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分娩所致血肿的处理

Authors
Daniel Kiefer, MD
Ashley S Roman, MD, MPH
Section Editor
Susan M Ramin, MD
Deputy Editor
Kristen Eckler, MD, FACOG
Translators
徐先明, 主任医师

引言

妊娠期子宫、阴道及外阴血供丰富，这些血管在分娩过程中有创伤风险，而创伤可能导致血肿形成。产后血肿的发生率为每300-1500次分娩出现1例，在罕见情况下是可能危及生命的分娩并发症[1,2]。

大多数产后血肿由手术分娩或会阴切开术相关的出血性撕裂伤导致，然而，不存在周围组织撕裂伤或切口时，血肿也可能由血管损伤导致(如，假性动脉瘤、创伤性动静脉瘘)[1,3-6]。下列女性发生产后血肿的风险增加：未经产或婴儿体重超过4000g、子痫前期、第二产程延长、多胎妊娠、外阴静脉曲张或凝血障碍[3,7-9]。

常见部位

发生产后血肿的最常见部位是外阴、阴道/阴道旁区以及腹膜后。

外阴 — 大多数外阴血肿是由会阴切开术过程中发生的阴部动脉分支(直肠下动脉、会阴动脉、阴唇后动脉和尿道动脉；阴道前庭动脉；阴蒂深动脉和背动脉)损伤导致，或是由会阴撕裂伤导致(图 1)[1,3]。这些血管通常位于骨盆前三角(尿生殖三角)或后三角的浅筋膜内(图 2)。前三角的浅筋膜鞘与腹股沟韧带下方的下腹部筋膜下间隙连通。Colles筋膜和尿生殖膈限制了前三角区内出血的扩散，而肛筋膜限制了后三角区内出血的扩散。因此，出血向疏松皮下组织提供非常小阻力的皮肤处积聚，从而形成血肿。浅表血肿可从前三角后缘(位于会阴横肌水平)向前经阴阜延伸至腹股沟韧带处的筋膜融合处。压迫性组织坏死和血肿周围组织破裂可能导致外出血[9]。

阴道/阴道旁区 — 阴道/阴道旁血肿是由子宫动脉分支损伤导致，主要是降支受损(图 3)[1,9]。这些血肿通常与产钳分娩有关，但也可能发生在自然分娩时。

           

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Literature review current through: 2017-06 . | This topic last updated: 2015-08-12.
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References
Top
  1. Zahn CM, Yeomans ER. Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol 1990; 33:422.
  2. Villella J, Garry D, Levine G, et al. Postpartum angiographic embolization for vulvovaginal hematoma. A report of two cases. J Reprod Med 2001; 46:65.
  3. Guerriero S, Ajossa S, Bargellini R, et al. Puerperal vulvovaginal hematoma: sonographic findings with MRI correlation. J Clin Ultrasound 2004; 32:415.
  4. SOTTO LS, COLLINS RJ. Perigenital hematomas; analysis of forty-seven consecutive cases. Obstet Gynecol 1958; 12:259.
  5. Po LK, Simons ME, Levinsky ES. Concealed postpartum hemorrhage treated with transcatheter arterial embolization. Obstet Gynecol 2012; 120:461.
  6. Nagayama C, Gibo M, Nitta H, et al. Rupture of pseudoaneurysm after vaginal delivery successfully treated by selective arterial embolization. Arch Gynecol Obstet 2011; 283:37.
  7. Saleem Z, Rydhström H. Vaginal hematoma during parturition: a population-based study. Acta Obstet Gynecol Scand 2004; 83:560.
  8. Propst AM, Thorp JM Jr. Traumatic vulvar hematomas: conservative versus surgical management. South Med J 1998; 91:144.
  9. Ridgway LE. Puerperal emergency. Vaginal and vulvar hematomas. Obstet Gynecol Clin North Am 1995; 22:275.
  10. Jain KA, Olcott EW. Magnetic resonance imaging of postpartum pelvic hematomas: early experience in diagnosis and treatment planning. Magn Reson Imaging 1999; 17:973.
  11. Benrubi G, Neuman C, Nuss RC, Thompson RJ. Vulvar and vaginal hematomas: a retrospective study of conservative versus operative management. South Med J 1987; 80:991.
  12. Sheikh GN. Perinatal genital hematomas. Obstet Gynecol 1971; 38:571.
  13. Zahn CM, Hankins GD, Yeomans ER. Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity. J Reprod Med 1996; 41:569.
  14. Tattersall M, Braithwaite W. Balloon tamponade for vaginal lacerations causing severe postpartum haemorrhage. BJOG 2007; 114:647.
  15. Gizzo S, Saccardi C, Patrelli TS, et al. Bakri balloon in vaginal-perineal hematomas complicating vaginal delivery: a new therapeutic approach. J Low Genit Tract Dis 2013; 17:125.
  16. Burchell RC. Physiology of internal iliac artery ligation. J Obstet Gynaecol Br Commonw 1968; 75:642.
  17. Smith WR, Moore EE, Osborn P, et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma 2005; 59:1510.
  18. Heffner LJ, Mennuti MT, Rudoff JC, McLean GK. Primary management of postpartum vulvovaginal hematomas by angiographic embolization. Am J Perinatol 1985; 2:204.
  19. Chin HG, Scott DR, Resnik R, et al. Angiographic embolization of intractable puerperal hematomas. Am J Obstet Gynecol 1989; 160:434.
  20. Hsu YR, Wan YL. Successful management of intractable puerperal hematoma and severe postpartum hemorrhage with DIC through transcatheter arterial embolization--two cases. Acta Obstet Gynecol Scand 1998; 77:129.
  21. Yamashita Y, Takahashi M, Ito M, Okamura H. Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury. Obstet Gynecol 1991; 77:160.
  22. Bolton H, Choji K, Pandit M. Embolization as first-line treatment in the management of puerperal hematoma in a case of congenital urogenital anomaly. Congenit Anom (Kyoto) 2008; 48:48.
  23. Kehila M, Mahjoub S, Kebaili S, et al. [Management of postpartum vaginal haematomas by embolisation: two cases]. Sante 2010; 20:105.
  24. Distefano M, Casarella L, Amoroso S, et al. Selective arterial embolization as a first-line treatment for postpartum hematomas. Obstet Gynecol 2013; 121:443.