背景:该研究旨在评估和报告临床特征,发病率,在马来西亚的单一培训和研究三级卫生保健中心,紧急和计划的围产期子宫切除术的危险因素和相关并发症。
方法:我们从2016年1月1日至2021年12月31日进行了为期6年的回顾性横断面研究。临床,人口特征,围手术期参数,手术适应症,失血,对产妇/新生儿结局和并发症进行分析.患者被细分,在紧急子宫切除术(EH)和计划子宫切除术(PH)两个亚组中进行了分析和研究。
结果:在100,567例分娩中,有65例进行围产期子宫切除,患病率为0.06%。总的来说,大多数患者是经产的(96.9%),既往有剖腹产疤痕(73.8%)或诊断为前置胎盘(75.4%)。超过一半的患者(61.5%)有先前的剖宫产疤痕和合并的前置胎盘。39例(60%)患者进行了EH,而26例(40%)患者接受了PH。PH组手术的唯一指征(100%)是胎盘异常,而EH组手术的最常见指征(53.8%)是与胎盘异常相关的产后出血。接受EH的患者更有可能出现大量失血(p=0.001),需要ICU入院(p=0.001),输入DIVC循环(平均[SD]方案:1.35[0.95]对0.54[0.99];p=0.002),术后血红蛋白水平较低(平均值[标准差,SD]血红蛋白:9.23g/l[SD1.8]与10.8g/l[SD1.86];p=0.001),术前/术后血红蛋白水平之间的差异更高(平均[SD]血红蛋白差异:1.78g/l[SD6.34]vs0.32g/l[SD1.7];p=0.008)与PH患者相比。红细胞输血,操作时间,逗留时间,两组婴儿体重和Apgar评分差异无统计学意义。研究的第一和下半年之间的失血量显着减少(平均[SD]失血量:6978ml[SD4999.45]与还观察到4100ml[SD2569.48];p=0.004)。在紧急小组中,“非胎盘原因”EH比“胎盘原因”需要更多的红细胞输血(p<0.05),而在PH组中,在手术时间方面,闭合性髂内动脉“球囊”和“无球囊”亚组之间没有观察到显著差异,完全失血或输血。总体并发症显示EH组有更多的术后发热和剖腹手术(18.4%vs.7.6%),而尿道损伤,包括膀胱和输尿管损伤仅发生在PH组(9.4%vs.0%)。
结论:大多数围产期子宫切除术病例是由于胎盘植入谱障碍。与紧急子宫切除术相比,计划的围产期子宫切除术的发病率较低。因此,早期发现胎盘植入谱系障碍和及时计划择期手术对于最大限度地减少急诊手术的需要至关重要.
BACKGROUND: The
study aims to evaluate and report on the clinical characteristics, incidence, risk factors and associated complications of emergency and planned peripartum hysterectomy in a single training and research tertiary health care centre in Malaysia.
METHODS: We conducted a 6-year retrospective cross-sectional
study from the 1st January 2016 until 31st December 2021. Clinical, demographic characteristics, perioperative parameters, operative indications, blood loss, maternal/neonatal outcomes and complications were analysed. Patients were subdivided, analysed and studied in two subgroups- emergency hysterectomy (EH) and planned hysterectomy (PH).
RESULTS: There were 65 cases of peripartum hysterectomy out of total 100,567 deliveries, with a prevalence rate of 0.06%. Overall, the majority of patients were multiparous (96.9%), having previous caesarean scar (73.8%) or diagnosed with placenta praevia (75.4%). More than half of the total patients (61.5%) have both previous caesarean scar and concomitant placenta praevia. EH was carried out in 39(60%) patients while 26(40%) patients underwent PH. The only indication for surgery in the PH group (100%) was abnormal placentation while the most common indication for surgery in the EH group (53.8%) was postpartum haemorrhage related to abnormal placentation. Patients who underwent EH were more likely to have massive blood loss (p=0.001), require ICU admissions (p=0.001), have DIVC cycles transfused (mean [SD] regime: 1.35 [0.95] vs 0.54 [0.99]; p=0.002), have lower postoperative haemoglobin level (mean [standard deviation, SD] haemoglobin: 9.23g/l [SD1.8] vs. 10.8 g/l [SD1.86]; p=0.001) and have higher difference between pre/post operative haemoglobin level (mean [SD] haemoglobin difference: 1.78g/l [SD6.34] vs 0.32g/l [SD1.7]; p=0.008) compared to patients with PH. Red blood cell transfusion, operating time, length of stay, weight of babies and Apgar score between two groups showed no significant differences. A significant reduction of blood loss between the first and the second half duration of the
study (mean [SD] blood loss: 6978 ml [SD 4999.45] vs. 4100ml [SD2569.48]; p=0.004) was also observed. In the emergency group, \'non-placental cause\' EH required significantly more red blood cell transfusion than \'placental cause\' (p<0.05) while in the PH group, no significant difference was observed between the occlusive internal iliac artery \'balloon\' and \'no balloon\' subgroup in terms of operating time, total blood loss or blood transfusion. Overall complications showed more cases of post operative fever and relaparotomy in the EH group (18.4% vs. 7.6%) while urinary tract injuries including injuries to bladder and ureter occurred only in the PH group (9.4% vs. 0%).
CONCLUSIONS: The majority of peripartum hysterectomy cases are due to placenta accreta spectrum disorders. Planned peripartum hysterectomies have a lower morbidity rate compared to emergency hysterectomies. Therefore, early identification of placenta accreta spectrum disorders and timely planning for elective procedures are crucial to minimise the need for emergency surgery.