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子宮(gong)(gong)破裂是指子宮(gong)(gong)體部(bu)或子宮(gong)(gong)下(xia)段于(yu)分(fen)娩期(qi)或妊娠期(qi)發(fa)(fa)生(sheng)裂傷，為產科(ke)嚴重并發(fa)(fa)癥，威脅母(mu)兒(er)生(sheng)命。主要死(si)于(yu)出血、感染休克。隨著產科(ke)質量的提(ti)高，城(cheng)鄉婦(fu)幼衛生(sheng)保健(jian)網的建(jian)立和逐步健(jian)全發(fa)(fa)生(sheng)率顯著下(xia)降。城(cheng)市醫院已很少見到(dao)，而農(nong)村偏遠地區時有發(fa)(fa)生(sheng)。子宮(gong)(gong)破裂絕大多(duo)數(shu)發(fa)(fa)生(sheng)于(yu)妊娠28周之后，分(fen)娩期(qi)最多(duo)見，目前發(fa)(fa)生(sheng)率控制(zhi)在1‰以下(xia)，產婦(fu)病死(si)率為5%，嬰兒(er)病死(si)率高達(da)50%～75%甚至更高。

病因

子(zi)(zi)宮(gong)(gong)破(po)裂(lie)多發生于(yu)難(nan)產、高齡多產和子(zi)(zi)宮(gong)(gong)曾(ceng)經手術或有過(guo)損傷(shang)的產婦。根據破(po)裂(lie)的原(yuan)因，可分(fen)為無瘢痕(hen)子(zi)(zi)宮(gong)(gong)破(po)裂(lie)和瘢痕(hen)子(zi)(zi)宮(gong)(gong)破(po)裂(lie)。

1.梗阻性難產

明顯的(de)骨盆(pen)(pen)狹窄頭盆(pen)(pen)不稱，軟產(chan)道(dao)畸(ji)形盆(pen)(pen)腔腫瘤(liu)和異常(chang)(chang)胎位等(deng)因素阻礙胎先露(lu)下降，子(zi)宮為(wei)克服阻力(li)加強收縮子(zi)宮下段(duan)被迫拉長變(bian)薄最終發(fa)生子(zi)宮破(po)裂。此種子(zi)宮破(po)裂為(wei)子(zi)宮破(po)裂中最常(chang)(chang)見類型，破(po)裂處多發(fa)生于子(zi)宮下段(duan)。

2.子(zi)宮瘢痕(hen)破裂

造成子(zi)(zi)宮(gong)(gong)(gong)(gong)瘢(ban)痕的(de)(de)(de)原因(yin)主要有剖宮(gong)(gong)(gong)(gong)產(chan)(chan)術，子(zi)(zi)宮(gong)(gong)(gong)(gong)肌瘤剝除術，子(zi)(zi)宮(gong)(gong)(gong)(gong)破(po)裂(lie)(lie)或穿孔(kong)修(xiu)補術，子(zi)(zi)宮(gong)(gong)(gong)(gong)畸形(xing)矯形(xing)術等(deng)；造成破(po)裂(lie)(lie)的(de)(de)(de)原因(yin)是(shi)妊娠子(zi)(zi)宮(gong)(gong)(gong)(gong)的(de)(de)(de)機械性(xing)牽拉導致瘢(ban)痕處破(po)裂(lie)(lie)或者(zhe)子(zi)(zi)宮(gong)(gong)(gong)(gong)瘢(ban)痕處內膜受損，胎盤植入，穿透性(xing)胎盤導致子(zi)(zi)宮(gong)(gong)(gong)(gong)自發破(po)裂(lie)(lie)。近些年(nian)剖宮(gong)(gong)(gong)(gong)產(chan)(chan)術迅速增加子(zi)(zi)宮(gong)(gong)(gong)(gong)體(ti)部(bu)縱切口(kou)(kou)剖宮(gong)(gong)(gong)(gong)產(chan)(chan)再次妊娠容易并(bing)發子(zi)(zi)宮(gong)(gong)(gong)(gong)破(po)裂(lie)(lie)，分析原因(yin)除宮(gong)(gong)(gong)(gong)體(ti)部(bu)縱切口(kou)(kou)和下段橫切口(kou)(kou)解(jie)剖性(xing)質(zhi)不(bu)同(tong)外，還要考慮(lv)感(gan)染因(yin)素(su)的(de)(de)(de)作(zuo)用，因(yin)為目前采用子(zi)(zi)宮(gong)(gong)(gong)(gong)體(ti)部(bu)縱切口(kou)(kou)剖宮(gong)(gong)(gong)(gong)產(chan)(chan)的(de)(de)(de)患(huan)者(zhe)通常經過了漫(man)長的(de)(de)(de)產(chan)(chan)程，多(duo)次陰道(dao)檢查(cha)，感(gan)染幾率增加。

