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子(zi)宮破裂是指(zhi)子(zi)宮體部或(huo)子(zi)宮下(xia)(xia)段于(yu)(yu)分(fen)娩(mian)期或(huo)妊(ren)娠(shen)期發(fa)(fa)(fa)(fa)生(sheng)(sheng)裂傷，為產(chan)科嚴(yan)重并發(fa)(fa)(fa)(fa)癥，威脅母(mu)兒生(sheng)(sheng)命。主要死(si)于(yu)(yu)出血(xue)、感染休克(ke)。隨著(zhu)產(chan)科質(zhi)量的提高(gao)(gao)，城鄉婦(fu)幼衛生(sheng)(sheng)保(bao)健網的建立和逐步健全發(fa)(fa)(fa)(fa)生(sheng)(sheng)率顯著(zhu)下(xia)(xia)降。城市醫院已很少(shao)見到，而農(nong)村偏遠(yuan)地(di)區時有發(fa)(fa)(fa)(fa)生(sheng)(sheng)。子(zi)宮破裂絕大多(duo)數發(fa)(fa)(fa)(fa)生(sheng)(sheng)于(yu)(yu)妊(ren)娠(shen)28周之后，分(fen)娩(mian)期最多(duo)見，目前發(fa)(fa)(fa)(fa)生(sheng)(sheng)率控制在1‰以下(xia)(xia)，產(chan)婦(fu)病(bing)死(si)率為5%，嬰(ying)兒病(bing)死(si)率高(gao)(gao)達(da)50%～75%甚至更(geng)高(gao)(gao)。

病因

子宮(gong)破裂(lie)多(duo)發生于(yu)難(nan)產、高齡多(duo)產和(he)子宮(gong)曾經手術或有過(guo)損傷的產婦。根據破裂(lie)的原因(yin)，可分為(wei)無瘢痕(hen)子宮(gong)破裂(lie)和(he)瘢痕(hen)子宮(gong)破裂(lie)。

1.梗阻性難產

明顯的骨(gu)盆狹(xia)窄頭盆不稱，軟(ruan)產(chan)道(dao)畸形盆腔腫瘤和(he)異常胎位等因素阻礙胎先露下降，子(zi)(zi)宮(gong)為(wei)克服阻力加強收(shou)縮子(zi)(zi)宮(gong)下段被迫(po)拉長變薄最(zui)終(zhong)發生子(zi)(zi)宮(gong)破裂(lie)。此種子(zi)(zi)宮(gong)破裂(lie)為(wei)子(zi)(zi)宮(gong)破裂(lie)中最(zui)常見類(lei)型，破裂(lie)處(chu)多發生于子(zi)(zi)宮(gong)下段。

2.子宮瘢痕破裂

造成(cheng)子(zi)(zi)宮(gong)(gong)瘢(ban)痕(hen)(hen)的(de)(de)原(yuan)因主要有剖宮(gong)(gong)產(chan)(chan)(chan)術(shu)，子(zi)(zi)宮(gong)(gong)肌瘤剝除(chu)術(shu)，子(zi)(zi)宮(gong)(gong)破裂或穿孔修(xiu)補術(shu)，子(zi)(zi)宮(gong)(gong)畸(ji)形(xing)(xing)矯形(xing)(xing)術(shu)等(deng)；造成(cheng)破裂的(de)(de)原(yuan)因是妊(ren)娠子(zi)(zi)宮(gong)(gong)的(de)(de)機(ji)械性(xing)牽拉導致瘢(ban)痕(hen)(hen)處破裂或者(zhe)子(zi)(zi)宮(gong)(gong)瘢(ban)痕(hen)(hen)處內膜(mo)受損，胎盤植入，穿透性(xing)胎盤導致子(zi)(zi)宮(gong)(gong)自發破裂。近些年(nian)剖宮(gong)(gong)產(chan)(chan)(chan)術(shu)迅速增(zeng)加子(zi)(zi)宮(gong)(gong)體(ti)部(bu)縱切口剖宮(gong)(gong)產(chan)(chan)(chan)再(zai)次妊(ren)娠容易并(bing)發子(zi)(zi)宮(gong)(gong)破裂，分析原(yuan)因除(chu)宮(gong)(gong)體(ti)部(bu)縱切口和下(xia)段橫切口解剖性(xing)質(zhi)不同外，還要考慮(lv)感(gan)染因素的(de)(de)作用(yong)(yong)，因為(wei)目前采用(yong)(yong)子(zi)(zi)宮(gong)(gong)體(ti)部(bu)縱切口剖宮(gong)(gong)產(chan)(chan)(chan)的(de)(de)患者(zhe)通常經過了漫(man)長的(de)(de)產(chan)(chan)(chan)程，多次陰(yin)道檢查，感(gan)染幾率(lv)增(zeng)加。

