胎兒娩(mian)出(chu)(chu)后(hou)(hou)(hou)(hou)24小(xiao)時內出(chu)(chu)血(xue)(xue)(xue)量(liang)超過500mL者稱為產(chan)(chan)后(hou)(hou)(hou)(hou)出(chu)(chu)血(xue)(xue)(xue),80%發(fa)生在產(chan)(chan)后(hou)(hou)(hou)(hou)2小(xiao)時內。晚期產(chan)(chan)后(hou)(hou)(hou)(hou)出(chu)(chu)血(xue)(xue)(xue)是指(zhi)分娩(mian)24小(xiao)時以后(hou)(hou)(hou)(hou),在產(chan)(chan)褥期內發(fa)生的(de)(de)子宮大量(liang)出(chu)(chu)血(xue)(xue)(xue),多見于(yu)產(chan)(chan)后(hou)(hou)(hou)(hou)1~2周。產(chan)(chan)后(hou)(hou)(hou)(hou)出(chu)(chu)血(xue)(xue)(xue)是分娩(mian)期嚴重(zhong)的(de)(de)并(bing)發(fa)癥,是導致孕產(chan)(chan)婦死亡的(de)(de)四(si)大原因(yin)之一(yi)。在我國產(chan)(chan)后(hou)(hou)(hou)(hou)出(chu)(chu)血(xue)(xue)(xue)近年來一(yi)直(zhi)是引起孕產(chan)(chan)婦死亡的(de)(de)第一(yi)位原因(yin),特(te)別是在邊遠落后(hou)(hou)(hou)(hou)地區這一(yi)情況更加(jia)突(tu)出(chu)(chu)。產(chan)(chan)后(hou)(hou)(hou)(hou)出(chu)(chu)血(xue)(xue)(xue)的(de)(de)發(fa)病(bing)率占分娩(mian)總數(shu)的(de)(de)2%~3%,由于(yu)測量(liang)和(he)收集出(chu)(chu)血(xue)(xue)(xue)量(liang)的(de)(de)主觀因(yin)素較大,實(shi)際(ji)發(fa)病(bing)率更高(gao)。
產(chan)后出血的發(fa)病原(yuan)(yuan)因(yin)(yin)依次為(wei)子宮(gong)收縮(suo)乏(fa)力、軟產(chan)道裂傷(shang)、胎(tai)盤因(yin)(yin)素(su)及凝(ning)血功(gong)能(neng)障(zhang)礙(ai)。四(si)大原(yuan)(yuan)因(yin)(yin)可以(yi)(yi)合并存在(zai),也可以(yi)(yi)互為(wei)因(yin)(yin)果。
1.宮縮乏力
是(shi)產(chan)后(hou)出血(xue)(xue)最常見(jian)的(de)原(yuan)因(yin),占(zhan)70%。子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖(xian)維(wei)(wei)的(de)解剖分布是(shi)內環、外縱(zong)、中交(jiao)織。正常情況(kuang)下(xia),胎兒(er)娩出后(hou),不同(tong)方向走行的(de)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖(xian)維(wei)(wei)收(shou)縮(suo)(suo)對(dui)(dui)肌(ji)(ji)束(shu)間(jian)的(de)血(xue)(xue)管起(qi)到有(you)(you)效的(de)壓(ya)迫作用(yong)。如(ru)果(guo)出現子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖(xian)維(wei)(wei)收(shou)縮(suo)(suo)無力(li)(li)即宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)縮(suo)(suo)乏(fa)(fa)力(li)(li)則(ze)失(shi)去對(dui)(dui)血(xue)(xue)管的(de)有(you)(you)效壓(ya)迫作用(yong)而(er)發(fa)生產(chan)后(hou)出血(xue)(xue)。常見(jian)的(de)因(yin)素有(you)(you):①全(quan)身因(yin)素:產(chan)婦因(yin)對(dui)(dui)分娩過度(du)(du)恐懼(ju)而(er)極度(du)(du)緊張,尤其對(dui)(dui)陰道分娩缺(que)乏(fa)(fa)足夠(gou)信心(xin)則(ze)可(ke)以引(yin)(yin)起(qi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)縮(suo)(suo)不協調(diao)或(huo)(huo)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)縮(suo)(suo)乏(fa)(fa)力(li)(li)。