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子(zi)宮(gong)破(po)裂是指子(zi)宮(gong)體(ti)部或(huo)子(zi)宮(gong)下(xia)段于分娩期或(huo)妊娠期發(fa)(fa)生(sheng)裂傷，為產科(ke)嚴重并(bing)發(fa)(fa)癥，威(wei)脅母兒(er)生(sheng)命。主(zhu)要(yao)死于出血、感染休克。隨著產科(ke)質量的(de)提高，城(cheng)鄉婦幼(you)衛生(sheng)保健網的(de)建立和逐步健全發(fa)(fa)生(sheng)率(lv)(lv)(lv)顯(xian)著下(xia)降。城(cheng)市醫院已很少見到，而農村偏遠(yuan)地區時有發(fa)(fa)生(sheng)。子(zi)宮(gong)破(po)裂絕大多數發(fa)(fa)生(sheng)于妊娠28周之后，分娩期最多見，目(mu)前發(fa)(fa)生(sheng)率(lv)(lv)(lv)控制在1‰以下(xia)，產婦病死率(lv)(lv)(lv)為5%，嬰兒(er)病死率(lv)(lv)(lv)高達50%～75%甚至(zhi)更(geng)高。

病因

子(zi)宮(gong)破裂(lie)多(duo)發(fa)生于難產、高齡多(duo)產和子(zi)宮(gong)曾(ceng)經手術(shu)或有過損傷的(de)產婦。根據破裂(lie)的(de)原(yuan)因，可分為無瘢痕子(zi)宮(gong)破裂(lie)和瘢痕子(zi)宮(gong)破裂(lie)。

1.梗阻性難產

明顯(xian)的(de)骨(gu)盆狹窄頭(tou)盆不稱(cheng)，軟產道畸形盆腔腫瘤(liu)和異常胎(tai)位等因素阻(zu)礙(ai)胎(tai)先(xian)露下降，子宮(gong)(gong)(gong)(gong)為克服阻(zu)力加強收縮子宮(gong)(gong)(gong)(gong)下段被迫拉長變薄最終發生子宮(gong)(gong)(gong)(gong)破裂。此種子宮(gong)(gong)(gong)(gong)破裂為子宮(gong)(gong)(gong)(gong)破裂中(zhong)最常見(jian)類型，破裂處多發生于子宮(gong)(gong)(gong)(gong)下段。

2.子宮瘢痕(hen)破裂

造成(cheng)子宮(gong)(gong)(gong)瘢痕的(de)(de)原因主(zhu)要有剖(pou)宮(gong)(gong)(gong)產(chan)術，子宮(gong)(gong)(gong)肌瘤剝除(chu)術，子宮(gong)(gong)(gong)破(po)裂(lie)(lie)或穿(chuan)孔修補術，子宮(gong)(gong)(gong)畸形(xing)矯(jiao)形(xing)術等；造成(cheng)破(po)裂(lie)(lie)的(de)(de)原因是妊(ren)娠子宮(gong)(gong)(gong)的(de)(de)機械性(xing)牽拉(la)導(dao)致瘢痕處破(po)裂(lie)(lie)或者子宮(gong)(gong)(gong)瘢痕處內膜受損，胎盤(pan)植入(ru)，穿(chuan)透性(xing)胎盤(pan)導(dao)致子宮(gong)(gong)(gong)自發(fa)破(po)裂(lie)(lie)。近些年剖(pou)宮(gong)(gong)(gong)產(chan)術迅(xun)速增(zeng)(zeng)加(jia)子宮(gong)(gong)(gong)體部縱(zong)(zong)切口剖(pou)宮(gong)(gong)(gong)產(chan)再(zai)次妊(ren)娠容易并發(fa)子宮(gong)(gong)(gong)破(po)裂(lie)(lie)，分析原因除(chu)宮(gong)(gong)(gong)體部縱(zong)(zong)切口和下(xia)段橫切口解剖(pou)性(xing)質不同外(wai)，還要考慮感染(ran)因素的(de)(de)作用，因為目前采(cai)用子宮(gong)(gong)(gong)體部縱(zong)(zong)切口剖(pou)宮(gong)(gong)(gong)產(chan)的(de)(de)患者通(tong)常(chang)經過了漫(man)長(chang)的(de)(de)產(chan)程(cheng)，多次陰(yin)道檢(jian)查，感染(ran)幾率增(zeng)(zeng)加(jia)。

