未诊断的产后出血160例临床分析
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摘要
目的:探讨未诊断的产后出血(undiagnosed postpartum hemorrhage,UDPPH)的发生原因、临床特点、影响因素及预防措施。方法:回顾性分析2013年1月—2017年12月于中国人民解放军第161医院行阴道分娩的产妇1 528例的临床资料,将其分为产后出血(postpartum hemorrhage,PPH)组、UDPPH组和对照组(既无PPH也无UDPPH者),分析UDPPH的临床特点及影响因素,并与PPH组进行比较。结果:阴道分娩中UDPPH和PPH发生率分别为10.5%和6.1%,UDPPH组和PPH组的产前血红蛋白均低于对照组,孕次、总产程时间、第三产程时间、胎盘滞留发生率、会阴损伤发生率均高于对照组,差异有统计学意义(P<0.05),UDPPH组的初产妇比例、会阴侧切发生率均高于对照组,差异有统计学意义(P<0.05),而PPH组初产妇比例、会阴侧切发生率与对照组比较差异无统计学意义(P>0.05),初产妇比例、会阴侧切发生率是UDPPH不同于PPH的影响因素。结论:UDPPH在阴道分娩产妇中很常见,为降低其发生率,需要加强产后观察、正确评估出血量以及针对其影响因素进行预防。
Objective:To discuss the causes,clinical characteristics, influence factors and preventions of undiagnosed postpartum hemorrhage(UDPPH). Methods: 1 528 cases of vaginal delivery from January 2013 to December 2017 were retrospectively analyzed,and were divided into three groups: UDPPH group, postpartum hemorrhage(PPH) group and control group(those cases with neither UDPPH nor PPH). The clinical characteristics and influence factors of UDPPH group were analyzed and compared with those of PPH group. Results: The incidence of UDPPH and PPH was 10.5% and 6.1% of vaginal deliveries, respectively. The antepartum hemoglobin of UDPPH group and PPH group were both lower than that of the control group. The gravidity, the total duration of labor, duration of the third stage of labor, the incidence of retained placenta and perineal trauma were all higher than those of the control group(P<0.05), with statistical differences between them. The rates of primiparity and episiotomy in UDPPH group were higher than those of the control group(P<0.05), and there were statistical differences between them. But there were no significant differences in the rates of primiparity and episiotomy between PPH group and control group. The rates of primiparity and episiotomy were the influence factors those UDPPH were different from PPH. Conclusions: UDPPH is frequent among women giving birth vaginally. To reduce the incidence,we need to strengthen the observation after delivery,estimate blood loss accurately and prevent it according to the influence factors.
Objective:To discuss the causes,clinical characteristics, influence factors and preventions of undiagnosed postpartum hemorrhage(UDPPH). Methods: 1 528 cases of vaginal delivery from January 2013 to December 2017 were retrospectively analyzed,and were divided into three groups: UDPPH group, postpartum hemorrhage(PPH) group and control group(those cases with neither UDPPH nor PPH). The clinical characteristics and influence factors of UDPPH group were analyzed and compared with those of PPH group. Results: The incidence of UDPPH and PPH was 10.5% and 6.1% of vaginal deliveries, respectively. The antepartum hemoglobin of UDPPH group and PPH group were both lower than that of the control group. The gravidity, the total duration of labor, duration of the third stage of labor, the incidence of retained placenta and perineal trauma were all higher than those of the control group(P<0.05), with statistical differences between them. The rates of primiparity and episiotomy in UDPPH group were higher than those of the control group(P<0.05), and there were statistical differences between them. But there were no significant differences in the rates of primiparity and episiotomy between PPH group and control group. The rates of primiparity and episiotomy were the influence factors those UDPPH were different from PPH. Conclusions: UDPPH is frequent among women giving birth vaginally. To reduce the incidence,we need to strengthen the observation after delivery,estimate blood loss accurately and prevent it according to the influence factors.
引文
[1]中华医学会妇产科学分会产科学组.产后出血预防与处理指南(2014)[J].中华妇产科杂志,2014,49(9):641-646.
[2]Girault A,Deneux-Tharaux C,Sentilhes L,et al.Undiagnosed abnormal postpartum blood loss:Incidence and risk factors[J].PLoSOne,2018,13(1):e0190845.
[3]Charafeddine N,Picone O,Bony E,et al.Advantage of systematic blood cell count 2 days post-delivery for the diagnosis of postpartum maternal anaemia[J].Br J Med Med Res,2013,3(4):1144-1153.
[4]Descargues G,Pitette P,Gravier A,et al.Missed diagnosis of postpartum hemorrhage[J].J Gynecol Obstet Biol Reprod(Paris),2001,30(6):590-600.
[5]Corwin EJ,Murray-Kolb LE,Beard JL.Low hemoglobin level is a risk factor for postpartum depression[J].J Nutr 2003,1339(12):4139-4142.
[6]Murray-Kolb LE,Beard JL.Iron deficiency and child and maternal health[J].Am J Clin Nutr,2009,89(3):946S-950S.