此種情況(kuang)在臨產(chan)后(hou)可(ke)能(neng)需要(yao)使用(yong)鎮靜劑及麻醉劑等將引(yin)(yin)增加產(chan)后(hou)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)縮(suo)(suo)乏(fa)(fa)力(li)(li)而(er)引(yin)(yin)起(qi)產(chan)后(hou)出血(xue)(xue);②產(chan)科因(yin)素:產(chan)程過長造成(cheng)產(chan)婦極度(du)(du)疲勞及全(quan)身衰竭,或(huo)(huo)產(chan)程過快,均可(ke)引(yin)(yin)起(qi)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)收(shou)縮(suo)(suo)乏(fa)(fa)力(li)(li);羊水(shui)過多(duo)、巨大兒(er)及多(duo)胎妊(ren)娠(shen)使子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖(xian)維(wei)(wei)過度(du)(du)伸(shen)展,產(chan)后(hou)肌(ji)(ji)纖(xian)維(wei)(wei)縮(suo)(suo)復能(neng)力(li)(li)差,多(duo)次分娩而(er)致子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖(xian)維(wei)(wei)受損,均可(ke)引(yin)(yin)起(qi)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)收(shou)縮(suo)(suo)乏(fa)(fa)力(li)(li)。子(zi)(zi)(zi)(zi)癇前期(重(zhong)度(du)(du))、嚴重(zhong)貧血(xue)(xue)、宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)腔(qiang)感染等產(chan)科并(bing)發(fa)癥及合并(bing)癥使子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖(xian)維(wei)(wei)水(shui)腫而(er)引(yin)(yin)起(qi)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)收(shou)縮(suo)(suo)乏(fa)(fa)力(li)(li);③子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)因(yin)素:子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)纖(xian)維(wei)(wei)發(fa)育不良,如(ru)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)畸形或(huo)(huo)子(zi)(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)(gong)肌(ji)(ji)瘤等。
2.胎盤因素
占產后(hou)(hou)出血原因(yin)(yin)的20%左右。根據胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)剝離(li)情況,胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)滯留、胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)粘連及部分胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)和/或胎(tai)(tai)膜殘(can)留均可(ke)(ke)影(ying)響(xiang)宮(gong)(gong)(gong)縮(suo)(suo)(suo),造(zao)成(cheng)產后(hou)(hou)出血。胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)滯留:胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)在(zai)(zai)胎(tai)(tai)兒娩出后(hou)(hou)30分鐘尚(shang)未排出者(zhe)稱(cheng)胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)滯留。可(ke)(ke)能與宮(gong)(gong)(gong)縮(suo)(suo)(suo)劑使(shi)用不當或粗暴按(an)摩(mo)子宮(gong)(gong)(gong)等,刺激產生(sheng)痙攣性(xing)宮(gong)(gong)(gong)縮(suo)(suo)(suo),在(zai)(zai)子宮(gong)(gong)(gong)上(shang)、下段交界處或宮(gong)(gong)(gong)頸外口形成(cheng)收縮(suo)(suo)(suo)環,將(jiang)剝離(li)的胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)嵌閉于宮(gong)(gong)(gong)腔(qiang)(qiang)內引(yin)起胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)滯留;宮(gong)(gong)(gong)縮(suo)(suo)(suo)乏力(li)或因(yin)(yin)膀胱充盈壓迫(po)子宮(gong)(gong)(gong)下段,也可(ke)(ke)以(yi)致(zhi)胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)雖已剝離(li)而(er)(er)滯留于宮(gong)(gong)(gong)腔(qiang)(qiang)。如胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)滯留妨礙正(zheng)常宮(gong)(gong)(gong)縮(suo)(suo)(suo)則引(yin)起產后(hou)(hou)出血,且血塊多聚于子宮(gong)(gong)(gong)腔(qiang)(qiang)內,進而(er)(er)引(yin)起宮(gong)(gong)(gong)腔(qiang)(qiang)增大致(zhi)宮(gong)(gong)(gong)縮(suo)(suo)(suo)乏力(li),如果不及時處理則形成(cheng)惡性(xing)循環并導致(zhi)嚴重后(hou)(hou)果;胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)粘連發生(sheng)的原因(yin)(yin)主要與操作手(shou)法(fa)不當有(you)關。