3.濫用宮縮劑

此(ci)處的宮(gong)縮劑(ji)應該包括各(ge)種刺激子宮(gong)收縮的物(wu)(wu)質包括最常用(yong)的縮宮(gong)素（催產素）和(he)近(jin)些年才應用(yong)的米索(suo)前列醇(chun)(chun)，報道的米索(suo)前列醇(chun)(chun)導致(zhi)子宮(gong)破裂的病例越來(lai)越多。原因主要包括藥物(wu)(wu)劑(ji)量過大(da)或給藥速度過快子宮(gong)頸不成(cheng)熟，胎位(wei)不正梗阻(zu)性難(nan)產，用(yong)藥期間對產程觀(guan)察(cha)不仔細等。

4.陰道助產手術損(sun)傷

宮(gong)口未開全，強行產鉗(qian)術(shu)或(huo)臀(tun)牽引術(shu)導致(zhi)子(zi)宮(gong)頸嚴重裂(lie)傷并上(shang)延到(dao)子(zi)宮(gong)下(xia)段(duan)。忽略性橫位內倒轉(zhuan)術(shu)，毀胎術(shu)部分人工剝(bo)離(li)胎盤術(shu)等由(you)于操作(zuo)不當，均可以造成子(zi)宮(gong)破裂(lie)。

5.子宮畸形和子宮壁發育不良

最常(chang)見(jian)的是雙角子(zi)宮或單角子(zi)宮。

6.子宮(gong)本身(shen)病變(bian)

多產(chan)婦多次刮(gua)宮(gong)史、感染性流產(chan)史宮(gong)腔(qiang)感染史、人工剝離胎盤(pan)史、葡(pu)萄(tao)胎史等(deng)。由于上(shang)述因素導致子宮(gong)內膜乃至(zhi)肌壁受損，妊(ren)娠后胎盤(pan)植入或穿(chuan)透，最終導致子宮(gong)破裂。

臨床表現

1.出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)破裂通常表現(xian)為(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)，出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)分(fen)為(wei)內(nei)(nei)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)、外(wai)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)或混合出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)。內(nei)(nei)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)指出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)積聚于闊(kuo)韌(ren)帶內(nei)(nei)或腹腔(qiang)內(nei)(nei)，導致闊(kuo)韌(ren)帶血(xue)(xue)(xue)(xue)(xue)腫或腹腔(qiang)積血(xue)(xue)(xue)(xue)(xue)；外(wai)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)指出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)自陰道排出(chu)(chu)(chu)(chu)(chu)(chu)(chu)。子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)破裂的(de)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)部(bu)位通常包括子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)及軟(ruan)產(chan)道破裂口(kou)和(he)胎(tai)(tai)盤剝(bo)離(li)面出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)，子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)和(he)軟(ruan)產(chan)道出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)通常需要(yao)損傷所在部(bu)位的(de)大血(xue)(xue)(xue)(xue)(xue)管，如果軟(ruan)產(chan)道損傷未(wei)傷及大血(xue)(xue)(xue)(xue)(xue)管，通常不表現(xian)為(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)或活(huo)(huo)動性(xing)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)。胎(tai)(tai)盤剝(bo)離(li)面的(de)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)與胎(tai)(tai)盤剝(bo)離(li)的(de)程度(du)和(he)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)收(shou)(shou)縮強度(du)有關，如果胎(tai)(tai)盤未(wei)完全剝(bo)離(li)或剝(bo)離(li)后(hou)未(wei)排出(chu)(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)(gong)(gong)腔(qiang)，影響子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)收(shou)(shou)縮，表現(xian)為(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)；反之如果胎(tai)(tai)盤完全剝(bo)離(li)并(bing)已經排出(chu)(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)(gong)(gong)腔(qiang)，子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)收(shou)(shou)縮很(hen)好(hao)，則胎(tai)(tai)盤剝(bo)離(li)面少量活(huo)(huo)動性(xing)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)。上(shang)述出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)指術前出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)，術后(hou)亦可(ke)以出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)，原因主要(yao)為(wei)闊(kuo)韌(ren)帶血(xue)(xue)(xue)(xue)(xue)腫清除(chu)后(hou)創面出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)或DIC出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)，或保守治(zhi)療子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)。出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)除(chu)引起失血(xue)(xue)(xue)(xue)(xue)性(xing)休克外(wai)，還由于產(chan)婦(fu)高凝狀態，出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)過多，休克時(shi)間過長，出(chu)(chu)(chu)(chu)(chu)(chu)(chu)現(xian)DIC。