3.濫用宮縮劑

此處的(de)宮(gong)(gong)縮(suo)劑應(ying)該包括各(ge)種刺激子宮(gong)(gong)收縮(suo)的(de)物質(zhi)包括最常用的(de)縮(suo)宮(gong)(gong)素（催產(chan)素）和近些(xie)年才應(ying)用的(de)米索前列醇(chun)，報(bao)道(dao)的(de)米索前列醇(chun)導致子宮(gong)(gong)破裂的(de)病(bing)例越來越多。原(yuan)因主要包括藥物劑量(liang)過(guo)(guo)大或給(gei)藥速度(du)過(guo)(guo)快子宮(gong)(gong)頸不成熟，胎(tai)位不正梗阻性難(nan)產(chan)，用藥期間對(dui)產(chan)程觀察不仔細等。

4.陰(yin)道助產手術損傷

宮口(kou)未開全，強(qiang)行產鉗(qian)術(shu)(shu)或臀牽引(yin)術(shu)(shu)導致子(zi)宮頸嚴重裂傷并上延到子(zi)宮下段。忽(hu)略性橫位(wei)內倒轉(zhuan)術(shu)(shu)，毀胎術(shu)(shu)部分人工(gong)剝離胎盤術(shu)(shu)等由于操作不當(dang)，均可以造成子(zi)宮破(po)裂。

5.子宮畸形和子宮壁發(fa)育不良

最常見的是雙角子宮或單角子宮。

6.子宮本(ben)身病變

多(duo)產(chan)(chan)婦(fu)多(duo)次刮(gua)宮(gong)史(shi)、感(gan)染性流產(chan)(chan)史(shi)宮(gong)腔感(gan)染史(shi)、人工剝離胎盤(pan)史(shi)、葡萄胎史(shi)等(deng)。由于上述因(yin)素導致子(zi)宮(gong)內膜乃至肌壁受損(sun)，妊娠后(hou)胎盤(pan)植(zhi)入或穿透，最終(zhong)導致子(zi)宮(gong)破裂(lie)。