[7]Deneux-Tharaux C,Dupont C,Colin C,et al.Multifaceted intervention to decrease the rate of severe postpartum haemorrhage:the PITHAGORE6 cluster-randomised controlled trial[J].BJOG,2010,117(10):1278-1287.
[8]Bergmann RL,Richter R,Bergmann KE,et al.Prevalence and risk factors for early postpartum anemia[J].Eur J Obstet Gynecol Reprod Biol,2010,150(2):126-131.
[9]Fawole B,Awolude OA,Adeniji AO,et al.WHO recommendations for the prevention of postpartum haemorrhage:RHL guideline.The WHO Reproductive Health Library[M].Geneva:World Health Organization,2010.
[10]Calvert C,Thomas SL,Ronsmans C,et al.Identifying regional variation in the prevalence of postpartum haemorrhage:a systematic review and meta-analysis[J].PLoS One,2012,7(7):e41114.
[11]Chen M,Chang Q,Duan T,et al.Uterine massage to reduce blood loss after vaginal delivery:a randomized controlled trial[J].Obstet Gynecol,2013,122(2 Pt 1):290-295.
[12]刘兴会,张力,张静.《产后出血预防与处理指南(草案)》(2009)及《产后出血预防与处理指南(2014年版)》解读[J].中华妇幼临床医学杂志(电子版),2015,11(4):433-447.
[13]Deneux-Tharaux C,Sentilhes L,Maillard F,et al.Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage:multicentre randomised controlled trial(TRACOR)[J].BMJ,2013,346:f1541.
[14]TournéG,Collet F,Lasnier P,et al.Usefulness of a collecting bag for the diagnosis of post-partum hemorrhage[J].J Gynecol Obstet Biol Reprod(Paris),2004,33(3):229-234.
[15]Caroli G,Cuesta C,Abalos E,et al.Epidemiology of postpartum haemorrhage:a systematic review[J].Best Pract Res Clin Obstet Gynaecol,2008,22(6):999-1012.
[16]Toledo P,McCarthy RJ,Hewlett BJ,et al.The accuracy of blood loss estimation after simulated vaginal delivery[J].Anesth Analg,2007,105(6):1736-1740.
[17]肖丽,傅璟,黄薇.会阴切开术在阴道分娩中的应用[J].实用妇产科杂志,2013,29(9):659-661.
[18]Raisanen S,Vehvilainen-Julkunen K,Heinonen S.Need for and consequences of episiotomy in vaginal birth:a critical approach[J].Midwifery,2010,26(3):348-356.
[19]Cam C,Asoglu MR,Selcuk S,et al.Does mediolateral episiotomy decrease central defects of the anterior vaginal wall?[J].Arch Gynecol Obstet,2012,285(2):4111-4115.
[20]Macleod M,Strachan B,Bahl R,et al.A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery[J].BJOG,2008,115(13):1688-1694.
[21]Rubio-魣lvarez A,Molina-Alarcón M,Hern觃ndez-Martínez A.Relationship between the degree of perineal trauma at vaginal birth and change in haemoglobin concentration[J].Women Birth,2017,30(5):382-388.
[22]郑丽,周娟.会阴无侧切分娩方式对母婴结局的影响[J].中国妇幼保健,2015,30(32):5701-5703.
[23]庄依亮.现代产科学[M].北京:科学出版社,2006:930-931.
[24]彭婷,周远鹏,耿秋莹.产后出血高危因素的三级预防分析[J].实用妇产科杂志,2015,31(5):350-353.
[25]Biguzzi E,Franchi F,Ambrogi F,et al.Risk factors for postpartum hemorrhage in a cohort of 6011 Italian women[J].Thromb Res,2012,129(4):e1-e7.
[26]刘兴会,陈锰.全球产后出血指南异同[J].中国实用妇科与产科杂志,2017,33(6):556-559.
[27]Magann EF,Evans S,Chauhan SP,et al.The length of the third stage of labor and the risk of postpartum hemorrhage[J].Obstet Gynecol,2005,105(2):290-293.
[28]Rabie NZ,Ounpraseuth S,Hughes D,et al.Association of the Length of the Third Stage of Labor and Blood Loss Following Vaginal Delivery[J].South Med J,2018,111(3):178-182.
[29]Cabrera-Guerra Y,Pascual-Pedreno A,Hernandez-Martínez A,et al.Evaluation and efficacy of preventive measures in intrapartum bleeding[J].Rev Calid Asist,2010,25(4):193-199.
[2]Girault A,Deneux-Tharaux C,Sentilhes L,et al.Undiagnosed abnormal postpartum blood loss:Incidence and risk factors[J].PLoSOne,2018,13(1):e0190845.
[3]Charafeddine N,Picone O,Bony E,et al.Advantage of systematic blood cell count 2 days post-delivery for the diagnosis of postpartum maternal anaemia[J].Br J Med Med Res,2013,3(4):1144-1153.
