卡前列甲酯栓联合Bakri子宫填塞球囊导管对产后出血的治疗效果

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罗清, 何立梅, 冯倩, 白春晓, 郝博星. 卡前列甲酯栓联合Bakri子宫填塞球囊导管对产后出血的治疗效果[J]. 武警医学, 2018,29(6): 575-577
LUO Qing, HE Limei, FENG Qian, BAI Chunxiao, HAO Boxing. Clinical effect of carboprost methylate suppository combined with Bakri uterine tamponade balloon catheter in postpartum hemorrhage[J]. Medical Journal of the Chinese People's Armed Police Forces, 2018,29(6): 575-577 复制到剪切板

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卡前列甲酯栓联合Bakri子宫填塞球囊导管对产后出血的治疗效果

罗清¹, 何立梅², 冯倩², 白春晓², 郝博星²

1.074100,河北省涞水县医院妇产科

2.072750,涿州市医院产科

作者简介:罗清,本科学历,副主任医师。

收稿日期: 2017-12-11

基金资助: 保定市科学技术研究与发展指导计划项目(17ZF121)

摘要

目的评价卡前列甲酯栓联合Bakri子宫填塞球囊导管对产后出血的治疗。方法将100例已签署知情同意书的产后出血患者随机分为观察组和对照组,各50例,对照组患者给予宫腔填塞纱布止血,观察组患者给予卡前列甲酯栓1 mg舌下含服,联合应用Bakri子宫填塞球囊导管止血。监测患者的生命体征和不良反应,统计预后情况,比较两组患者治疗前、治疗后2 h、24 h的出血量、舒张压、收缩压、脉搏及血红蛋白。结果观察组有效止血率、输血率等预后指标均显著优于对照组( P<0.05);两组患者治疗后的出血量较治疗前显著减少( P<0.05),在治疗后24 h出血量的比较上,观察组远好于对照组,两组患者比较的差异具有统计学意义( P<0.05);观察组患者治疗后24 h的收缩压明显优于治疗前,而两组患者在舒张压、收缩压、脉搏以及血红蛋白上的比较差异无统计学意义,两组产妇发生不良反应的差异无统计学意义。结论卡前列甲酯栓联合Bakri子宫填塞球囊导管在产后出血中的临床效果确切,预后较好,值得推广。

关键词: 卡前列甲酯栓; Bakri球囊; 子宫填塞; 产后出血

中图分类号:R714.461

Clinical effect of carboprost methylate suppository combined with Bakri uterine tamponade balloon catheter in postpartum hemorrhage

LUO Qing¹, HE Limei², FENG Qian², BAI Chunxiao², HAO Boxing²

1.Department of Obstetrics and Gynecology, Laishui County Hospital, Laishui 074100, China

2.Department of Obstetrics and Gynecology, Zhuozhou City Hospital,Zhuozhou 072750, China

Abstract

Objective To evaluate the clinical efficacy of carboprost methylate suppository combined with Bakri uterine tamponade balloon catheter in postpartum hemorrhage.Methods One hundred cases of postpartum hemorrhage who had signed informed consent were randomly divided into the observation group and control group, with 50 cases in each. Patients in the control group were given intra-uterine pack with sterilized gauze to stanch blood while the observation group was treated with carboprost methylate suppository 1 mg sublingual combined with Bakri uterine tamponade balloon catheter to stop bleeding. The patients’ vital signs, adverse reactions and prognosis were monitored. The amount of bleeding, diastolic blood pressure, systolic blood pressure, pulse and hemoglobin were measured before treatment and 2 h, 24 h after treatment.Results The prognostic indexes, such as the effective hemostatic rate and blood transfusion rate, of the observation group were significantly better than those of the control group( P<0.05). The amount of bleeding in the two groups was significantly lower after treatment( P<0.05). The systolic blood pressure of the observation group was better than that before treatment, and the difference was statistically significant( P<0.05). There was no significant difference between the two groups in the diastolic blood pressure, systolic blood pressure, pulse, hemoglobin or adverse reactions.Conclusions The clinical effect of carboprost methylate suppository combined with Bakri uterine tamponade balloon catheter in postpartum hemorrhage is definite and the prognosis is better. This treatment is worthy of clinical application.

