改良式TACS术对剖宫产PPH患者子宫动脉血流动力学及凝血、卵巢功能的改善效应研究

Study on improvement effects of modified TACS on uterine artery hemodynamics, coagulation function and ovarian function of patients with PPH after cesarean section

摘要

目的 探究剖宫产产后出血(PPH)患者经改良式子宫下段横形环状压迫缝合术(TACS)治疗后子宫动脉血流动力学及凝血、卵巢功能的变化特点。方法 选取2021年6月至2023年5月江阴市人民医院收治的122例PPH患者为研究对象,根据治疗方法分为研究组(接受TACS治疗,64例)和对照组(给予“8”字缝合法联合宫腔内的球囊压迫止血,58例)。采用倾向性评分匹配法进行1∶1匹配,共匹配成功100例,两组各50例。比较两组患者术前、术后24 h、术后48 h子宫动脉血流动力学、凝血功能及卵巢功能。采用重复测量方差分析法比较两组患者的子宫动脉血流动力学的动态变化。采用二元Log-binomial回归计算两组并发症发生率的相对危险度(RR)。结果 与术前比较,两组患者术后的阻力指数(RI)、子宫动脉搏动指数(PI)、收缩压最大血流速度与舒张末期最大血流速比值(S/D)均有下降,平均血流速度(Vm)显著提升(F介于14.159到69.831之间,P<0.05);术后48 h,研究组RI、PI、S/D均低于对照组,Vm高于对照组(t介于2.622到9.055之间,P<0.05)。两组患者术后的凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)及研究组雌二醇(E₂)均低于术前,纤维蛋白原(FIB)、促黄体生成素(LH)、促卵泡生长激素(FSH)均高于术前(F介于2.416到39.812之间,P<0.05);研究组PT、APTT、E₂水平显著低于对照组,FIB、LH、FSH水平显著高于对照组(t介于2.660到14.652之间,P<0.05)。研究组总有效率显著高于对照组(χ²=5.005,P<0.05)。研究组患者并发症的总风险显著降低(RR<1,P<0.05)。结论 改良式子宫下段横形环状压迫缝合术可显著改善PPH患者子宫动脉血流动力学、凝血功能及卵巢功能,提高临床疗效。

Abstract

Objective To explore characteristics of changes in uterine artery hemodynamics, coagulation and ovarian functions of patients with postpartum hemorrhage (PPH) after cesarean section treated with modified transverse annular compression sutures (TACS) of the lower uterine segment. Methods A total of 122 patients with PPH who admitted to Jiangyin People's Hospital from June 2021 to May 2023 were selected as study subjects. According to treatment method, they were divided into study group (64 patients received TACS operation) and control group (58 patients received “8-shape” suture combined with intrauterine balloon compression for hemostasis). Propensity score matching (PSM) method was used to match pairs of patients in 1∶1 ratio, and a total of 100 patients were successfully matched, 50 patients in each group. The hemodynamic parameters of uterine arteries, coagulation function indexes and ovarian function indexes of the patients before surgery, at 24 hours after surgery and at 48 hours after surgery were compared between the two groups. Repeated measures analysis of variance (ANOVA) method was used to analyze and compare dynamic changes in hemodynamic parameters of uterine arteries of the patients between the two groups. Log-binomial regression was used to calculate relative risk (RR) of complication incidence in the two groups. Results Compared with hemodynamic parameters before operation, resistance index (RI), uterine artery pulsatility index (PI), and ratio of maximum systolic blood flow velocity to maximum diastolic blood flow velocity (S/D) of the PPH patients in both groups decreased after operation, while average blood flow velocity (mean velocity, Vm) significantly increased (F values ranged from 14.159 to 69.831, all P<0.05). At 48 hours after operation, PI, RI, S/D of the PPH patients in the study group were all lower than those in the control group, while Vm was higher than that in the control group (t=2.622-9.055, all P<0.05). Prothrombin time (PT), activated partial thromboplastin time (APTT) of the PPH patients in the two groups after operation, and estradiol (E2) level of the PPH patients in the study group after operation were lower than those before operation, while fibrinogen (FIB), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels were higher than those before operation (F=2.416-39.812, all P<0.05). After operation, the levels of PT, APTT and E2 in the study group were significantly lower than those in the control group, while the levels of FIB, LH and FSH were significantly higher than those in the control group (t=2.660-14.652, all P<0.05). The total effective rate in the study group was significantly higher than that in the control group (χ²=5.005, P<0.05). The total risk of complications in the study group was significantly decreased (RR<1, P<0.05). Conclusion Modified TACS can significantly improve hemodynamics of uterine artery, coagulation function and ovarian function of the patients with PPH, and improve clinical efficacy for treatment of PPH.

