奚杰等

[摘要] 目的 探讨产后出血阶梯式评估及技术优化的临床价值，为产科临床提供参考。 方法 将2012年10月～2014年9月上海市嘉定区妇幼保健院（以下简称“我院”）收治的产后出血量≥400 mL的827例住院产妇（项目组）纳入出血阶梯式方案项目管理组，对其实施产后出血反复评估并不断改进止血新技术。观察管理期间项目组产妇缝合技术和止血新技术的实施情况、产后出血比例、宫缩剂有效比例及子宫切除比例等指标，并与2011年10月～2012年9月我院收治的384例产后出血量≥400 mL的产妇（对照组）进行比较，分析产后出血阶梯式评估及技术优化的临床价值。 结果 项目组新开展Cho缝合术比例与对照组比较差异有统计学意义（P < 0.05）；项目组实施B-Lynch缝合术比例明显少于对照组（P < 0.05）。项目组实施新技术子宫动脉结扎8例、子宫动脉栓塞8例，两项新技术均有1例为治疗有效。项目组产后出血发生率明显低于对照组（P < 0.05）。 结论 产后出血阶梯式方案管理，通过对产后早期出血量进行正确评估，配合子宫按摩、药物促宫缩治疗和合理的止血术式，可以减少产后出血的发生。新技术子宫动脉栓塞与子宫动脉结扎能够提高产后出血的止血效果，值得在临床推广应用。

[关键词] 阶梯式方案；产后出血；子宫压迫缝合技术；子宫动脉结扎；子宫动脉栓塞；子宫切除

[中图分类号] R714.46 [文献标识码] A [文章编号] 1673-7210（2015）05（c）-0012-04

[Abstract] Objective To study the clinical value of step evaluation management for postpartum hemorrhage and the optimization of technology， to provide a reference for obstetrics clinic. Methods 827 cases hospitalized puerperal were brought into the bleeding ladder scheme project management group， which were treated in the Maternal and Child Health Hospital of Jiading District in Shanghai （“our hospital” for short） from October 2012 to September 2014 and the postpartum hemorrhage was more than 400 mL （project group）， they were given the repeated assessment of postpartum hemorrhage and developed new hemostatic suture. The implementation of new technology and hemostatic suture technique， the ratio of postpartum hemorrhage， proportion of effective tocolytic agents， and the ratio of uterus removal， etc. were observed. And those were compared with the 384 cases of hospitalized puerperal， which were treated in our hospital from October 2011 to September 2012 （control group）. The clinical value of step evaluation management and optimization techniques of hemostatic suture were analyzed. Results The rate of Cho hemostatic suture in the project group was higher than that of the control group， the difference was statistically significant （P < 0.05）. The implementation of B-Lynch suture of project group was less than that of the control group， the difference was statistically significant （P < 0.05）. In the project group， the implementation of new technology as uterine artery ligation in 8 cases and uterine artery embolization in 8 cases， with 1 case effectively. The incidence of postpartum hemorrhage of project group was lower than that of the control group， the difference was statistically significant （P < 0.05）. Conclusion The step evaluation management can reduce the incidence of postpartum hemorrhage， thorough properly assessment of bleeding volume， uterine massage， the treatment with uterine contraction drugs and combined with reasonable operation of hemostasis. The uterine artery embolization and uterine artery ligation can improve the hemostatic effect of postpartum hemorrhage， worth to popularize application in the clinic.

[Key words] Step evalution management； Postpartum hemorrhage； Uterine compression suturing technology； Uterine arterial embolization； Uterine arterial ligation； Hysterectomy

在世界范围内，产后出血特别是产后大出血一直被认为的导致孕产妇死亡的主要原因，如何快速、高效地实现产后止血是妇产科临床所面临的重要任务。我国近年来的统计结果显示，产后大出血的发生率为2%～3%[1]，剖宫产率和非必要引产率等的上升也在使产后出血的发生率呈上升趋势。鉴于产后出血的危害，产后出血量的准确评估和合理的止血策略对于保障产妇和胎儿的生命安全尤为重要。为寻求合理有效的产后出血的止血策略，上海市嘉定区妇幼保健院（以下简称“我院”）在上海市嘉定区卫生局的授权下开展了产后出血阶梯式方案及技术优化研究，旨在优化当前产科的止血方案，为产科临床提供参考。……