如胎(tai)(tai)兒娩出后(hou)(hou)過(guo)早或過(guo)重按(an)摩(mo)子宮(gong)(gong)(gong),干擾了子宮(gong)(gong)(gong)的正(zheng)常收縮(suo)(suo)(suo)和縮(suo)(suo)(suo)復,致(zhi)胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)部分剝離(li),剝離(li)面血竇(dou)開放(fang)而(er)(er)出血過(guo)多;也可(ke)(ke)由于既往多次刮宮(gong)(gong)(gong)或宮(gong)(gong)(gong)腔(qiang)(qiang)操作使(shi),使(shi)子宮(gong)(gong)(gong)內膜損傷而(er)(er)易引(yin)起胎(tai)(tai)盤(pan)(pan)(pan)(pan)(pan)粘連或植入(ru)。
3.軟產道裂傷
軟產道裂傷(shang)包括會陰、陰道及宮(gong)頸及子(zi)宮(gong)下段裂傷(shang)。常見(jian)因(yin)素:外陰組織(zhi)彈性(xing)差(cha),外陰、陰道炎癥改(gai)變;急產、產力過強,巨大兒;陰道手術助(zhu)產;軟產道檢(jian)查不仔(zi)細,遺(yi)漏出血(xue)點。縫合、止血(xue)不徹底等。
4.凝(ning)血功能障礙
常見原因有胎(tai)盤早剝、羊水栓塞、死胎(tai)及(ji)妊娠期急(ji)性脂肪肝等引起(qi)的凝血(xue)功能障礙(ai)(ai),少數由原發性血(xue)液(ye)疾病(bing)如血(xue)小板減少癥(zheng)(zheng)、白血(xue)病(bing)、再生障礙(ai)(ai)性貧(pin)血(xue)或(huo)重癥(zheng)(zheng)病(bing)毒性肝炎等引起(qi)。
5.子宮內翻
少(shao)見,多因第(di)三產程(cheng)處理不當造成,如(ru)用力(li)壓迫宮底或猛力(li)牽引臍帶等。
產(chan)后(hou)出(chu)血多發生在胎(tai)(tai)兒娩出(chu)后(hou)2小時內,可(ke)(ke)發生在胎(tai)(tai)盤娩出(chu)之前、之后(hou)或前后(hou)兼有(you)。陰道流血可(ke)(ke)為短期內大出(chu)血,亦可(ke)(ke)長時間持(chi)續(xu)少量出(chu)血。一般為顯性,但也(ye)有(you)隱(yin)性出(chu)血者(zhe)。
臨床表(biao)現(xian)主要為陰(yin)道流(liu)血(xue)(xue)(xue)、失血(xue)(xue)(xue)性(xing)休(xiu)克(ke)(ke)、繼發(fa)性(xing)貧血(xue)(xue)(xue),若失血(xue)(xue)(xue)過多(duo)可并發(fa)彌(mi)散性(xing)血(xue)(xue)(xue)管內凝血(xue)(xue)(xue)。癥狀的(de)輕重視失血(xue)(xue)(xue)量、速(su)(su)度(du)及(ji)合并貧血(xue)(xue)(xue)與否而不同。短期內大出血(xue)(xue)(xue),可迅速(su)(su)出現(xian)休(xiu)克(ke)(ke)。需(xu)要注意在(zai)休(xiu)克(ke)(ke)早(zao)期由于(yu)機體(ti)內的(de)代償機制(zhi)患者生命體(ti)征如(ru)脈搏(bo)、血(xue)(xue)(xue)壓等可能均在(zai)正常(chang)范圍(wei)內,但此(ci)時仍需(xu)要嚴密監(jian)測,對風(feng)險(xian)因素進行早(zao)期識別,評估出血(xue)(xue)(xue)量并進行積極救治。臨床中往往存在(zai)當(dang)失血(xue)(xue)(xue)到一定程度(du)出現(xian)失代償表(biao)現(xian)如(ru)脈搏(bo)增(zeng)快、血(xue)(xue)(xue)壓下降才引起重視,這樣(yang)失去了最(zui)佳(jia)救治時機。此(ci)外,如(ru)產婦(fu)原已(yi)患貧血(xue)(xue)(xue),即使出血(xue)(xue)(xue)不多(duo),亦可發(fa)生休(xiu)克(ke)(ke),且(qie)不易(yi)糾正。因此(ci),對每個(ge)產婦(fu)必須(xu)作全(quan)面仔細的(de)觀察和分析,以(yi)免(mian)延誤搶救時機。
診(zhen)(zhen)斷產后出(chu)(chu)血(xue)(xue)(xue)的(de)(de)關鍵在于對失(shi)血(xue)(xue)(xue)量(liang)(liang)(liang)正確的(de)(de)測量(liang)(liang)(liang)和(he)估計(ji)。臨床上常用的(de)(de)估計(ji)失(shi)血(xue)(xue)(xue)量(liang)(liang)(liang)的(de)(de)方法(fa)有:容積法(fa);稱重(zhong)(zhong)法(fa);面(mian)積法(fa);休克指數等。出(chu)(chu)血(xue)(xue)(xue)量(liang)(liang)(liang)測量(liang)(liang)(liang)不準確將喪(sang)失(shi)產后出(chu)(chu)血(xue)(xue)(xue)的(de)(de)最佳搶救時(shi)機。突然大量(liang)(liang)(liang)的(de)(de)產后出(chu)(chu)血(xue)(xue)(xue)易得到重(zhong)(zhong)視(shi)和(he)早期(qi)診(zhen)(zhen)斷,而緩慢的(de)(de)持續(xu)少量(liang)(liang)(liang)出(chu)(chu)血(xue)(xue)(xue)(如軟產道裂傷縫合時(shi)間長)和(he)未被(bei)發現的(de)(de)血(xue)(xue)(xue)腫常常是延誤診(zhen)(zhen)治的(de)(de)重(zhong)(zhong)要(yao)原(yuan)因。