Keyword: carboprost methylate suppository; Bakri balloon; uterine tamponade; postpartum hemorrhage

产后出血(postpartum hemorrhage, PPH)是指产妇正常阴道分娩后24 h内出血量大于500 ml或剖宫产后24 h内的出血量大于1000 ml。引起出血的高危因素包括胎盘早剥、前置胎盘、宫缩乏力和妊娠高血压等^{[1, 2]}。产后出血量常难以准确估计, 临床估计的出血量比产妇的实际出血量低30%~50%^[3], 因而其来势汹涌是导致产妇死亡的主要原因^[4], 需要引起高度重视。临床上通常给予产妇宫腔纱布填塞治疗产后出血, 但往往伴随着子宫感染的增加, 对止血效果的后续观察也不尽如人意。近年来, 随着球囊止血技术的发展^[5], Bakri子宫填塞球囊导管在产后出血的治疗中日益受到重视。目前关于卡前列甲酯栓联合Bakri子宫填塞球囊导管治疗产后出血的相关研究较少, 因此本研究意在为产后出血的早期治疗提供新思路, 以降低子宫切除率和输血率。

1 对象与方法

1.1 对象

选择2016-02至2017-04河北涞水县医院、涿州市医院产科收治的经阴道分娩发生产后出血的产妇100例, 年龄21~37岁, 平均(25.7± 5.0)岁, 根据随机数字表法将研究对象随机分为观察组和对照组, 各50例。研究对象均为单胎妊娠, 足月实施分娩, 且排除胎盘因素、软产道裂伤、凝血功能障碍、卡前列甲酯过敏, 以及合并心、肝、肾等基础疾患的产妇。本研究获医院伦理委员会的批准, 产妇均签署了知情同意书。

1.2 方法

给予对照组患者宫腔填塞纱布止血, 将浸湿碘伏的不脱脂纱布条(8 cm× 200 cm)沿子宫底部由左向右逐步填紧宫腔上半部分, 然后填塞下半部分, 尾端纱布条放入宫颈外口下方约2 cm处。缝合子宫切口时在中间打结, 勿将纱条缝入。纱布在宫腔内的放置时间根据患者止血情况决定。给予观察组患者卡前列甲酯栓(卡孕, 0.5 mg/枚, 东北制药集团生产)2枚舌下含服; 经按摩子宫后仍无效, 在常规消毒后, 在超声引导下自阴道处置入1个Bakri子宫填塞球囊导管(型号:J-SOS-100500, 美国库克公司生产), 依据患者宫腔大小注入生理盐水1000~1500 ml, 以充盈球囊来压迫止血。

1.3 评价指标

监测患者的生命体征, 统计预后情况, 比较两组患者治疗前、治疗后2 h、24 h的出血量、舒张压、收缩压、脉搏及血红蛋白。采用容积法和面积法测量出血量, 在患者臀下放置计量型垫单进行血液收集, 并以浸血纱布和血染产单的面积计算其出血量; 记录患者恶心、呕吐、腹泻等不良反应; 有效止血的判定:与治疗前相比, 子宫收缩改善, 阴道流血减少, 无需采取其他治疗措施。

1.4 统计学处理

使用SPSS 20.0统计学软件进行分析, 计数以例(%)的形式表示, 采用χ ²检验, 计量资料采用t检验。P< 0.05为差异具有统计学意义。

2 结果

2.1 一般资料

两组患者在年龄、孕周、孕次、胎次、血小板计数等各项一般资料比较的差异均无统计学意义(P> 0.05), 具有可比性(表1)。

表1 两组产后出血患者一般资料比较(

\overset{̅}{x}

± s)