3.濫用宮縮劑

此處(chu)的(de)宮縮(suo)劑應該包括各種刺(ci)激子(zi)(zi)宮收縮(suo)的(de)物質(zhi)包括最常用(yong)的(de)縮(suo)宮素（催產素）和近些年才應用(yong)的(de)米(mi)索前(qian)列(lie)醇，報道的(de)米(mi)索前(qian)列(lie)醇導致子(zi)(zi)宮破裂的(de)病例越來越多。原因主要包括藥(yao)物劑量過(guo)大或給藥(yao)速度過(guo)快子(zi)(zi)宮頸不成熟，胎位不正(zheng)梗阻性難產，用(yong)藥(yao)期間對產程觀(guan)察(cha)不仔細等。

4.陰道助產手術損傷

宮(gong)口(kou)未開(kai)全，強行產鉗術(shu)(shu)(shu)或臀牽引術(shu)(shu)(shu)導致(zhi)子宮(gong)頸(jing)嚴重裂傷并上延(yan)到子宮(gong)下段。忽略性橫位(wei)內倒(dao)轉術(shu)(shu)(shu)，毀胎術(shu)(shu)(shu)部(bu)分人工剝離胎盤術(shu)(shu)(shu)等由于操作不當(dang)，均可以(yi)造成子宮(gong)破裂。

5.子宮(gong)畸形和(he)子宮(gong)壁發育不良

最常(chang)見的是(shi)雙角(jiao)子宮或(huo)單角(jiao)子宮。

6.子(zi)宮本身病變

多(duo)產婦多(duo)次刮宮(gong)(gong)(gong)(gong)史、感(gan)染性流(liu)產史宮(gong)(gong)(gong)(gong)腔感(gan)染史、人(ren)工剝(bo)離胎(tai)盤史、葡萄胎(tai)史等。由(you)于上(shang)述因素導致子宮(gong)(gong)(gong)(gong)內膜乃至肌壁受損，妊娠(shen)后胎(tai)盤植入或穿透，最(zui)終(zhong)導致子宮(gong)(gong)(gong)(gong)破裂。