根據陰道(dao)出(chu)血時間、數量和胎(tai)兒、胎(tai)盤(pan)娩出(chu)的關系,可初步判斷造成產后出(chu)血的原(yuan)因(yin)(yin)。幾種原(yuan)因(yin)(yin)常常互(hu)為因(yin)(yin)果。
產后出血的處理原則為針(zhen)對病因,迅速止血,補充血容量(liang)、糾正(zheng)休克及(ji)防治(zhi)感染。
1.止血
子宮(gong)收縮(suo)乏力性出血,加強宮(gong)縮(suo)是(shi)最迅速有效的(de)止血方(fang)法。
(1)去除引起宮縮乏力的原因 改善全身狀況(kuang),導尿緩解膀胱過(guo)度充(chong)盈。
(2)按(an)(an)(an)(an)(an)(an)摩(mo)子(zi)(zi)宮 腹(fu)部(bu)按(an)(an)(an)(an)(an)(an)摩(mo)子(zi)(zi)宮是最簡單有效(xiao)的(de)促使子(zi)(zi)宮收縮(suo)以減少出血的(de)方法。出血停止后,還須間歇(xie)性(xing)均(jun)勻(yun)節律的(de)按(an)(an)(an)(an)(an)(an)摩(mo),以防子(zi)(zi)宮再(zai)度(du)松(song)弛(chi)出血。必(bi)要時(shi)需要雙手(shou)按(an)(an)(an)(an)(an)(an)摩(mo)子(zi)(zi)宮,可置一(yi)手(shou)于陰(yin)道前穹(qiong)隆,頂住子(zi)(zi)宮前壁(bi),另有一(yi)手(shou)在腹(fu)部(bu)按(an)(an)(an)(an)(an)(an)壓子(zi)(zi)宮后壁(bi),同(tong)時(shi)進行按(an)(an)(an)(an)(an)(an)摩(mo)。按(an)(an)(an)(an)(an)(an)摩(mo)手(shou)法應輕柔、有節奏(zou)地進行,切忌持續長時(shi)間過度(du)用力按(an)(an)(an)(an)(an)(an)摩(mo)而損(sun)傷(shang)子(zi)(zi)宮肌肉而導致(zhi)無效(xiao)。
(3)宮(gong)(gong)縮(suo)劑①縮(suo)宮(gong)(gong)素為預防和(he)治療產后出血(xue)的一(yi)線藥(yao)物(wu)。給(gei)藥(yao)速度應(ying)根據患者(zhe)(zhe)子(zi)宮(gong)(gong)收縮(suo)和(he)出血(xue)情(qing)況調整。靜(jing)脈(mo)滴注(zhu)能立即起效,但半(ban)衰期短,故需持(chi)續靜(jing)脈(mo)滴注(zhu)。如果催產素受體(ti)過(guo)飽和(he)后不發(fa)揮(hui)作(zuo)用(yong),因此24小時(shi)內(nei)總(zong)量應(ying)控(kong)制(zhi)在60U。②卡(ka)前(qian)(qian)列素氨丁三醇為前(qian)(qian)列腺素F2α衍生物(wu)(15-甲基(ji)PGF2α),引起全子(zi)宮(gong)(gong)協調有力的收縮(suo)。哮喘、心(xin)臟病(bing)和(he)青光眼患者(zhe)(zhe)禁(jin)用(yong),高血(xue)壓(ya)患者(zhe)(zhe)慎用(yong)。常(chang)見(jian)副反應(ying)為惡心(xin)、嘔(ou)吐(tu),腹瀉(xie)等。③米(mi)索(suo)前(qian)(qian)列醇系前(qian)(qian)列腺素PGE1的衍生物(wu),引起全子(zi)宮(gong)(gong)有力收縮(suo),但米(mi)索(suo)前(qian)(qian)列醇副反應(ying)較大,惡心(xin)、嘔(ou)吐(tu)、腹瀉(xie)、寒戰和(he)體(ti)溫升高較常(chang)見(jian);高血(xue)壓(ya)、活動(dong)性心(xin)肝腎(shen)(shen)病(bing)及腎(shen)(shen)上腺皮質功能不全者(zhe)(zhe)慎用(yong),青光眼、哮喘及過(guo)敏體(ti)質者(zhe)(zhe)禁(jin)用(yong)。
(4)宮腔(qiang)(qiang)填塞 以(yi)上(shang)治療(liao)無效時,為(wei)保留(liu)子宮或為(wei)減少術前失血(xue),可行(xing)宮腔(qiang)(qiang)填塞紗布壓迫(po)止(zhi)血(xue)。注意(yi)自宮底(di)及兩側角向宮腔(qiang)(qiang)填塞,要塞緊填滿,不留(liu)空隙(xi),以(yi)達到壓迫(po)止(zhi)血(xue)的(de)目(mu)的(de)。如出血(xue)停止(zhi),紗條可于24~48小(xiao)時后取出。填塞后需用(yong)抗生(sheng)素預防感染,取出前應注射宮縮(suo)劑。
(5)B-Lynch縫合(he) 適(shi)(shi)用于宮縮乏力(li)、胎盤(pan)因素(su)和(he)凝血功能(neng)異(yi)常性產后出血,手(shou)(shou)法按摩和(he)宮縮劑無效并(bing)有(you)可(ke)(ke)(ke)(ke)能(neng)切(qie)除子宮的(de)(de)患者(zhe)。先試用兩手(shou)(shou)加壓(ya)觀察出血量是否(fou)減(jian)少以(yi)估計B-Lynch縫合(he)成功止血的(de)(de)可(ke)(ke)(ke)(ke)能(neng)性,應(ying)(ying)用可(ke)(ke)(ke)(ke)吸(xi)收線縫合(he)。B-Lynch術(shu)后并(bing)發癥(zheng)的(de)(de)報道較為罕見(jian),但有(you)感(gan)染和(he)組織(zhi)壞死的(de)(de)可(ke)(ke)(ke)(ke)能(neng),應(ying)(ying)掌握手(shou)(shou)術(shu)適(shi)(shi)應(ying)(ying)證。