臨床表現

1.出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)子(zi)宮(gong)(gong)(gong)(gong)破(po)裂(lie)通(tong)(tong)常(chang)(chang)表(biao)(biao)現(xian)為(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)，出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)分為(wei)內(nei)(nei)(nei)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)、外出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)或(huo)(huo)混(hun)合出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)。內(nei)(nei)(nei)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)指(zhi)(zhi)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)積聚于闊韌(ren)帶內(nei)(nei)(nei)或(huo)(huo)腹腔內(nei)(nei)(nei)，導致闊韌(ren)帶血(xue)(xue)(xue)(xue)腫(zhong)或(huo)(huo)腹腔積血(xue)(xue)(xue)(xue)；外出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)指(zhi)(zhi)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)自陰道(dao)(dao)排(pai)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)。子(zi)宮(gong)(gong)(gong)(gong)破(po)裂(lie)的(de)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)部位通(tong)(tong)常(chang)(chang)包括子(zi)宮(gong)(gong)(gong)(gong)及軟(ruan)(ruan)產道(dao)(dao)破(po)裂(lie)口和胎盤剝(bo)(bo)(bo)離(li)面(mian)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)，子(zi)宮(gong)(gong)(gong)(gong)和軟(ruan)(ruan)產道(dao)(dao)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)通(tong)(tong)常(chang)(chang)需要(yao)損(sun)傷所在(zai)部位的(de)大血(xue)(xue)(xue)(xue)管，如果軟(ruan)(ruan)產道(dao)(dao)損(sun)傷未傷及大血(xue)(xue)(xue)(xue)管，通(tong)(tong)常(chang)(chang)不表(biao)(biao)現(xian)為(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)或(huo)(huo)活動性出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)。胎盤剝(bo)(bo)(bo)離(li)面(mian)的(de)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)與胎盤剝(bo)(bo)(bo)離(li)的(de)程度和子(zi)宮(gong)(gong)(gong)(gong)收縮(suo)(suo)強度有關，如果胎盤未完全剝(bo)(bo)(bo)離(li)或(huo)(huo)剝(bo)(bo)(bo)離(li)后未排(pai)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)(gong)(gong)腔，影響子(zi)宮(gong)(gong)(gong)(gong)收縮(suo)(suo)，表(biao)(biao)現(xian)為(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)；反之如果胎盤完全剝(bo)(bo)(bo)離(li)并已經(jing)排(pai)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)(gong)(gong)腔，子(zi)宮(gong)(gong)(gong)(gong)收縮(suo)(suo)很好，則胎盤剝(bo)(bo)(bo)離(li)面(mian)少(shao)量活動性出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)。上述出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)指(zhi)(zhi)術前出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)，術后亦(yi)可以出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)，原因主(zhu)要(yao)為(wei)闊韌(ren)帶血(xue)(xue)(xue)(xue)腫(zhong)清(qing)除后創(chuang)面(mian)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)或(huo)(huo)DIC出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)，或(huo)(huo)保守治療子(zi)宮(gong)(gong)(gong)(gong)出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)。出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)除引起失血(xue)(xue)(xue)(xue)性休克外，還由于產婦高凝狀態，出(chu)(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)過多，休克時間過長，出(chu)(chu)(chu)(chu)(chu)(chu)(chu)現(xian)DIC。

2.感(gan)(gan)染(ran)子(zi)(zi)宮(gong)(gong)(gong)破裂后(hou)容(rong)(rong)易出(chu)現感(gan)(gan)染(ran)的(de)(de)(de)(de)部位主(zhu)(zhu)要(yao)有(you)(you)(you)盆(pen)(pen)腔(qiang)(qiang)(qiang)、腹(fu)腔(qiang)(qiang)(qiang)、盆(pen)(pen)腔(qiang)(qiang)(qiang)腹(fu)膜后(hou)和軟(ruan)產道(dao)(dao)。造成(cheng)感(gan)(gan)染(ran)的(de)(de)(de)(de)原因(yin)主(zhu)(zhu)要(yao)有(you)(you)(you)：盆(pen)(pen)腹(fu)腔(qiang)(qiang)(qiang)或(huo)(huo)闊韌(ren)帶內(nei)與子(zi)(zi)宮(gong)(gong)(gong)腔(qiang)(qiang)(qiang)和陰(yin)道(dao)(dao)相(xiang)通，相(xiang)通后(hou)有(you)(you)(you)細菌進入；子(zi)(zi)宮(gong)(gong)(gong)破裂后(hou)大出(chu)血，嚴(yan)重貧血或(huo)(huo)DIC，抵(di)抗力下降容(rong)(rong)易感(gan)(gan)染(ran)；腹(fu)腔(qiang)(qiang)(qiang)或(huo)(huo)盆(pen)(pen)腔(qiang)(qiang)(qiang)內(nei)的(de)(de)(de)(de)積血或(huo)(huo)腹(fu)膜外(wai)的(de)(de)(de)(de)積血，容(rong)(rong)易感(gan)(gan)染(ran)；子(zi)(zi)宮(gong)(gong)(gong)破裂后(hou)的(de)(de)(de)(de)子(zi)(zi)宮(gong)(gong)(gong)切除或(huo)(huo)修補，均于有(you)(you)(you)菌條件下進行；子(zi)(zi)宮(gong)(gong)(gong)破裂后(hou)診斷期間(jian)可能有(you)(you)(you)較(jiao)多的(de)(de)(de)(de)陰(yin)道(dao)(dao)操作(zuo)；時間(jian)較(jiao)久的(de)(de)(de)(de)子(zi)(zi)宮(gong)(gong)(gong)破裂更容(rong)(rong)易導(dao)致(zhi)多部位的(de)(de)(de)(de)各種感(gan)(gan)染(ran)。另(ling)外(wai)值得提(ti)出(chu)的(de)(de)(de)(de)感(gan)(gan)染(ran)是呼吸道(dao)(dao)感(gan)(gan)染(ran)，引起感(gan)(gan)染(ran)的(de)(de)(de)(de)因(yin)素(su)很多，休(xiu)克時間(jian)過長正常呼吸道(dao)(dao)的(de)(de)(de)(de)排痰和防御機制受損與之有(you)(you)(you)關，同(tong)時不能除外(wai)誤吸等因(yin)素(su)。