臨床表現

1.出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)子(zi)(zi)(zi)宮(gong)(gong)破裂通(tong)常(chang)表現(xian)為(wei)(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)，出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)分為(wei)(wei)內出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)、外出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)或(huo)混(hun)合出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)。內出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)指(zhi)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)積聚于闊(kuo)韌(ren)帶(dai)內或(huo)腹腔內，導致(zhi)闊(kuo)韌(ren)帶(dai)血(xue)(xue)(xue)(xue)(xue)(xue)腫或(huo)腹腔積血(xue)(xue)(xue)(xue)(xue)(xue)；外出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)指(zhi)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)自陰道排出(chu)(chu)(chu)(chu)(chu)(chu)。子(zi)(zi)(zi)宮(gong)(gong)破裂的(de)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)部位(wei)(wei)通(tong)常(chang)包(bao)括子(zi)(zi)(zi)宮(gong)(gong)及軟(ruan)(ruan)產道破裂口和胎(tai)盤(pan)(pan)(pan)剝(bo)離(li)(li)面出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)，子(zi)(zi)(zi)宮(gong)(gong)和軟(ruan)(ruan)產道出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)通(tong)常(chang)需(xu)要損傷(shang)所在(zai)部位(wei)(wei)的(de)大血(xue)(xue)(xue)(xue)(xue)(xue)管(guan)，如(ru)果軟(ruan)(ruan)產道損傷(shang)未(wei)傷(shang)及大血(xue)(xue)(xue)(xue)(xue)(xue)管(guan)，通(tong)常(chang)不表現(xian)為(wei)(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)或(huo)活(huo)動性出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)。胎(tai)盤(pan)(pan)(pan)剝(bo)離(li)(li)面的(de)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)與(yu)胎(tai)盤(pan)(pan)(pan)剝(bo)離(li)(li)的(de)程度和子(zi)(zi)(zi)宮(gong)(gong)收縮(suo)強(qiang)度有(you)關(guan)，如(ru)果胎(tai)盤(pan)(pan)(pan)未(wei)完全剝(bo)離(li)(li)或(huo)剝(bo)離(li)(li)后(hou)未(wei)排出(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)腔，影響子(zi)(zi)(zi)宮(gong)(gong)收縮(suo)，表現(xian)為(wei)(wei)大出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)；反之(zhi)如(ru)果胎(tai)盤(pan)(pan)(pan)完全剝(bo)離(li)(li)并已經(jing)排出(chu)(chu)(chu)(chu)(chu)(chu)宮(gong)(gong)腔，子(zi)(zi)(zi)宮(gong)(gong)收縮(suo)很好(hao)，則胎(tai)盤(pan)(pan)(pan)剝(bo)離(li)(li)面少量(liang)活(huo)動性出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)。上述出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)指(zhi)術前出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)，術后(hou)亦(yi)可(ke)以(yi)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)，原因主(zhu)要為(wei)(wei)闊(kuo)韌(ren)帶(dai)血(xue)(xue)(xue)(xue)(xue)(xue)腫清除(chu)后(hou)創面出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)或(huo)DIC出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)，或(huo)保守治(zhi)療子(zi)(zi)(zi)宮(gong)(gong)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)。出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)除(chu)引(yin)起失(shi)血(xue)(xue)(xue)(xue)(xue)(xue)性休克(ke)外，還由于產婦高凝狀態(tai)，出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)(xue)(xue)過多(duo)，休克(ke)時間過長(chang)，出(chu)(chu)(chu)(chu)(chu)(chu)現(xian)DIC。

2.感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)子(zi)(zi)宮(gong)(gong)(gong)破(po)(po)裂(lie)(lie)后(hou)容(rong)易出(chu)現(xian)感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)的(de)部(bu)位主要有(you)(you)盆(pen)(pen)腔、腹腔、盆(pen)(pen)腔腹膜(mo)后(hou)和(he)軟產道(dao)。造成感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)的(de)原因(yin)主要有(you)(you)：盆(pen)(pen)腹腔或(huo)闊韌帶(dai)內與(yu)子(zi)(zi)宮(gong)(gong)(gong)腔和(he)陰道(dao)相通，相通后(hou)有(you)(you)細菌進入；子(zi)(zi)宮(gong)(gong)(gong)破(po)(po)裂(lie)(lie)后(hou)大出(chu)血(xue)，嚴(yan)重貧血(xue)或(huo)DIC，抵抗力下(xia)降容(rong)易感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)；腹腔或(huo)盆(pen)(pen)腔內的(de)積血(xue)或(huo)腹膜(mo)外的(de)積血(xue)，容(rong)易感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)；子(zi)(zi)宮(gong)(gong)(gong)破(po)(po)裂(lie)(lie)后(hou)的(de)子(zi)(zi)宮(gong)(gong)(gong)切除(chu)或(huo)修補(bu)，均于有(you)(you)菌條件下(xia)進行；子(zi)(zi)宮(gong)(gong)(gong)破(po)(po)裂(lie)(lie)后(hou)診斷期間(jian)可能有(you)(you)較(jiao)多(duo)的(de)陰道(dao)操(cao)作；時(shi)間(jian)較(jiao)久(jiu)的(de)子(zi)(zi)宮(gong)(gong)(gong)破(po)(po)裂(lie)(lie)更容(rong)易導致多(duo)部(bu)位的(de)各(ge)種感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)。另外值得(de)提出(chu)的(de)感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)是呼吸(xi)道(dao)感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)，引(yin)起(qi)感(gan)(gan)(gan)(gan)(gan)(gan)染(ran)的(de)因(yin)素很多(duo)，休(xiu)克時(shi)間(jian)過長正常呼吸(xi)道(dao)的(de)排痰和(he)防御(yu)機制受損(sun)與(yu)之有(you)(you)關，同時(shi)不(bu)能除(chu)外誤吸(xi)等因(yin)素。