(6)結扎雙(shuang)(shuang)側(ce)子(zi)宮(gong)動(dong)脈上、下行(xing)支及髂(qia)內動(dong)脈妊娠(shen)時(shi)90%的子(zi)宮(gong)血流經過子(zi)宮(gong)動(dong)脈,結扎雙(shuang)(shuang)側(ce)上、下行(xing)支及髂(qia)內動(dong)脈,出血多(duo)被(bei)控制。以上措(cuo)施均可(ke)保留(liu)子(zi)宮(gong),保留(liu)生育(yu)機能。
(7)壓迫腹主動(dong)脈 出(chu)血(xue)不止時(shi),可(ke)經(jing)腹壁向脊柱(zhu)方向壓迫腹主動(dong)脈,亦可(ke)經(jing)子(zi)宮后(hou)壁壓迫腹主動(dong)脈。當子(zi)宮肌肉缺氧時(shi),可(ke)誘發宮縮減少(shao)出(chu)血(xue)。獲得(de)暫時(shi)效(xiao)果,為采取其他措施爭得(de)時(shi)間(jian)。
(8)經導管動脈(mo)(mo)(mo)栓塞術(TAE)局麻下經皮從股動脈(mo)(mo)(mo)插管造影,顯示髂(qia)內動脈(mo)(mo)(mo)后(hou),注射一種能(neng)被吸收的(de)栓塞劑,使髂(qia)內動脈(mo)(mo)(mo)栓塞從而達到止血目的(de)。操作所耗時間(jian)與操作者熟練程度(du)有(you)關。
(9)子宮(gong)切(qie)除 是控制產科出血(xue)最有效(xiao)的手(shou)段(duan)。各種止血(xue)措(cuo)施無明顯效(xiao)果,出血(xue)未(wei)能控制,為(wei)挽救生命在(zai)輸血(xue)、抗休克的同(tong)時,即行(xing)子宮(gong)次全或(huo)全子宮(gong)切(qie)除術。
2.軟(ruan)產道損(sun)傷所致出血
在充分暴露軟產道的情況下(xia),查明裂傷(shang)部位,注意有無(wu)多(duo)處裂傷(shang)。縫合(he)(he)時盡量恢復原解剖關系,并(bing)應超(chao)過(guo)撕裂頂(ding)端0.5cm縫合(he)(he)。裂傷(shang)超(chao)過(guo)1cm,即(ji)使無(wu)活動出血(xue),也應當(dang)進行(xing)縫合(he)(he)。血(xue)腫(zhong)應切開,清除積血(xue),縫扎(zha)止血(xue)或碘(dian)紡紗條填塞血(xue)腫(zhong)壓迫止血(xue),24~48小時后取出。小血(xue)腫(zhong)可密切觀察,采用冷敷、壓迫等(deng)保守治療。
如(ru)子宮內翻(fan)(fan)及(ji)時(shi)發(fa)現,產婦無嚴(yan)重(zhong)性(xing)休克或出(chu)血,子宮頸環尚未縮緊(jin),可立即將(jiang)內翻(fan)(fan)子宮體(ti)還(huan)(huan)納(na)(必要時(shi)可麻(ma)醉(zui)后還(huan)(huan)納(na)),還(huan)(huan)納(na)后靜(jing)脈點滴縮宮素,直至宮縮良好后將(jiang)手(shou)撤(che)出(chu)。由于產婦疼痛劇(ju)烈并多有(you)休克表現,臨床中常需在(zai)麻(ma)醉(zui)及(ji)生命體(ti)征監測下進行(xing)復位。如(ru)經陰(yin)道(dao)還(huan)(huan)納(na)失敗,可改為經腹部(bu)子宮還(huan)(huan)納(na)術,如(ru)果患(huan)者血壓(ya)不穩定,在(zai)抗休克同時(shi)行(xing)還(huan)(huan)納(na)術。
對完全性子(zi)宮破(po)裂或不全性子(zi)宮破(po)裂立即開腹行手術(shu)修補術(shu)或行子(zi)宮切除術(shu)。
3.胎(tai)盤(pan)因素所(suo)致(zhi)出血
(1)胎(tai)(tai)盤(pan)滯留(liu)或胎(tai)(tai)盤(pan)胎(tai)(tai)膜殘留(liu)所致的出(chu)(chu)(chu)血胎(tai)(tai)兒娩出(chu)(chu)(chu)后(hou)超過30分鐘,雖經一般處理胎(tai)(tai)盤(pan)仍未剝(bo)離(li)(li),或伴大(da)出(chu)(chu)(chu)血者(zhe),應盡快徒手剝(bo)離(li)(li)胎(tai)(tai)盤(pan)。胎(tai)(tai)盤(pan)自然娩出(chu)(chu)(chu)或人工剝(bo)離(li)(li)后(hou),檢查胎(tai)(tai)盤(pan)胎(tai)(tai)膜有殘留(liu)者(zhe),可(ke)用大(da)刮匙輕輕搔(sao)刮清除(chu)。若胎(tai)(tai)盤(pan)已經完全剝(bo)離(li)(li)但嵌頓于宮(gong)(gong)腔內,宮(gong)(gong)頸口(kou)緊、攣縮,可(ke)以(yi)在麻醉狀態(tai)下徒手取出(chu)(chu)(chu)。
(2)胎(tai)(tai)盤(pan)植入或(huo)胎(tai)(tai)盤(pan)穿透已(yi)明確胎(tai)(tai)盤(pan)植入者,不要強行(xing)鉗(qian)夾或(huo)刮宮(gong)以(yi)免引起致命(ming)行(xing)產后大(da)出血(xue)。可(ke)以(yi)根(gen)據胎(tai)(tai)盤(pan)植入面積大(da)小及(ji)所(suo)在醫(yi)院(yuan)條件選擇宮(gong)腔填塞紗布壓迫止血(xue)、水囊壓迫止血(xue)、子(zi)宮(gong)動(dong)脈或(huo)髂內動(dong)脈結扎或(huo)栓塞止血(xue),如果(guo)出血(xue)過(guo)多且經上述方法止血(xue)無效,為挽救產婦生命(ming)應及(ji)時選擇子(zi)宮(gong)次全(quan)或(huo)全(quan)子(zi)宮(gong)切除術(shu)。