3.導致產道及其他腹腔和(he)(he)盆腔器官(guan)組織損(sun)傷(shang)(shang)子(zi)宮(gong)(gong)破(po)(po)裂的(de)(de)損(sun)傷(shang)(shang)包(bao)括手(shou)(shou)術干預(yu)前和(he)(he)手(shou)(shou)術干預(yu)后的(de)(de)損(sun)傷(shang)(shang)。手(shou)(shou)術干預(yu)前的(de)(de)損(sun)傷(shang)(shang)包(bao)括子(zi)宮(gong)(gong)體、子(zi)宮(gong)(gong)下段、子(zi)宮(gong)(gong)頸(jing)和(he)(he)陰(yin)道的(de)(de)各種(zhong)損(sun)傷(shang)(shang)，同時也可能有原(yuan)發的(de)(de)由于胎(tai)頭壓迫(po)造成的(de)(de)膀胱損(sun)傷(shang)(shang)。子(zi)宮(gong)(gong)破(po)(po)裂患者診斷過(guo)(guo)(guo)程和(he)(he)手(shou)(shou)術治(zhi)療過(guo)(guo)(guo)程中(zhong)的(de)(de)損(sun)傷(shang)(shang)很多，有時甚至超過(guo)(guo)(guo)原(yuan)發損(sun)傷(shang)(shang)。診斷過(guo)(guo)(guo)程中(zhong)過(guo)(guo)(guo)多的(de)(de)不必要的(de)(de)陰(yin)道操作或檢查(cha)導致產道損(sun)傷(shang)(shang)加重(zhong)；開腹探查(cha)術，清理積血或清理胎(tai)兒、胎(tai)盤和(he)(he)胎(tai)膜，操作不當(dang)，導致腸道或大網膜損(sun)傷(shang)(shang)；清理闊韌帶(dai)血腫，引起盆底血管輸尿管和(he)(he)膀胱損(sun)傷(shang)(shang)；子(zi)宮(gong)(gong)破(po)(po)裂時間(jian)過(guo)(guo)(guo)長，對腹腔器官(guan)的(de)(de)損(sun)傷(shang)(shang)更重(zhong)。

4.對(dui)胎(tai)兒的影(ying)(ying)響子宮(gong)破裂后(hou)對(dui)胎(tai)兒的影(ying)(ying)響主要是不同(tong)時(shi)間和不同(tong)程(cheng)度(du)的出血造成的損傷，多(duo)數胎(tai)兒死亡。存活(huo)胎(tai)兒的圍(wei)生兒發(fa)(fa)病率和病死率明顯增高，遠(yuan)期并(bing)發(fa)(fa)癥也明顯增高。