3.導致產(chan)道(dao)及其他腹腔(qiang)和(he)(he)盆(pen)腔(qiang)器(qi)官(guan)組織(zhi)損(sun)傷(shang)(shang)子(zi)宮(gong)(gong)破(po)裂(lie)的損(sun)傷(shang)(shang)包括手(shou)(shou)(shou)術(shu)干(gan)預前(qian)和(he)(he)手(shou)(shou)(shou)術(shu)干(gan)預后的損(sun)傷(shang)(shang)。手(shou)(shou)(shou)術(shu)干(gan)預前(qian)的損(sun)傷(shang)(shang)包括子(zi)宮(gong)(gong)體、子(zi)宮(gong)(gong)下段、子(zi)宮(gong)(gong)頸和(he)(he)陰道(dao)的各(ge)種(zhong)損(sun)傷(shang)(shang)，同(tong)時(shi)也(ye)可能有原(yuan)發(fa)的由(you)于(yu)胎頭壓迫造成的膀(bang)胱損(sun)傷(shang)(shang)。子(zi)宮(gong)(gong)破(po)裂(lie)患者診斷(duan)過(guo)(guo)程(cheng)(cheng)和(he)(he)手(shou)(shou)(shou)術(shu)治療過(guo)(guo)程(cheng)(cheng)中的損(sun)傷(shang)(shang)很(hen)多，有時(shi)甚(shen)至超過(guo)(guo)原(yuan)發(fa)損(sun)傷(shang)(shang)。診斷(duan)過(guo)(guo)程(cheng)(cheng)中過(guo)(guo)多的不必要的陰道(dao)操作或(huo)檢查導致產(chan)道(dao)損(sun)傷(shang)(shang)加重；開腹探查術(shu)，清理積血或(huo)清理胎兒、胎盤和(he)(he)胎膜，操作不當，導致腸道(dao)或(huo)大網膜損(sun)傷(shang)(shang)；清理闊韌帶血腫，引起盆(pen)底血管(guan)輸尿管(guan)和(he)(he)膀(bang)胱損(sun)傷(shang)(shang)；子(zi)宮(gong)(gong)破(po)裂(lie)時(shi)間過(guo)(guo)長，對腹腔(qiang)器(qi)官(guan)的損(sun)傷(shang)(shang)更(geng)重。

4.對胎(tai)兒(er)的(de)影(ying)響子(zi)宮破裂后對胎(tai)兒(er)的(de)影(ying)響主要是不同時間和(he)不同程度的(de)出血造(zao)成(cheng)的(de)損傷，多數(shu)胎(tai)兒(er)死亡。存活胎(tai)兒(er)的(de)圍生(sheng)兒(er)發病率和(he)病死率明(ming)顯增(zeng)高，遠(yuan)期(qi)并發癥也明(ming)顯增(zeng)高。