组别	观察组	对照组	t	P
例数	50	50
年龄(岁)	25.9± 5.3	25.6± 4.9	0.797	> 0.05
孕周(周)	38.6± 1.5	38.8± 1.9	0.360	> 0.05
孕次(次)	1.4± 0.7	1.8± 1.3	0.612	> 0.05
胎次(次)	1.2± 0.4	1.5± 0.8	0.471	> 0.05
血小板计数 (× 10⁹/L)	204.5± 49.2	206.2± 53.1	1.566	> 0.05

表1 两组产后出血患者一般资料比较(

\overset{̅}{x}

± s)

2.2 预后情况

观察组患者的有效止血率为94%, 输血率为2%, 均显著优于对照组(P< 0.05), 观察组无一例行子宫切除术, 对照组有一例患者因阴道大量流血发生失血性休克行子宫切除术(表2)。

表2 两组产后出血患者预后情况的比较(n; %)

2.3 出血量

两组治疗后出血量较治疗前显著减少(P< 0.05), 治疗后24 h出血量, 观察组远好于对照组, 两组比较差异具有统计学意义(P< 0.05); 治疗后2 h出血量比较, 两组无明显差异(表3)。

表3 两组产后出血患者出血量比较(

\overset{̅}{x}

± s)

组别	例数	出血量(ml)
组别	例数	治疗前	治疗后2 h	治疗后24 h
观察组	50	628.5± 74.9	135.1± 36.7^①	191.8± 50.2^①②
对照组	50	633.0± 81.4	156.2± 40.9^①	242.5± 62.4^①

注:与治疗前比较, ①P< 0.05; 与对照组比较, ②P< 0.05

表3 两组产后出血患者出血量比较(

\overset{̅}{x}

± s)

2.4 舒张压、收缩压及脉搏

观察组治疗后24 h的收缩压明显优于治疗前(P< 0.05), 而两组舒张压、收缩压、脉搏及血红蛋白比较无明显差异(表4)。

表4 两组产后出血患者舒张压、收缩压以及脉搏的比较(n=50;

\overset{̅}{x}

± s)

组别	治疗前	治疗后2 h	治疗后24 h
观察组
舒张压(mmHg)	74.9± 6.3	72.1± 5.4	71.3± 5.1
收缩压(mmHg)	125.0± 4.7	117.± 3.8	109.5± 2.2^①
脉搏(次/min)	79.7± 7.2	82.0± 7.7	81.4± 7.5
血红蛋白(g/L)	70.1± 6.4	74.5± 6.8	77.2± 6.9
对照组
舒张压(mmHg)	75.1± 6.4	73.0± 5.5	72.8± 5.1
收缩压(mmHg)	124.9± 4.6	119.6± 4.0	114.2± 3.7
脉搏(次/min)	79.6± 7.1	81.8± 7.4	81.5± 7.3
血红蛋白(g/L)	69.8± 6.2	73.1± 6.6	75.3± 6.7

注:与治疗前相比较, ①P< 0.05

表4 两组产后出血患者舒张压、收缩压以及脉搏的比较(n=50;

\overset{̅}{x}

± s)

2.5 两组不良反应比较

观察组发生不良反应2例, 发生率4 %, 其中恶心、呕吐各1例, 无因放置Bakri子宫填塞球囊导管诉严重不适者; 对照组发生发热1例。两组产妇不良反应发生率比较差异无统计学意义(P> 0.05), 且不良反应症状较轻, 持续时间短, 患者均能够耐受。

3 讨论

在产科止血方面, Bakri子宫填塞球囊导管是美国库克公司根据子宫形态为治疗产后出血而专门设计的球囊导管, 具有填塞和压迫止血的双重作用。Bakri具有双球囊的结构^[6], 出血经内球囊引流, 因而方便观察止血效果。球囊置入患者子宫腔后, 注入生理盐水使其扩张充分, 通过有力的压迫作用, 对子宫表面的毛细血管和静脉出血都有着较好的控制作用。正是由于以上的优点, Bakri子宫填塞球囊导管也已成为欧美国家产后出血处理指南的推荐方法^[7]。