4.凝血功能(neng)障礙所致(zhi)出血
應在積(ji)極(ji)救治(zhi)原(yuan)(yuan)(yuan)發(fa)病基礎上確診(zhen)應迅速補充(chong)相(xiang)應的(de)凝(ning)(ning)血(xue)因(yin)子。血(xue)小(xiao)板:血(xue)小(xiao)板低(di)于(yu)(20~50)×109/L或血(xue)小(xiao)板降(jiang)低(di)出(chu)現(xian)不(bu)可控制滲血(xue)時使用(yong);新鮮(xian)冰凍血(xue)漿(jiang):是(shi)新鮮(xian)抗凝(ning)(ning)全血(xue)于(yu)6~8小(xiao)時內分離血(xue)漿(jiang)并快速冰凍,幾乎保存了血(xue)液中所(suo)有凝(ning)(ning)血(xue)因(yin)子、血(xue)漿(jiang)蛋白(bai)、纖維(wei)蛋白(bai)原(yuan)(yuan)(yuan);冷(leng)沉(chen)(chen)淀(dian):輸(shu)注冷(leng)沉(chen)(chen)淀(dian)主要(yao)為糾正纖維(wei)蛋白(bai)原(yuan)(yuan)(yuan)的(de)缺乏,如纖維(wei)蛋白(bai)原(yuan)(yuan)(yuan)濃度高于(yu)150mg/dL不(bu)必輸(shu)注冷(leng)沉(chen)(chen)淀(dian)。纖維(wei)蛋白(bai)原(yuan)(yuan)(yuan):輸(shu)入纖維(wei)蛋白(bai)原(yuan)(yuan)(yuan)1g可提升血(xue)液中纖維(wei)蛋白(bai)原(yuan)(yuan)(yuan)25g/L;凝(ning)(ning)血(xue)酶原(yuan)(yuan)(yuan)復合物。
5.防治休克
(1)發生(sheng)產后(hou)出血(xue)(xue)時,應在止(zhi)血(xue)(xue)的(de)(de)(de)(de)(de)同(tong)時,酌情(qing)輸液(ye)、輸血(xue)(xue),注(zhu)意保溫,給(gei)予適量鎮靜劑等(deng),以(yi)防休(xiu)克發生(sheng)。出現休(xiu)克后(hou)就(jiu)按失血(xue)(xue)性休(xiu)克搶救。失血(xue)(xue)所致(zhi)低血(xue)(xue)容量休(xiu)克的(de)(de)(de)(de)(de)主要死因(yin)(yin)是(shi)組(zu)織低灌(guan)注(zhu)以(yi)及大出血(xue)(xue)、感染和再灌(guan)注(zhu)損傷等(deng)原因(yin)(yin)導致(zhi)的(de)(de)(de)(de)(de)多器官功能(neng)障礙綜合征(MODS)。因(yin)(yin)此(ci)救治關鍵在于盡早(zao)去除休(xiu)克病(bing)因(yin)(yin)的(de)(de)(de)(de)(de)同(tong)時,盡快恢(hui)復有效的(de)(de)(de)(de)(de)組(zu)織灌(guan)注(zhu),以(yi)改善組(zu)織細(xi)胞(bao)的(de)(de)(de)(de)(de)氧(yang)供,重建氧(yang)的(de)(de)(de)(de)(de)供需平衡(heng)和恢(hui)復正常的(de)(de)(de)(de)(de)細(xi)胞(bao)功能(neng)。
(2)低血容量休(xiu)克的(de)早(zao)期診斷(duan)(duan)對預后至關重要。傳統的(de)診斷(duan)(duan)主(zhu)要依據為病(bing)史(shi)、癥狀、體征,包括精神狀態改(gai)變、皮膚濕冷、收縮壓下降(40mmHg)或(huo)脈(mo)(mo)壓差減少(shao)(100/min、中心靜脈(mo)(mo)壓(CVP)<5mmHg或(huo)肺動脈(mo)(mo)楔(xie)壓(PAWP)<8mmHg等指標。有研究(jiu)證實血乳酸和堿缺失在低血容量休(xiu)克的(de)監測和預后判斷(duan)(duan)中具有重要意義。
(3)有效的(de)(de)(de)監(jian)(jian)測(ce)(ce)可(ke)(ke)以(yi)對(dui)低血容(rong)量(liang)休(xiu)克患(huan)者的(de)(de)(de)病情(qing)和(he)治(zhi)療(liao)反(fan)應做出正(zheng)確、及時(shi)的(de)(de)(de)評估(gu)和(he)判(pan)斷,以(yi)利于指(zhi)導和(he)調整治(zhi)療(liao)計劃,改善休(xiu)克患(huan)者的(de)(de)(de)預后(hou)。一般(ban)臨(lin)床監(jian)(jian)測(ce)(ce)包括皮溫與色澤、心率、血壓(ya)、尿量(liang)和(he)精神狀態等(deng)監(jian)(jian)測(ce)(ce)指(zhi)標(biao)。心率加快通常(chang)是休(xiu)克的(de)(de)(de)早期診斷指(zhi)標(biao)之一。血壓(ya)至少(shao)維(wei)持平均動(dong)脈壓(ya)(MAP)在60~80mmHg比較恰當(dang)。尿量(liang)是反(fan)映腎灌注(zhu)較好的(de)(de)(de)指(zhi)標(biao),可(ke)(ke)以(yi)間(jian)接反(fan)映循環狀態。當(dang)尿量(liang)<0.5mL/(kg·h)時(shi),應繼續進行液體(ti)(ti)復蘇。體(ti)(ti)溫監(jian)(jian)測(ce)(ce)亦十分重要,當(dang)中心體(ti)(ti)溫<34℃時(shi),可(ke)(ke)導致嚴重的(de)(de)(de)凝血功能障礙。強調在產(chan)后(hou)出血1000mL左右時(shi),由于機體(ti)(ti)代償(chang)機制(zhi)可(ke)(ke)能產(chan)婦的(de)(de)(de)生(sheng)命(ming)體(ti)(ti)征仍在正(zheng)常(chang)范圍內,不容(rong)忽視觀察產(chan)婦早期休(xiu)克表(biao)現并及時(shi)救治(zhi),同時(shi)應加強實驗室監(jian)(jian)測(ce)(ce)。
