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围产期子宫切除治疗出血

Author
Daniela A Carusi, MD, MSc
Section Editors
Charles J Lockwood, MD, MHCM
Howard T Sharp, MD
Deputy Editor
Kristen Eckler, MD, FACOG
Translators
刘琦, 主任医师，教授

引言

围产期子宫切除可定义为分娩时或分娩后24小时内进行的子宫切除。另有定义为在该次住院期间，从分娩至出院的任何时间内进行的子宫切除。

该手术可能是或为紧急手术，或为是计划性手术。紧急手术最常见指征是保守措施无法控制的严重子宫出血。此类出血多为胎盘形成异常或宫缩乏力所致，两者各占围产期子宫切除的30%-50%[1-4]。其他可能引起产时或产后子宫严重出血的原因包括：子宫破裂、子宫平滑肌瘤及子宫血管撕裂。产前诊断为胎盘粘连或ⅠA2及ⅠB1期宫颈癌患者，可行计划性围产期子宫切除术。感染似乎也是围产期子宫切除的一个重要因素。不仅产后严重盆腔感染是手术的潜在指征，而且病理学分析也显示因宫缩乏力而切除的子宫中感染和炎症发生率也相对较高[5]。

紧急情况下，在求助激进的外科手术前，应先尝试诸多保守措施以控制子宫出血(表 1)。如果一项干预没有效果，下一项治疗措施应紧随其后。保守措施目的在于避免子宫切除所致并发症和绝育。对于必须接受子宫切除的患者，应立即手术(而不是采用多种保守措施后再手术)，以降低输血需求，和减少并发症[6]，此外，术前耽误的时间越长，患者失血量越多。因此，保守治疗措施应快速衔接，当大出血或母体病情不稳时，应立即准备子宫切除术。 (参见“产后出血概述”)

手术计划

产科医生需做好围产期紧急子宫切除的应对准备工作，尤其是存在高危因素或产后大出血患者。子宫切除通常不能在待产和分娩室进行，根据附近手术室条件，选择一间普通手术室即可。在进行紧急子宫切除时，需备好此单位待产和分娩室专用设备、其他物品和手术器械清单(表 2)。

术前风险评估 — 有时产科医师根据患者危险因素，可预估是否需围产期子宫切除。这能确保患者产前准备充分和得到咨询服务，并获知详尽手术计划，要尽可能避免紧急手术。这对胎盘形成异常的女性来说是相当重要的。

                      

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Literature review current through: 2017-06 . | This topic last updated: 2016-04-14.
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