本研究中, 我们将Bakri子宫填塞球囊导管与纱布填塞作比较, 发现Bakri还具有操作简单、取出方便等优点。此外, 观察组中有4例前置胎盘患者, 同样取得了很好的止血效果。我们分析, Bakri的置入使宫腔受力均匀, 不留死腔, 针对前置胎盘附着处的子宫内膜表面压迫止血、效果确切。而纱布填塞还存在填塞不紧、留有空隙的可能, 反复填塞还容易引起感染, 对照组1例患者治疗后发热, 血常规提示:白细胞升高, 由此说明感染与反复填塞有关。

笔者还探索性地将卡前列甲酯栓联合应用, 获得了满意的临床效果, 观察组患者无一例行子宫切除术, 有效止血率和输血率均显著优于对照组, 治疗后24 h的出血量也远少于对照组(P< 0.05), 这一研究数据与董开杰和曲晓燕^[8]结果相一致。究其原因, 我们认为这与卡前列甲酯栓作为前列腺素F2α 的衍生物^[9]这一特性密切相关。前列腺素作为钙离子的重要载体^[10], 在快速增加肌细胞内钙离子浓度的过程中起到了关键作用, 促使子宫平滑肌强烈收缩, 达到迅速止血的目的。但在两组患者血压、脉搏的比较上, 观察组与对照组差异不大, 这可能与患者失血量在500~1000 ml时, 血压、脉搏常维持在正常范围内有关。

本研究不足之处是未能对卡前列甲酯栓的服药时机进行研究。相关研究表明, 在胎儿娩出后立即给予产妇卡前列甲酯栓比产后出血发生后给药, 止血效果更佳^[11], 这一点值得进一步深入研究。

The authors have declared that no competing interests exist.

参考文献

文献列表

[1]	呼改琴, 黑江荣. 产后出血4280例相关因素分析[J]. 陕西医学杂志, 2014, 43(7): 802-803. [本文引用:1]
[2]	韩秀琴, 李荣英, 孙亚丽. 卡贝缩宫素预防宫缩乏力性产后出血疗效观察[J]. 武警医学, 2016, 27(5): 479-481. [本文引用:1]
[3]	漆洪波, 贾小燕. 如何准确评估出血量及产后出血的早期识别[J]. 中国实用妇科与产科杂志, 2014, 30(4): 254-256. [本文引用:1]
[4]	Matsubara S, Yano H, Ohkuchi A, et al. Uterine compression sutures for postpartum hemorrhage: an overview[J]. Acta Obstet Gynecol Scand , 2013, 92(4): 378-385. [本文引用:1]
[5]	Cekmez Y, Ozkaya E, Ocal F D, et al. Experience with different techniques for the management of postpartum hemorrhage due to uterine atony: compression sutures, artery ligation and Bakri balloon[J]. Ir J Med Sci, 2015, 184(2): 399-402. [本文引用:1]
[6]	蒋小芒. 宫腔内放置球囊压迫在治疗产后出血中的应用[J]. 陕西医学杂志, 2015, 44(10): 1305-1306. [本文引用:1]
[7]	Dahlke J, Mendez-Figueroa H, Maggio L, et al. Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines[J]. Am J Obstet Gynecol, 2015, 213(1): 76-80. [本文引用:1]
[8]	董开杰, 曲晓燕. 卡前列甲酯栓联合Bakri球囊治疗产后出血的疗效观察[J]. 现代药物与临床, 2016, 31(6): 893-896. [本文引用:1]
[9]	陈寒波. 卡前列甲酯栓对产妇产后出血的预防效果及安全性评价[J]. 实用药物与临床, 2014, 17(2): 240-242. [本文引用:1]
[10]	何川, 尹智华, 杨孜, 等. 卡前列甲酯防治产后出血系统评价[J]. 中国实用妇科与产科杂志, 2013, 29(6): 486-492. [本文引用:1]
[11]	江晓丽, 邹橞怡, 岑晓燕. 浅谈卡前列甲酯栓在预防产后出血中的效果[J]. 中国现代药物应用, 2016, 10(11): 220-221. [本文引用:1]

2014

0.0

... 引起出血的高危因素包括胎盘早剥、前置胎盘、宫缩乏力和妊娠高血压等^[1,2] ...