(4)在(zai)緊急容(rong)量復蘇(su)時必須迅(xun)速(su)建(jian)立有效的(de)靜(jing)脈通路。液(ye)體(ti)復蘇(su)治(zhi)療(liao)時可以選擇晶體(ti)溶(rong)液(ye)和膠體(ti)溶(rong)液(ye)。由于5%葡(pu)萄糖(tang)溶(rong)液(ye)很快分布到細胞(bao)內間隙,因(yin)此不推薦(jian)用于液(ye)體(ti)復蘇(su)治(zhi)療(liao)。
在(zai)一(yi)般情況下,輸(shu)注晶(jing)體液后會(hui)進行血(xue)(xue)管內外(wai)再分(fen)布,約有(you)25%存留在(zai)血(xue)(xue)管內;而其余75%則分(fen)布于(yu)血(xue)(xue)管外(wai)間(jian)隙以(yi)補充組(zu)織(zhi)間(jian)隙液體丟(diu)失量(liang)(liang),同時維持組(zu)織(zhi)間(jian)隙酸(suan)堿(jian)平衡,但過量(liang)(liang)也可以(yi)引起組(zu)織(zhi)水腫。臨床上低血(xue)(xue)容量(liang)(liang)休克(ke)復蘇治療中應(ying)用(yong)的膠體液主(zhu)要(yao)有(you)羥(qian)乙基淀粉和(he)白(bai)(bai)蛋白(bai)(bai)。在(zai)使(shi)用(yong)安全(quan)性方面應(ying)關注對(dui)腎功能(neng)的影響(xiang)、對(dui)凝(ning)血(xue)(xue)的影響(xiang)以(yi)及可能(neng)的過敏反應(ying),并且具有(you)一(yi)定的劑量(liang)(liang)相關性。白(bai)(bai)蛋白(bai)(bai)價格昂貴,并有(you)傳播血(xue)(xue)源性疾病的潛在(zai)風險臨床應(ying)用(yong)較少。
6.輸血治療
輸(shu)血(xue)(xue)(xue)及輸(shu)注(zhu)血(xue)(xue)(xue)制(zhi)品在低血(xue)(xue)(xue)容量休克(ke)中應(ying)用(yong)廣泛(fan)。產后(hou)(hou)出血(xue)(xue)(xue)、失(shi)血(xue)(xue)(xue)性(xing)休克(ke)時,機(ji)(ji)體(ti)發(fa)(fa)生(sheng)(sheng)自身輸(shu)血(xue)(xue)(xue)(即血(xue)(xue)(xue)液(ye)重(zhong)(zhong)(zhong)新分布以(yi)(yi)(yi)保(bao)證重(zhong)(zhong)(zhong)要臟器心及腦的(de)供應(ying))和自身輸(shu)液(ye)的(de)病(bing)理生(sheng)(sheng)理改變以(yi)(yi)(yi)達(da)到機(ji)(ji)體(ti)代償(chang)作用(yong)。尤其是(shi)(shi)當機(ji)(ji)體(ti)處于失(shi)代償(chang)階段時原(yuan)則上應(ying)快(kuai)速輸(shu)入晶體(ti)以(yi)(yi)(yi)保(bao)證組(zu)織(zhi)(zhi)(zhi)間隙(xi)液(ye)體(ti)的(de)丟(diu)失(shi)量和組(zu)織(zhi)(zhi)(zhi)間隙(xi)微環(huan)境的(de)酸(suan)堿平衡,然后(hou)(hou)最(zui)重(zhong)(zhong)(zhong)要的(de)是(shi)(shi)提(ti)高血(xue)(xue)(xue)紅蛋白濃度以(yi)(yi)(yi)保(bao)證組(zu)織(zhi)(zhi)(zhi)細(xi)胞能夠進行正(zheng)常(chang)的(de)氧合代謝。因為在子(zi)宮肌纖維(wei)處于嚴重(zhong)(zhong)(zhong)缺血(xue)(xue)(xue)缺氧狀態下對(dui)宮縮(suo)劑及各(ge)種止血(xue)(xue)(xue)方(fang)法均不敏感。在上述(shu)基礎上凝血(xue)(xue)(xue)因子(zi)的(de)補(bu)充以(yi)(yi)(yi)糾(jiu)(jiu)正(zheng)凝血(xue)(xue)(xue)功能異(yi)常(chang)也(ye)很重(zhong)(zhong)(zhong)要。強調產后(hou)(hou)出血(xue)(xue)(xue)液(ye)體(ti)復蘇(su)一(yi)定是(shi)(shi)依據(ju)產后(hou)(hou)出血(xue)(xue)(xue)發(fa)(fa)生(sheng)(sheng)后(hou)(hou)機(ji)(ji)體(ti)發(fa)(fa)生(sheng)(sheng)的(de)病(bing)理生(sheng)(sheng)理改變,根(gen)據(ju)產后(hou)(hou)出血(xue)(xue)(xue)量及生(sheng)(sheng)命(ming)體(ti)征監測情況,在規(gui)范化(hua)液(ye)體(ti)復蘇(su)治(zhi)療(liao)的(de)基礎上選擇個體(ti)化(hua)的(de)液(ye)體(ti)復蘇(su)治(zhi)療(liao)方(fang)案(an)。同時應(ying)注(zhu)意及時糾(jiu)(jiu)正(zheng)酸(suan)中毒、保(bao)護(hu)胃腸黏膜(mo)屏障功能,維(wei)持體(ti)溫也(ye)是(shi)(shi)復蘇(su)的(de)關鍵(jian),因此應(ying)采(cai)取加溫輸(shu)血(xue)(xue)(xue)以(yi)(yi)(yi)提(ti)高復蘇(su)成功率。