2.感(gan)染(ran)(ran)(ran)子(zi)宮破(po)(po)裂(lie)后容(rong)易出現感(gan)染(ran)(ran)(ran)的(de)(de)部(bu)位主要(yao)有(you)盆(pen)(pen)腔(qiang)(qiang)、腹(fu)腔(qiang)(qiang)、盆(pen)(pen)腔(qiang)(qiang)腹(fu)膜(mo)后和軟(ruan)產道(dao)(dao)。造(zao)成感(gan)染(ran)(ran)(ran)的(de)(de)原因主要(yao)有(you)：盆(pen)(pen)腹(fu)腔(qiang)(qiang)或闊韌帶內與子(zi)宮腔(qiang)(qiang)和陰(yin)道(dao)(dao)相(xiang)通，相(xiang)通后有(you)細菌進(jin)入；子(zi)宮破(po)(po)裂(lie)后大出血，嚴重(zhong)貧血或DIC，抵抗力下降容(rong)易感(gan)染(ran)(ran)(ran)；腹(fu)腔(qiang)(qiang)或盆(pen)(pen)腔(qiang)(qiang)內的(de)(de)積(ji)血或腹(fu)膜(mo)外(wai)的(de)(de)積(ji)血，容(rong)易感(gan)染(ran)(ran)(ran)；子(zi)宮破(po)(po)裂(lie)后的(de)(de)子(zi)宮切除或修(xiu)補，均(jun)于有(you)菌條(tiao)件下進(jin)行；子(zi)宮破(po)(po)裂(lie)后診斷(duan)期(qi)間(jian)可能有(you)較(jiao)多(duo)的(de)(de)陰(yin)道(dao)(dao)操作；時間(jian)較(jiao)久(jiu)的(de)(de)子(zi)宮破(po)(po)裂(lie)更容(rong)易導致多(duo)部(bu)位的(de)(de)各種感(gan)染(ran)(ran)(ran)。另外(wai)值得提出的(de)(de)感(gan)染(ran)(ran)(ran)是(shi)呼吸(xi)道(dao)(dao)感(gan)染(ran)(ran)(ran)，引起感(gan)染(ran)(ran)(ran)的(de)(de)因素很多(duo)，休克(ke)時間(jian)過(guo)長正常呼吸(xi)道(dao)(dao)的(de)(de)排痰(tan)和防御機制受損與之有(you)關，同時不(bu)能除外(wai)誤吸(xi)等因素。

3.導致產道(dao)及其他腹腔和(he)(he)盆(pen)(pen)腔器官(guan)組織損(sun)(sun)(sun)傷(shang)(shang)子(zi)(zi)宮(gong)破裂(lie)(lie)(lie)的損(sun)(sun)(sun)傷(shang)(shang)包括手(shou)術(shu)干預前(qian)和(he)(he)手(shou)術(shu)干預后的損(sun)(sun)(sun)傷(shang)(shang)。手(shou)術(shu)干預前(qian)的損(sun)(sun)(sun)傷(shang)(shang)包括子(zi)(zi)宮(gong)體、子(zi)(zi)宮(gong)下段、子(zi)(zi)宮(gong)頸和(he)(he)陰(yin)道(dao)的各(ge)種損(sun)(sun)(sun)傷(shang)(shang)，同時(shi)也可能有原發的由于胎頭(tou)壓迫造(zao)成的膀胱(guang)(guang)損(sun)(sun)(sun)傷(shang)(shang)。子(zi)(zi)宮(gong)破裂(lie)(lie)(lie)患者診斷過(guo)(guo)程和(he)(he)手(shou)術(shu)治療(liao)過(guo)(guo)程中的損(sun)(sun)(sun)傷(shang)(shang)很(hen)多，有時(shi)甚至超過(guo)(guo)原發損(sun)(sun)(sun)傷(shang)(shang)。診斷過(guo)(guo)程中過(guo)(guo)多的不必要的陰(yin)道(dao)操作或檢查(cha)導致產道(dao)損(sun)(sun)(sun)傷(shang)(shang)加(jia)重；開腹探查(cha)術(shu)，清理積(ji)血或清理胎兒、胎盤和(he)(he)胎膜(mo)，操作不當(dang)，導致腸道(dao)或大(da)網膜(mo)損(sun)(sun)(sun)傷(shang)(shang)；清理闊韌帶(dai)血腫，引起盆(pen)(pen)底血管輸尿(niao)管和(he)(he)膀胱(guang)(guang)損(sun)(sun)(sun)傷(shang)(shang)；子(zi)(zi)宮(gong)破裂(lie)(lie)(lie)時(shi)間(jian)過(guo)(guo)長(chang)，對腹腔器官(guan)的損(sun)(sun)(sun)傷(shang)(shang)更(geng)重。

