fu)(fu)膜(mo)后(hou)(hou)和軟產道。造成感(gan)(gan)(gan)染的(de)(de)原(yuan)因(yin)主要有(you)(you):盆(pen)腹(fu)(fu)(fu)腔或(huo)闊韌帶內與子(zi)宮(gong)腔和陰道相通(tong),相通(tong)后(hou)(hou)有(you)(you)細菌進入(ru);子(zi)宮(gong)破(po)裂(lie)后(hou)(hou)大出(chu)(chu)血,嚴重貧血或(huo)DIC,抵抗力下(xia)降容(rong)易感(gan)(gan)(gan)染;腹(fu)(fu)(fu)腔或(huo)盆(pen)腔內的(de)(de)積(ji)血或(huo)腹(fu)(fu)(fu)膜(mo)外(wai)的(de)(de)積(ji)血,容(rong)易感(gan)(gan)(gan)染;子(zi)宮(gong)破(po)裂(lie)后(hou)(hou)的(de)(de)子(zi)宮(gong)切除(chu)(chu)或(huo)修(xiu)補,均于(yu)有(you)(you)菌條件下(xia)進行;子(zi)宮(gong)破(po)裂(lie)后(hou)(hou)診斷期間可能有(you)(you)較(jiao)多的(de)(de)陰道操(cao)作;時間較(jiao)久的(de)(de)子(zi)宮(gong)破(po)裂(lie)更容(rong)易導致多部(bu)位的(de)(de)各種(zhong)感(gan)(gan)(gan)染。另外(wai)值得(de)提(ti)出(chu)(chu)的(de)(de)感(gan)(gan)(gan)染是呼吸(xi)(xi)道感(gan)(gan)(gan)染,引起感(gan)(gan)(gan)染的(de)(de)因(yin)素很(hen)多,休克時間過(guo)長正常呼吸(xi)(xi)道的(de)(de)排痰和防(fang)御機制受損與之有(you)(you)關,同時不能除(chu)(chu)外(wai)誤(wu)吸(xi)(xi)等(deng)因(yin)素。
3.導致產(chan)道及(ji)其他腹(fu)腔和(he)(he)盆腔器(qi)官(guan)組織損(sun)傷子(zi)(zi)(zi)宮(gong)(gong)破(po)裂的(de)(de)(de)損(sun)傷包(bao)括(kuo)手(shou)術(shu)干(gan)預前(qian)和(he)(he)手(shou)術(shu)干(gan)預后的(de)(de)(de)損(sun)傷。手(shou)術(shu)干(gan)預前(qian)的(de)(de)(de)損(sun)傷包(bao)括(kuo)子(zi)(zi)(zi)宮(gong)(gong)體、子(zi)(zi)(zi)宮(gong)(gong)下段、子(zi)(zi)(zi)宮(gong)(gong)頸和(he)(he)陰(yin)道的(de)(de)(de)各種(zhong)損(sun)傷,同時(shi)(shi)(shi)也可能有原(yuan)發(fa)的(de)(de)(de)由于胎(tai)頭壓迫造成的(de)(de)(de)膀胱損(sun)傷。子(zi)(zi)(zi)宮(gong)(gong)破(po)裂患者(zhe)診(zhen)斷(duan)過(guo)(guo)程和(he)(he)手(shou)術(shu)治療過(guo)(guo)程中(zhong)(zhong)的(de)(de)(de)損(sun)傷很多(duo),有時(shi)(shi)(shi)甚至超過(guo)(guo)原(yuan)發(fa)損(sun)傷。診(zhen)斷(duan)過(guo)(guo)程中(zhong)(zhong)過(guo)(guo)多(duo)的(de)(de)(de)不必要的(de)(de)(de)陰(yin)道操(cao)(cao)作或檢查(cha)導致產(chan)道損(sun)傷加重;開腹(fu)探查(cha)術(shu),清理積血或清理胎(tai)兒(er)、胎(tai)盤和(he)(he)胎(tai)膜(mo),操(cao)(cao)作不當,導致腸道或大(da)網膜(mo)損(sun)傷;清理闊韌帶血腫,引(yin)起盆底血管輸尿管和(he)(he)膀胱損(sun)傷;子(zi)(zi)(zi)宮(gong)(gong)破(po)裂時(shi)(shi)(shi)間過(guo)(guo)長,對腹(fu)腔器(qi)官(guan)的(de)(de)(de)損(sun)傷更(geng)重。