[4]Descargues G,Pitette P,Gravier A,et al.Missed diagnosis of postpartum hemorrhage[J].J Gynecol Obstet Biol Reprod(Paris),2001,30(6):590-600.
[5]Corwin EJ,Murray-Kolb LE,Beard JL.Low hemoglobin level is a risk factor for postpartum depression[J].J Nutr 2003,1339(12):4139-4142.
[6]Murray-Kolb LE,Beard JL.Iron deficiency and child and maternal health[J].Am J Clin Nutr,2009,89(3):946S-950S.
[7]Deneux-Tharaux C,Dupont C,Colin C,et al.Multifaceted intervention to decrease the rate of severe postpartum haemorrhage:the PITHAGORE6 cluster-randomised controlled trial[J].BJOG,2010,117(10):1278-1287.
[8]Bergmann RL,Richter R,Bergmann KE,et al.Prevalence and risk factors for early postpartum anemia[J].Eur J Obstet Gynecol Reprod Biol,2010,150(2):126-131.
[9]Fawole B,Awolude OA,Adeniji AO,et al.WHO recommendations for the prevention of postpartum haemorrhage:RHL guideline.The WHO Reproductive Health Library[M].Geneva:World Health Organization,2010.
[10]Calvert C,Thomas SL,Ronsmans C,et al.Identifying regional variation in the prevalence of postpartum haemorrhage:a systematic review and meta-analysis[J].PLoS One,2012,7(7):e41114.
[11]Chen M,Chang Q,Duan T,et al.Uterine massage to reduce blood loss after vaginal delivery:a randomized controlled trial[J].Obstet Gynecol,2013,122(2 Pt 1):290-295.
[12]刘兴会,张力,张静.《产后出血预防与处理指南(草案)》(2009)及《产后出血预防与处理指南(2014年版)》解读[J].中华妇幼临床医学杂志(电子版),2015,11(4):433-447.
[13]Deneux-Tharaux C,Sentilhes L,Maillard F,et al.Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage:multicentre randomised controlled trial(TRACOR)[J].BMJ,2013,346:f1541.
[14]TournéG,Collet F,Lasnier P,et al.Usefulness of a collecting bag for the diagnosis of post-partum hemorrhage[J].J Gynecol Obstet Biol Reprod(Paris),2004,33(3):229-234.
[15]Caroli G,Cuesta C,Abalos E,et al.Epidemiology of postpartum haemorrhage:a systematic review[J].Best Pract Res Clin Obstet Gynaecol,2008,22(6):999-1012.
[16]Toledo P,McCarthy RJ,Hewlett BJ,et al.The accuracy of blood loss estimation after simulated vaginal delivery[J].Anesth Analg,2007,105(6):1736-1740.
[17]肖丽,傅璟,黄薇.会阴切开术在阴道分娩中的应用[J].实用妇产科杂志,2013,29(9):659-661.
[18]Raisanen S,Vehvilainen-Julkunen K,Heinonen S.Need for and consequences of episiotomy in vaginal birth:a critical approach[J].Midwifery,2010,26(3):348-356.
[19]Cam C,Asoglu MR,Selcuk S,et al.Does mediolateral episiotomy decrease central defects of the anterior vaginal wall?[J].Arch Gynecol Obstet,2012,285(2):4111-4115.
[20]Macleod M,Strachan B,Bahl R,et al.A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery[J].BJOG,2008,115(13):1688-1694.
[21]Rubio-魣lvarez A,Molina-Alarcón M,Hern觃ndez-Martínez A.Relationship between the degree of perineal trauma at vaginal birth and change in haemoglobin concentration[J].Women Birth,2017,30(5):382-388.
[22]郑丽,周娟.会阴无侧切分娩方式对母婴结局的影响[J].中国妇幼保健,2015,30(32):5701-5703.
[23]庄依亮.现代产科学[M].北京:科学出版社,2006:930-931.
[24]彭婷,周远鹏,耿秋莹.产后出血高危因素的三级预防分析[J].实用妇产科杂志,2015,31(5):350-353.
[25]Biguzzi E,Franchi F,Ambrogi F,et al.Risk factors for postpartum hemorrhage in a cohort of 6011 Italian women[J].Thromb Res,2012,129(4):e1-e7.
[26]刘兴会,陈锰.全球产后出血指南异同[J].中国实用妇科与产科杂志,2017,33(6):556-559.
[27]Magann EF,Evans S,Chauhan SP,et al.The length of the third stage of labor and the risk of postpartum hemorrhage[J].Obstet Gynecol,2005,105(2):290-293.
[28]Rabie NZ,Ounpraseuth S,Hughes D,et al.Association of the Length of the Third Stage of Labor and Blood Loss Following Vaginal Delivery[J].South Med J,2018,111(3):178-182.
[29]Cabrera-Guerra Y,Pascual-Pedreno A,Hernandez-Martínez A,et al.Evaluation and efficacy of preventive measures in intrapartum bleeding[J].Rev Calid Asist,2010,25(4):193-199.