7.預防感染
由于(yu)失血多,機體(ti)抵抗力下降,加之多有經陰道宮(gong)腔操作等,產(chan)婦易發生產(chan)褥感染,應積極防(fang)治。
1.加強(qiang)產前檢查(cha)
對有產(chan)后(hou)出血、滯(zhi)產(chan)、難產(chan)史以(yi)及有貧(pin)血、產(chan)前(qian)出血、妊(ren)高(gao)征、胎兒較大、雙胎或羊水過多(duo)等(deng)情況時(shi),均應(ying)積(ji)極做好防(fang)治產(chan)后(hou)出血的(de)準備工作(zuo)。積(ji)極糾(jiu)正貧(pin)血、治療(liao)基礎疾病,充分認識產(chan)后(hou)出血的(de)高(gao)危(wei)因素,高(gao)危(wei)孕婦應(ying)于分娩前(qian)轉診到有輸血和搶(qiang)救條件的(de)醫院。
2.產程(cheng)中識別產后出血高危因素
產(chan)程中識別產(chan)后出血(xue)高危因素,及(ji)(ji)時(shi)干預處理(li)。避免產(chan)程過(guo)(guo)長,注意產(chan)婦(fu)進(jin)食、休息(xi)等情況,產(chan)程較(jiao)(jiao)長的孕婦(fu)應(ying)(ying)(ying)保證充分能量(liang)攝入,及(ji)(ji)時(shi)排空膀胱,必(bi)要時(shi)適當(dang)應(ying)(ying)(ying)用鎮靜劑(ji)、輸液(ye)及(ji)(ji)導尿。第二產(chan)程注意控制胎頭娩出速度,避免產(chan)道裂(lie)傷(shang)、出血(xue)。手術助產(chan)時(shi)切忌操作粗暴,以(yi)免損傷(shang)軟產(chan)道。對于產(chan)程過(guo)(guo)長、急產(chan)或活躍(yue)期至(zhi)第二產(chan)程較(jiao)(jiao)快(kuai)的孕產(chan)婦(fu),均(jun)應(ying)(ying)(ying)警(jing)惕產(chan)后出血(xue)。及(ji)(ji)早上臺準備接生,適時(shi)應(ying)(ying)(ying)用宮(gong)縮劑(ji),恰當(dang)按摩子宮(gong),準確計量(liang)出血(xue)量(liang)。
3.積極處理(li)第三(san)產(chan)程
第三(san)產(chan)程積極干預(yu)能有效減少(shao)產(chan)后(hou)(hou)出(chu)(chu)血量(liang)。主要的干預(yu)措施包括:胎(tai)(tai)(tai)頭娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu)隨(sui)即前肩娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu)后(hou)(hou),預(yu)防(fang)性(xing)應(ying)用縮(suo)宮素(su)。非(fei)頭位(wei)胎(tai)(tai)(tai)兒(er)可于胎(tai)(tai)(tai)兒(er)全身娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu)后(hou)(hou)、多胎(tai)(tai)(tai)妊娠最后(hou)(hou)一個胎(tai)(tai)(tai)兒(er)娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu)后(hou)(hou),預(yu)防(fang)性(xing)應(ying)用縮(suo)宮素(su);胎(tai)(tai)(tai)兒(er)娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu)后(hou)(hou)有控(kong)制的牽拉臍帶協助(zhu)胎(tai)(tai)(tai)盤(pan)(pan)娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu);胎(tai)(tai)(tai)盤(pan)(pan)娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu)后(hou)(hou)按摩子宮。此外,胎(tai)(tai)(tai)盤(pan)(pan)娩(mian)(mian)(mian)(mian)(mian)出(chu)(chu)后(hou)(hou)應(ying)仔細檢查胎(tai)(tai)(tai)盤(pan)(pan)、胎(tai)(tai)(tai)膜是否(fou)完(wan)整,有無(wu)副胎(tai)(tai)(tai)盤(pan)(pan)、有無(wu)產(chan)道(dao)損傷,發現問題及時處理。
4.其他
產后2小(xiao)時(shi)(shi)(shi)是發生產后出(chu)血(xue)的高危時(shi)(shi)(shi)段(duan),密切觀(guan)察子宮收(shou)縮情況(kuang)和出(chu)血(xue)量(liang),應及時(shi)(shi)(shi)排空膀胱。產后24小(xiao)時(shi)(shi)(shi)之(zhi)內,應囑產婦注(zhu)意出(chu)血(xue)情況(kuang)。產后有(you)出(chu)血(xue)量(liang)增多趨勢的患者,應認真測量(liang)出(chu)血(xue)量(liang),以免對失血(xue)量(liang)估計不足。