4.對胎兒(er)的(de)(de)影響子宮(gong)破(po)裂后對胎兒(er)的(de)(de)影響主(zhu)要是不同時間和不同程度(du)的(de)(de)出血造(zao)成的(de)(de)損(sun)傷,多(duo)數胎兒(er)死(si)亡。存活胎兒(er)的(de)(de)圍生兒(er)發病(bing)率(lv)和病(bing)死(si)率(lv)明(ming)顯(xian)增高,遠期并發癥也明(ming)顯(xian)增高。
診(zhen)斷完全性(xing)(xing)子(zi)宮破(po)裂一般(ban)困難(nan)不(bu)大,根據病史、分娩(mian)經過(guo)、臨床表現及體征可(ke)作出診(zhen)斷。不(bu)完全性(xing)(xing)子(zi)宮破(po)裂只(zhi)有在(zai)嚴密觀察下方能發現。個別晚(wan)期(qi)妊娠破(po)裂者,只(zhi)有出現子(zi)宮破(po)裂的癥狀和體征時方能確診(zhen)。
個別難產(chan)病(bing)例經多次陰道檢(jian)查,可能感染出現腹(fu)膜(mo)炎而表現為(wei)類似子(zi)宮破裂癥象。陰道檢(jian)查時(shi)由(you)于(yu)(yu)胎先露(lu)部仍高、子(zi)宮下段菲薄(bo),雙合診時(shi)雙手指相觸猶如只隔腹(fu)壁(bi),有時(shi)容易誤診為(wei)子(zi)宮破裂,這種情況胎體(ti)不會進入腹(fu)腔(qiang),而妊娠子(zi)宮也不會縮小而位(wei)于(yu)(yu)胎體(ti)旁側。
發現(xian)先兆子(zi)(zi)(zi)宮(gong)(gong)(gong)破(po)裂(lie),必須立(li)即(ji)采(cai)取有效措施抑制子(zi)(zi)(zi)宮(gong)(gong)(gong)收縮,如給乙醚(mi)全(quan)(quan)麻(ma)、肌肉注(zhu)射度冷丁100mg等,以緩解子(zi)(zi)(zi)宮(gong)(gong)(gong)破(po)裂(lie)的進程(cheng)。最好能(neng)盡快行剖宮(gong)(gong)(gong)產術,術中注(zhu)意檢查(cha)子(zi)(zi)(zi)宮(gong)(gong)(gong)是否已(yi)有破(po)裂(lie)。子(zi)(zi)(zi)宮(gong)(gong)(gong)破(po)裂(lie)胎兒(er)未娩(mian)出(chu)者(zhe),即(ji)使(shi)死胎也(ye)不(bu)應經陰道先娩(mian)出(chu)胎兒(er),這會使(shi)裂(lie)口擴(kuo)大,增加出(chu)血,促使(shi)感(gan)染(ran)擴(kuo)散,應迅速剖腹取出(chu)死胎,視患(huan)者(zhe)狀態、裂(lie)傷部位情況、感(gan)染(ran)程(cheng)度和患(huan)者(zhe)是否已(yi)有子(zi)(zi)(zi)女(nv)(nv)等綜合考慮,若子(zi)(zi)(zi)宮(gong)(gong)(gong)裂(lie)口較易縫(feng)合、感(gan)染(ran)不(bu)嚴(yan)重(zhong)、患(huan)者(zhe)狀態欠佳時(shi),可作裂(lie)口修補縫(feng)合,有子(zi)(zi)(zi)女(nv)(nv)者(zhe)結扎輸卵管,無子(zi)(zi)(zi)女(nv)(nv)者(zhe)保留其(qi)生育功能(neng)。否則可行子(zi)(zi)(zi)宮(gong)(gong)(gong)全(quan)(quan)切除(chu)或次全(quan)(quan)切除(chu)。子(zi)(zi)(zi)宮(gong)(gong)(gong)下段(duan)破(po)裂(lie)者(zhe),應注(zhu)意檢查(cha)膀胱、輸尿管、宮(gong)(gong)(gong)頸(jing)及陰道,若有損傷,應及時(shi)修補。
子(zi)宮破裂多伴有嚴重的出血(xue)及存在感(gan)(gan)染,術(shu)(shu)前應輸(shu)血(xue)、輸(shu)液,給(gei)予乳酸鈉,積極(ji)進行抗休克治療,術(shu)(shu)中、術(shu)(shu)后應用較大劑量廣(guang)譜抗生素控(kong)制感(gan)(gan)染。