診斷

診(zhen)斷完(wan)全(quan)性子(zi)宮(gong)破(po)裂(lie)(lie)一般(ban)困難不大，根據(ju)病(bing)史、分娩經過、臨床表現及體征可(ke)作(zuo)出(chu)診(zhen)斷。不完(wan)全(quan)性子(zi)宮(gong)破(po)裂(lie)(lie)只有(you)在嚴密觀察(cha)下方(fang)能發現。個別晚期妊(ren)娠破(po)裂(lie)(lie)者，只有(you)出(chu)現子(zi)宮(gong)破(po)裂(lie)(lie)的癥狀和體征時方(fang)能確診(zhen)。

個(ge)別難產病例(li)經多次陰道檢(jian)查，可能感染出現腹膜(mo)炎而表現為(wei)(wei)類似(si)子(zi)宮(gong)(gong)破(po)裂癥象。陰道檢(jian)查時由于胎先露部仍高、子(zi)宮(gong)(gong)下(xia)段菲(fei)薄，雙(shuang)合診時雙(shuang)手(shou)指相觸猶如只隔(ge)腹壁，有時容易誤(wu)診為(wei)(wei)子(zi)宮(gong)(gong)破(po)裂，這(zhe)種情(qing)況胎體(ti)不會(hui)進入腹腔，而妊娠(shen)子(zi)宮(gong)(gong)也(ye)不會(hui)縮小而位于胎體(ti)旁側。

治療

發現先兆(zhao)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)破(po)(po)(po)裂(lie)(lie)，必須立即(ji)采(cai)取有(you)效(xiao)措施抑制(zhi)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)收(shou)縮，如給乙醚全麻(ma)、肌肉注射度冷丁100mg等(deng)，以緩解子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)破(po)(po)(po)裂(lie)(lie)的進程。最好能盡快行(xing)剖(pou)宮(gong)(gong)(gong)(gong)產術(shu)，術(shu)中(zhong)注意檢(jian)查子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)是否(fou)已有(you)破(po)(po)(po)裂(lie)(lie)。子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)破(po)(po)(po)裂(lie)(lie)胎兒未娩出者(zhe)(zhe)，即(ji)使(shi)死胎也不應經陰道先娩出胎兒，這會使(shi)裂(lie)(lie)口擴大(da)，增加出血，促使(shi)感(gan)染擴散，應迅速剖(pou)腹取出死胎，視患(huan)者(zhe)(zhe)狀態(tai)、裂(lie)(lie)傷部位情況、感(gan)染程度和(he)患(huan)者(zhe)(zhe)是否(fou)已有(you)子(zi)(zi)(zi)女(nv)等(deng)綜(zong)合(he)(he)考慮，若(ruo)(ruo)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)裂(lie)(lie)口較易(yi)縫合(he)(he)、感(gan)染不嚴重、患(huan)者(zhe)(zhe)狀態(tai)欠佳時，可(ke)(ke)作裂(lie)(lie)口修補縫合(he)(he)，有(you)子(zi)(zi)(zi)女(nv)者(zhe)(zhe)結扎輸卵管(guan)，無子(zi)(zi)(zi)女(nv)者(zhe)(zhe)保留其生育(yu)功能。否(fou)則可(ke)(ke)行(xing)子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)全切除(chu)或次(ci)全切除(chu)。子(zi)(zi)(zi)宮(gong)(gong)(gong)(gong)下段破(po)(po)(po)裂(lie)(lie)者(zhe)(zhe)，應注意檢(jian)查膀胱、輸尿管(guan)、宮(gong)(gong)(gong)(gong)頸及(ji)陰道，若(ruo)(ruo)有(you)損傷，應及(ji)時修補。

子宮破裂多伴有嚴重的出血及存(cun)在感(gan)染，術前應輸血、輸液，給予乳酸(suan)鈉(na)，積極(ji)進行抗休克治療(liao)，術中、術后應用較大劑量廣譜抗生素(su)控制(zhi)感(gan)染。