子宫下段收缩不良导致的产后出血的危险因素及早期干预

Risk factors and early intervention for postpartum hemorrhage caused by lower uterine segment atony

摘要

目的 探讨阴道分娩后子宫下段收缩不良导致产后出血的发生率、高危因素及早期识别对改善产后不良结局的影响。 方法 回顾性分析2020年7月至2025年6月两家三级围产中心足月单胎阴道分娩产妇(n=42 253)的临床资料,提取产后出血产妇(n=1 408)的产科特征,比较每年严重产后出血组(≥1 000 mL,n=428)和轻度产后出血组(500~1 000 mL,n=980)子宫下段收缩不良导致的产后出血的发生率,采用二元logistic回归分析子宫下段收缩不良导致的产后出血的高危因素,并比较其早期识别和干预(胎盘娩出后30 min内,早期干预组,n=214)、晚期识别和干预(胎盘娩出后30 min后,晚期干预组,n=53)对于产后出血量、开腹手术率的影响。 结果 子宫下段收缩不良导致的产后出血267例,占产后出血的18.96%。严重产后出血组子宫下段收缩不良导致的产后出血发生率(24.53%)显著高于轻度产后出血组(16.53%)(P<0.001)。二元logistic回归分析显示,年龄增大(5岁)(OR=1.245, 95%CI:1.040~1.491)、瘢痕子宫(OR=18.760, 95%CI:2.155~163.282)、巨大胎儿(OR=1.801, 95%CI:1.031~3.146)和低置胎盘(OR=5.426, 95%CI:1.796~16.389)是子宫下段收缩不良导致的产后出血的独立危险因素(P<0.05)。早期干预组的红细胞输注率(19.16% vs. 39.62%)、开腹手术率(0% vs. 5.66%)和出血量≥2 000 mL发生率(1.87% vs. 13.21%)均显著低于晚期干预组(P<0.05),晚期干预组中1例子宫切除后死亡。 结论 阴道分娩后的产后出血约1/5源于子宫下段收缩不良,年龄、瘢痕子宫、巨大胎儿及低置胎盘是其高危因素,早期识别并针对性干预可显著降低不良结局风险。

Abstract

Objective To investigate the incidence, risk factors of postpartum hemorrhage caused by lower segment atony(PPH-LSA)after vaginal delivery and the impact of its early identification and intervention on improving adverse postpartum outcomes. Methods Clinical data of all consecutive term singleton vaginal deliveries in two tertiary perinatal centers from July 2020 to June 2025(n=42,253)were retrospectively analyzed. Obstetric characteristics of women with postpartum hemorrhage(PPH, n=1,408)were extracted. The incidence of PPH-LSA was compared between the severe PPH group(≥1,000 mL, n=428)and the mild PPH group(500-1,000 mL, n=980). Binary logistic regression analysis was performed to identify independent risk factors for PPH-LSA. The effects of early intervention(within 30 minutes after placental delivery, n=214)versus late intervention(after 30 minutes after placental delivery, n=53)on postpartum blood loss volume and laparotomy rate were further evaluated. Results A total of 42,253 term singleton vaginal deliveries were included, among whom 1,408 women(3.33%)were diagnosed with PPH. Of these, 267 cases(18.96%)were classified as PPH-LSA. The incidence of PPH-LSA in the severe PPH group(24.53%)was significantly higher than that in the mild PPH group(16.53%)(P<0.001). Binary logistic regression analysis revealed that advanced age(per 5-year increment)(OR=1.245, 95%CI: 1.040-1.491), uterine scar(OR=18.760, 95%CI: 2.155-163.282), macrosomia(OR=1.801, 95%CI: 1.031-3.146), and low-lying placenta(OR=5.426, 95%CI: 1.796-16.389)were independent risk factors for PPH-LSA(P<0.05). Compared with the late intervention group, the early intervention group had significantly lower rates of red blood cell transfusion(19.16% vs. 39.62%), laparotomy(0% vs. 5.66%), and severe blood loss(≥2,000 mL, 1.87% vs. 13.21%)(P<0.05). One case of hysterectomy followed by maternal death occurred in the late intervention group. Conclusion Approximately one-fifth of PPH cases after vaginal delivery are attributed to PPH-LSA. Advanced age, uterine scar, macrosomia, and low-lying placenta are independent risk factors for this condition. Early identification and targeted intervention can significantly reduce the risk of severe adverse maternal outcomes.

关键词

产后出血 / 子宫下段收缩不良 / 高危因素 / 早期干预

Key words

Postpartum hemorrhage / Lower segment atony / Risk factors / Early intervention

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基金资助

济南市临床医学科技创新计划项目(202225045)