2016

0.0

韩秀琴, 李荣英, 孙亚丽. 卡贝缩宫素预防宫缩乏力性产后出血疗效观察[J]. 武警医学, 2016, 27(5): 479-481.

Objective To study the preventive effect of carbetocin on postpartum hemorrhage. Methods 400 pregnant women of normal term delivery were divided into two groups, 200 cases in vaginal delivery group, 200 in cesarean section group, each group was divided into carbetocin group and oxytocin group. The carbetocin group was given carbetocin 100 μg into the pot after the delivery of the fetus, while for the oxytocin group, oxytocin 10 u was given into the perfusion tube infusion immediately after the delivery of the fetus, 10u into intravenous perfusion lasting for 2 hours after the delivery. The amount of bleeding intrapartum (the surgery) ,within 2 hours and 24 hours after the delivery(after surgery) between the carbetocin group and the oxytocin group was compared. At the same time, the hemoglobin change before the delivery and 24 hours after the delivery was compared. Results 2 h post partum and 24 h postpartum average bleeding volumes in carbetocin vaginal delivery group and cesarean section group were smaller than those in oxytocin vaginal delivery group and cesarean section group:120 ml,poor value respectively at time of delivery, about 45 ml postpartum,about 170 ml 24 hours postpartum.24 h postpartum hemoglobin declining value was also lower than that in carbetocin vaginal delivery group and cesarean sestion group,10 g/L versus and 15 g/L,with significant differences ( P 0.05).Conclusion Carbetocin can effectively prevent and reduce postpartum hemorrhage,its effect is significantly higher than that of oxytocin.

1.Department of Gynecology and Obstetrics,Shanxi Provinical Corps Hospital of Chinese People’s Armed Police Force,Taiyuan 030006,China; 2. Department of Radiotherapy,Shanxi Provincial Cancer Hospital,Taiyuan 030003,China; 3.Department of Gynecology and Obstetrics,First Affiliated Hospital of School of Shanxi Province Medicine,Taiyuan 030001,China

目的观察卡贝缩宫素预防宫缩乏力性产后出血的临床疗效。方法选择400例正常足月分娩的孕妇，分为两组，阴道分娩组200例，剖宫产组200例，将各组又分为卡贝缩宫素组和缩宫素组。卡贝缩宫素组:胎儿娩出后将卡贝缩宫素100 μg静脉滴注(滴斗入);缩宫素组:胎儿娩出后将缩宫素10 U静脉滴注(滴斗入)，同时持续10 U入液体静脉滴注至产后2 h。比较卡贝缩宫素组和缩宫素组产时(术时)、产后(术后)2 h及产后(术后)24 h的出血量。孕妇分娩前和分娩24 h后血红蛋白变化。结果卡贝缩宫素阴道分娩及剖宫产组均比缩宫素阴道分娩及剖宫产组产时、产后2 h及产后24 h平均出血量均少，差值分别约为:产时120 ml，产后约45 ml，产后24 h约170 ml，卡贝缩宫素阴道分娩及剖宫产组产后24 h血红蛋白下降值也均比缩宫素阴道分娩及剖宫产组低，差值分别约为10 g/L、15 g/L，对比差异均有统计学意义( P 0.05)。结论卡贝缩宫素能有效预防和减少产后出血，疗效明显高于缩宫素。

... 引起出血的高危因素包括胎盘早剥、前置胎盘、宫缩乏力和妊娠高血压等^[1,2] ...