4.對(dui)胎(tai)兒(er)(er)的(de)(de)影響子(zi)宮(gong)破裂后對(dui)胎(tai)兒(er)(er)的(de)(de)影響主要(yao)是不同(tong)時間和不同(tong)程度的(de)(de)出血造成的(de)(de)損傷，多數胎(tai)兒(er)(er)死亡(wang)。存活胎(tai)兒(er)(er)的(de)(de)圍生(sheng)兒(er)(er)發(fa)病率和病死率明(ming)顯增(zeng)高(gao)，遠期(qi)并發(fa)癥也明(ming)顯增(zeng)高(gao)。

診斷

診斷完全(quan)性(xing)子(zi)(zi)宮破裂(lie)(lie)一般困難不大，根據(ju)病史、分娩(mian)經過、臨床表現(xian)(xian)及體(ti)征可(ke)作出診斷。不完全(quan)性(xing)子(zi)(zi)宮破裂(lie)(lie)只有在嚴密觀察下方能發(fa)現(xian)(xian)。個(ge)別晚期妊娠(shen)破裂(lie)(lie)者，只有出現(xian)(xian)子(zi)(zi)宮破裂(lie)(lie)的癥狀和體(ti)征時方能確診。

個別(bie)難產病例經多次(ci)陰道檢查，可能(neng)感染(ran)出現(xian)腹(fu)膜炎(yan)而(er)(er)表現(xian)為類似子(zi)宮(gong)破(po)裂(lie)癥象。陰道檢查時(shi)由于(yu)胎(tai)先露部仍高、子(zi)宮(gong)下段菲薄(bo)，雙合診時(shi)雙手指相觸猶如(ru)只隔腹(fu)壁，有(you)時(shi)容(rong)易誤診為子(zi)宮(gong)破(po)裂(lie)，這種情況胎(tai)體(ti)不會(hui)進入(ru)腹(fu)腔，而(er)(er)妊娠子(zi)宮(gong)也不會(hui)縮小而(er)(er)位于(yu)胎(tai)體(ti)旁側。

治療

發現先(xian)兆子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)破(po)(po)裂，必須立即(ji)采取(qu)有(you)效措施抑制子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)收縮，如給乙醚全(quan)麻、肌肉注(zhu)射度冷(leng)丁100mg等，以緩解子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)破(po)(po)裂的進程。最好能盡快行(xing)剖宮(gong)(gong)(gong)(gong)(gong)(gong)產術，術中注(zhu)意檢(jian)(jian)查子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)是否(fou)已(yi)有(you)破(po)(po)裂。子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)破(po)(po)裂胎(tai)兒(er)未娩出者，即(ji)使(shi)死(si)胎(tai)也(ye)不(bu)應(ying)(ying)經(jing)陰道先(xian)娩出胎(tai)兒(er)，這會(hui)使(shi)裂口(kou)擴大，增加出血，促使(shi)感染擴散，應(ying)(ying)迅(xun)速剖腹(fu)取(qu)出死(si)胎(tai)，視患(huan)者狀態、裂傷(shang)部位情(qing)況(kuang)、感染程度和患(huan)者是否(fou)已(yi)有(you)子(zi)(zi)女等綜合(he)考(kao)慮，若子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)裂口(kou)較(jiao)易縫(feng)合(he)、感染不(bu)嚴重、患(huan)者狀態欠佳時，可作裂口(kou)修(xiu)補(bu)縫(feng)合(he)，有(you)子(zi)(zi)女者結扎輸卵管(guan)，無子(zi)(zi)女者保留其(qi)生育(yu)功能。否(fou)則可行(xing)子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)全(quan)切除(chu)或次全(quan)切除(chu)。子(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)下段破(po)(po)裂者，應(ying)(ying)注(zhu)意檢(jian)(jian)查膀胱、輸尿管(guan)、宮(gong)(gong)(gong)(gong)(gong)(gong)頸及陰道，若有(you)損傷(shang)，應(ying)(ying)及時修(xiu)補(bu)。

子宮(gong)破裂(lie)多伴有(you)嚴(yan)重的出(chu)血及(ji)存(cun)在感(gan)染，術(shu)前(qian)應輸血、輸液，給予乳酸(suan)鈉，積極(ji)進行抗(kang)休克治療，術(shu)中、術(shu)后應用較(jiao)大劑量廣譜抗(kang)生素控制感(gan)染。