Management of Persistent Postpartum Hemorrhage Caused by Inner Myometrial Lacerations.
Management of Persistent Postpartum Hemorrhage Caused by Inner Myometrial Lacerations.
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内肌层撕裂引起的持续性产后出血的治疗。
DOI：
10.1097/aog.0000000000001170
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发表时间：
2015
影响因子：
7.2
通讯作者：
A. Page
中科院分区：
文献类型：
--
作者：
G. Page;A. Page
我们最近遇到了一例类似于Conrad等报道的产后出血病例，因此我们饶有兴趣地阅读了他们的报道。在我们的病例中，进行了子宫切除术，提供了肉眼图像记录和病理学描述，表明在没有覆盖子宫内膜的情况下，存在厚的子宫肌层和多个扭曲和出血的血管。在子宫背峡部区域描述了多个（4个）清晰的撕裂伤。图像完全符合Hayashi等人发表的图像。我们的患者在持续性横位胎儿真空分娩失败后，由于胎儿状态不安全而延长了分娩时间，并通过剖宫产分娩。患者在剖宫产后第7天出现迟发性产后出血。这是治疗3天的静脉子宫收缩药物。她的临床情况稳定，子宫超声检查未提示妊娠产物残留，因此未进行刮宫术。然而，在第10天，她经历了严重的阴道出血。医生为她提供了栓塞或子宫切除术治疗，这对夫妇选择了子宫切除术，因为他们已经完成了他们的家庭。根据我们的临床经验，子宫肌层撕裂伤出血是在子宫张力降低后发生的，因此，当女性接受子宫收缩治疗时，发生出血的可能性较小。延迟性产后出血的其他原因包括残留物、张力缺乏和子宫内膜炎。虽然，子宫切除术后，血培养大肠杆菌阳性，在我们的病人，没有感染的临床或解剖病理学迹象。我们的解释是，子宫肌层出血可导致延迟性产后出血，如果及时进行，保留子宫手术或栓塞可能会对产后出血有反应。
We recently encountered a case of postpartum hemorrhage analogous to that reported by Conrad et al, so we read their report with interest. In our case, a hysterectomy was performed, which provided both macroscopic image documentation and a surgical–pathologic description indicating the presence of thick myometrium with multiple distorted and hemorrhagic vessels in the absence of overlying endometrium. Multiple (four) clear lacerations were described in the dorsal isthmic region of the uterus. Images are in full compliance with those published by Hayashi et al. Our patient had a prolonged labor and was delivered by cesarean owing to nonreassuring fetal status after failed vacuum delivery of a persistent transverse-position fetus. The patient had a delayed postpartum hemorrhage, presenting on day 7 after cesarean birth. This was treated with 3 days of intravenous uterotonic medications. She was stable clinically, and uterine ultrasonography did not suggest retained products of conception, so no curettage was done. On day 10, however, she experienced heavy vaginal bleeding. She was offered either embolization or hysterectomy for treatment, and the couple opted for hysterectomy because they had completed their family. In our clinical experience, bleeding from myometrial lacerations follows reduction of uterine tone and as such is less likely to develop when the woman is on uterotonic therapy. Other causes of delayed postpartum hemorrhage include retained products, atony, and endometritis. Although, after hysterectomy, blood cultures were positive for Escherichia coli in our patient, no clinical or anatomopathologic signs of infection were present. Our explanation is that myometrial bleeding can cause delayed postpartum hemorrhage, which may respond to uterine-sparing surgery or embolization if done in a timely fashion.