2014

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... 产后出血量常难以准确估计,临床估计的出血量比产妇的实际出血量低30%~50%^[3],因而其来势汹涌是导致产妇死亡的主要原因^[4],需要引起高度重视 ...

2013

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... 产后出血量常难以准确估计,临床估计的出血量比产妇的实际出血量低30%~50%^[3],因而其来势汹涌是导致产妇死亡的主要原因^[4],需要引起高度重视 ...

2015

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... 近年来,随着球囊止血技术的发展^[5],Bakri子宫填塞球囊导管在产后出血的治疗中日益受到重视 ...

2015

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... Bakri具有双球囊的结构^[6],出血经内球囊引流,因而方便观察止血效果 ...

2015

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... 正是由于以上的优点,Bakri子宫填塞球囊导管也已成为欧美国家产后出血处理指南的推荐方法^[7] ...

2016

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董开杰, 曲晓燕. 卡前列甲酯栓联合Bakri球囊治疗产后出血的疗效观察[J]. 现代药物与临床, 2016, 31(6): 893-896.

Objective To explore clinical efficacy of Carboprost Methylate Suppositories combined with Bakri Balloon in treatment of postpartum hemorrhage. Methods Patients (90 cases) with postpartum hemorrhage in Yantai Affiliated Hospital of Binzhou Medical University from June 2014 to June 2015 were selected. The patients were randomly divided into control group and treatment group, and each group had 45 cases. Patients in the control group were given one Bakri Balloon in vagina or uterine incision during caesarean section, and then given 200 - 300 mL normal saline. Patients in the treatment group were given one Carboprost Methylate Suppositories in vagina on the basis of the control group. The patients in two groups were treated for 24 h. After treatment, the clinical efficacy, systolic pressure (SBP), diastolic pressure (DBP), and oxygen saturation (SaO 2 ), amount of bleeding, and adverse reactions in two groups were compared. Results After treatment, the efficacies in the control and treatment groups were 86.67% and 97.78%, respectively, and there was difference between two groups ( P 2 in two groups were improved, and the differences were statistically significant in the same group ( P P P Conclusion Carboprost Methylate Suppositories combined with Bakri Balloon has good effect in treatment of postpartum hemorrhage, can decrease amount of bleeding with good safety, which has a certain clinical application value.

目的探讨卡前列甲酯栓联合Bakri球囊治疗产后出血的临床疗效。方法选取2014年6月-2015年6月滨州医学院烟台附属医院收治的产后出血患者90例,随机分为对照组和治疗组,每组各45例。对照组自阴道或剖宫产术中子宫切口处置入1个Bakri球囊,并注入200~300 mL生理盐水,治疗组在对照组基础上从阴道置入1枚卡前列甲酯栓。两组患者均治疗24 h。比较两组患者的临床疗效,收缩压(SBP)、舒张压(DBP)和血氧饱和度(SaO 2 )、出血量以及不良反应情况。结果治疗后,对照组和治疗组的总有效率分别为86.67%、97.78%,两组比较差异有统计学意义( P 2 均较治疗前显著改善,同组治疗前后差异有统计学意义( P 2 比较差异无统计学意义;治疗2、24 h后,两组出血量均较治疗前明显减少,同组治疗前后差异有统计学意义( P P 结论卡前列甲酯栓联合Bakri球囊治疗产后出血具有较好的临床疗效,可减少出血量,且安全性较高,具有一定的临床推广应用价值。

... 05),这一研究数据与董开杰和曲晓燕^[8]结果相一致 ...

2014

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... 的衍生物^[9]这一特性密切相关 ...

2013

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... 前列腺素作为钙离子的重要载体^[10],在快速增加肌细胞内钙离子浓度的过程中起到了关键作用,促使子宫平滑肌强烈收缩,达到迅速止血的目的 ...

2016

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... 相关研究表明,在胎儿娩出后立即给予产妇卡前列甲酯栓比产后出血发生后给药,止血效果更佳^[11],这一点值得进一步深入研究 ...