診斷

診(zhen)(zhen)斷(duan)完全(quan)性子宮破(po)裂一(yi)般困(kun)難不(bu)大，根據病史、分娩經過、臨(lin)床表(biao)現及體(ti)征(zheng)可作出診(zhen)(zhen)斷(duan)。不(bu)完全(quan)性子宮破(po)裂只有在嚴密觀察下方(fang)能發現。個別晚期妊娠破(po)裂者，只有出現子宮破(po)裂的癥狀(zhuang)和體(ti)征(zheng)時方(fang)能確(que)診(zhen)(zhen)。

個別難產病(bing)例經多次陰(yin)(yin)道(dao)(dao)檢查，可能(neng)感染出現腹(fu)膜炎而表(biao)現為類似(si)子(zi)宮破(po)(po)裂(lie)癥象。陰(yin)(yin)道(dao)(dao)檢查時(shi)由(you)于胎先露部仍高、子(zi)宮下(xia)段(duan)菲(fei)薄(bo)，雙(shuang)(shuang)合診時(shi)雙(shuang)(shuang)手指相觸猶如只隔腹(fu)壁(bi)，有時(shi)容易(yi)誤(wu)診為子(zi)宮破(po)(po)裂(lie)，這種情況胎體(ti)(ti)不會進入腹(fu)腔(qiang)，而妊娠子(zi)宮也不會縮小(xiao)而位于胎體(ti)(ti)旁側。

治療

發現先兆子(zi)(zi)(zi)宮(gong)(gong)(gong)破裂(lie)，必須立即(ji)采取(qu)(qu)有(you)效措施(shi)抑(yi)制子(zi)(zi)(zi)宮(gong)(gong)(gong)收縮(suo)，如給乙醚全麻、肌肉注(zhu)射(she)度(du)冷丁100mg等，以緩解子(zi)(zi)(zi)宮(gong)(gong)(gong)破裂(lie)的進程。最好能盡快行剖宮(gong)(gong)(gong)產(chan)術，術中注(zhu)意檢查(cha)子(zi)(zi)(zi)宮(gong)(gong)(gong)是(shi)否(fou)已(yi)有(you)破裂(lie)。子(zi)(zi)(zi)宮(gong)(gong)(gong)破裂(lie)胎(tai)兒未娩出者(zhe)，即(ji)使(shi)(shi)死胎(tai)也不應經陰道(dao)先娩出胎(tai)兒，這會使(shi)(shi)裂(lie)口擴大，增加出血，促使(shi)(shi)感(gan)染(ran)擴散，應迅速剖腹取(qu)(qu)出死胎(tai)，視(shi)患(huan)者(zhe)狀(zhuang)態(tai)、裂(lie)傷部位情況、感(gan)染(ran)程度(du)和(he)患(huan)者(zhe)是(shi)否(fou)已(yi)有(you)子(zi)(zi)(zi)女等綜合(he)(he)考慮(lv)，若(ruo)子(zi)(zi)(zi)宮(gong)(gong)(gong)裂(lie)口較易縫合(he)(he)、感(gan)染(ran)不嚴重、患(huan)者(zhe)狀(zhuang)態(tai)欠佳(jia)時(shi)，可(ke)作裂(lie)口修(xiu)補(bu)(bu)縫合(he)(he)，有(you)子(zi)(zi)(zi)女者(zhe)結扎輸(shu)卵管，無子(zi)(zi)(zi)女者(zhe)保(bao)留其生育功能。否(fou)則可(ke)行子(zi)(zi)(zi)宮(gong)(gong)(gong)全切(qie)除或次全切(qie)除。子(zi)(zi)(zi)宮(gong)(gong)(gong)下段破裂(lie)者(zhe)，應注(zhu)意檢查(cha)膀胱、輸(shu)尿管、宮(gong)(gong)(gong)頸及(ji)陰道(dao)，若(ruo)有(you)損傷，應及(ji)時(shi)修(xiu)補(bu)(bu)。

子宮破裂多伴有嚴重的(de)出(chu)血(xue)及存在感染，術前(qian)應輸血(xue)、輸液，給予乳酸鈉，積極進(jin)行抗休克治療，術中、術后應用(yong)較大劑(ji)量廣譜抗生素控制感染。