关键词

剖宫产 / 产后出血 / 改良式子宫下段横形环状压迫缝合术 / 子宫动脉 / 血流动力学

Key words

caesarean section / postpartum hemorrhage / modified transverse annular compression sutures / uterine artery / hemodynamics

参考文献

[1] Cheema H A, Ahmad A B, Ehsan M, et al. Tranexamic acid for the prevention of blood loss after cesarean section: an updated systematic review and meta-analysis of randomized controlled trials[J]. Am J Obstet Gynecol MFM, 2023, 5(8): 101049.

[2] 于莹, 沈汝冈, 刘凯波, 等. 北京市6 194例阴道分娩产后出血影响因素分析[J]. 中国妇幼健康研究, 2023, 34(10): 53-59.

[3] Mappa I, Masturzo B, Ghi T, et al. Current practice of ultrasound in the management of postpartum hemorrhage: a secondary analysis of a national survey[J]. J Perinat Med, 2024, 52(8): 896-898.

[4] 刘妍, 霍苗, 薛薇薇, 等. 欣母沛联合子宫下段横形环状压迫缝合术对二次剖宫产产后出血患者止血效果的影响[J]. 中国妇产科临床杂志, 2024, 25(3): 264-266.

[5] Han L, Zhang B, Xu H, et al. A new step-wise surgical technique of knapsack-like uterine compression sutures for intractable postpartum hemorrhage in cesarean section[J]. BMC Pregnancy Childbirth, 2024, 24(1): 9.

[6] 毕冬华, 周芳芳, 刘宇, 等. 子宫血管缝扎术及宫颈环状缝扎术联合双侧髂内动脉球囊阻断治疗PPP合并胎盘植入效果[J]. 中国计划生育学杂志, 2024, 32(8): 1856-1859.

[7] Yang X, Tian X, Liu H, et al. Homocysteine increases uterine artery blood flow resistance in women with pregnancy loss[J]. J Gynecol Obstet Hum Reprod, 2023, 52(2): 102533.

[8] Allerkamp H H, Leighton S, Pole T, et al. Synergistic regulation of uterine radial artery adaptation to pregnancy by paracrine and hemodynamic factors[J]. Am J Physiol Heart Circ Physiol, 2023, 325(4): H790-H805.

[9] 祖丽菲娅·阿布力克木, 黄莺, 努尔比也·地里夏提. 血清TSP-2联合PTX3水平对产后出血的预测价值[J]. 中国妇幼健康研究, 2024, 35(7): 91-95.

[10] Gök S, Kaleli M B. Investigation of the effects of oxytocin administration timing on postpartum hemorrhage during cesarean section[J]. Medicina (Kaunas), 2023, 59(2): 222.

[11] Zewdu D, Tantu T. Incidence and predictors of severe postpartum hemorrhage after cesarean delivery in south central Ethiopia: a retrospective cohort study[J]. Sci Rep, 2023, 13(1): 3635.

[12] 黄君莉, 李念. 子宫下段横形环状压迫缝合术用于前置胎盘剖宫产产后出血的有效率及安全性研究[J]. 现代消化及介入诊疗, 2021, 26(S2): 1120- 1120.

[13] Siargkas A, Tsakiridis I, Kappou D, et al. The Association Between Uterine Artery Pulsatility Index at Mid-Gestation and the Method of Conception: A Cohort Study[J]. Medicina (Kaunas), 2025, 61(6): 1093.

[14] van Zijl M D, Koullali B, Mol B WJ, et al. The predictive capacity of uterine artery Doppler for preterm birth: a cohort study[J]. Acta Obstet Gynecol Scand, 2020, 99(4): 494-502.

[15] Kuang L, Lin W, Wang D, et al. Abnormal coagulation after hepatectomy in patients with normal preoperative coagulation function[J]. BMC Surg, 2024, 24(1): 136.

[16] 王梅, 刘德佩, 张成思, 等. 卡贝缩宫素合Bakri球囊压迫对宫缩乏力性产后出血患者卵巢功能和凝血功能的影响[J]. 现代生物医学进展, 2022, 22(2): 299-303.

[17] 陈文英, 邹晴燕, 张凤英, 等. 加味左归丸联合雌孕激素序贯治疗对早发性卵巢功能不全患者子宫动脉血流动力学,氧化应激和免疫因子的影响[J]. 现代生物医学进展, 2023, 23(16): 3097-3101.

基金资助

无锡市卫生健康委妇幼健康适宜技术推广项目(FYTG202207)