目的：探讨剖宫产术后患者再次妊娠时出现盆腔粘连情况的相关高危因素及对再次剖宫产手术的影响。方法选择：选取2019年1月~2021年12月之间在青岛大学附属医院行子宫下段剖宫产术的患者资料进行回顾性分析。根据术中所见将其分为两组。术中见盆腔脏器有膜状粘连或致密粘连者定义为盆腔粘连组，共计133例；盆腔脏器无粘连者为正常组，共计778例。对两组患者肌层是否连续、是否有妊娠期高血压疾病、是否有妊娠期糖尿病、两次剖宫产时间间隔、宫腔操作次数、首次术后发热、新生儿体质量、剖宫产次数、年龄、首次手术宫口开大情况、再次手术出血量、再次手术时间等数据利用SPSS26.0进行数据分析。结果：此911例患者未发生盆腔粘连患者778例，发生盆腔粘连患者133例，778例无盆腔粘连患者中妊娠高血压者60例、剖宫产次数大于2次者72例、年龄大于35岁者233例；133例有盆腔粘连患者中妊娠高血压者20例、剖宫产次数大于2次者25例、年龄大于35岁者50例，差别有统计学意义(P分别为0.006、0.001、0.038、0.004)。未发生盆腔粘连的778例患者中再次手术时间大于40分钟者578例，发生盆腔粘连的133例患者中手术时间大于40分钟者114例，差别有统计学意义(P为0.004)。结论：妊娠相关高血压患者、剖宫产次数大于2次、年龄大于35岁者易发生盆腔粘连，且出现盆腔粘连后再次手术时间较普通剖宫产时间长。 Objective: To investigate the high risk factors of pelvic adhesions in patients with second pregnancy after cesarean section and their influence. Methods Selection: The data of patients who underwent lower segment cesarean section in the Affiliated Hospital of Qingdao University from January 2019 to December 2021 were retrospectively analyzed. They were divided into two groups according to the intraoperative findings. Pelvic organs with membranous or dense adhesions were defined as pelvic adhesions group (133 cases in total); there were 778 normal cases without pelvic organ ad-hesion. SPSS26.0 was used to analyze the data of the two groups of patients on whether the muscu-lar layer was continuous, whether they had hypertensive disorder complicating pregnancy, whether they had diabetes complicating pregnancy, the interval between two cesarean sections, the number of uterine cavity operations, whether they had fever after the first operation, the body mass of the newborn, the number of cesarean sections, age, the opening of the uterine orifice during the first operation, the amount of bleeding during the second operation, and the time of the second opera-tion. Results: Of the 911 patients, 778 had no pelvic adhesions, 133 had pelvic adhesions. Among the 778 patients without pelvic adhesions, 60 had pregnancy induced hypertension, 72 had cesar-ean section more than twice, and 233 were older than 35 years; Among the 133 patients with pelvic adhesions, 20 had pregnancy induced hypertension, 25 had cesarean section more than twice, and 50 were older than 35 years old. The differences were statistically significant (P = 0.006, 0.001, 0.038, 0.004). Among 778 patients without pelvic adhesions, 578 patients underwent reoperation for more than 40 minutes, and among 133 patients with pelvic adhesions, 114 patients underwent reoperation for more than 40 minutes, the difference was statistically significant (P = 0.004). Con-clusion: Patients with pregnancy related hypertension, those with more than two caesarean sec-tions and those over 35 years old are prone to pelvic adhesions, and the reoperation time after pel-vic adhesions is longer than that of ordinary caesarean sections.
目的：探讨剖宫产术后患者再次妊娠时出现盆腔粘连情况的相关高危因素及对再次剖宫产手术的影响。方法选择：选取2019年1月~2021年12月之间在青岛大学附属医院行子宫下段剖宫产术的患者资料进行回顾性分析。根据术中所见将其分为两组。术中见盆腔脏器有膜状粘连或致密粘连者定义为盆腔粘连组，共计133例；盆腔脏器无粘连者为正常组，共计778例。对两组患者肌层是否连续、是否有妊娠期高血压疾病、是否有妊娠期糖尿病、两次剖宫产时间间隔、宫腔操作次数、首次术后发热、新生儿体质量、剖宫产次数、年龄、首次手术宫口开大情况、再次手术出血量、再次手术时间等数据利用SPSS26.0进行数据分析。结果：此911例患者未发生盆腔粘连患者778例，发生盆腔粘连患者133例，778例无盆腔粘连患者中妊娠高血压者60例、剖宫产次数大于2次者72例、年龄大于35岁者233例；133例有盆腔粘连患者中妊娠高血压者20例、剖宫产次数大于2次者25例、年龄大于35岁者50例，差别有统计学意义(P分别为0.006、0.001、0.038、0.004)。未发生盆腔粘连的778例患者中再次手术时间大于40分钟者578例，发生盆腔粘连的133例患者中手术时间大于40分钟者114例，差别有统计学意义(P为0.004)。结论：妊娠相关高血压患者、剖宫产次数大于2次、年龄大于35岁者易发生盆腔粘连，且出现盆腔粘连后再次手术时间较普通剖宫产时间长。
子宫下段剖宫产术，瘢痕子宫，盆腔粘连，再次手术
Shenglong Xu1, Hui Wang2, Fumin Zheng2, Gaona Zhang1, Ying Zhan2*
1Medical Science Center of Qingdao University, Qingdao Shandong
2Department of Obstetrics, Affiliated Hospital of Qingdao University, Qingdao Shandong
Received: Nov. 26th, 2022; accepted: Dec. 23rd, 2022; published: Dec. 30th, 2022
Objective: To investigate the high risk factors of pelvic adhesions in patients with second pregnancy after cesarean section and their influence. Methods Selection: The data of patients who underwent lower segment cesarean section in the Affiliated Hospital of Qingdao University from January 2019 to December 2021 were retrospectively analyzed. They were divided into two groups according to the intraoperative findings. Pelvic organs with membranous or dense adhesions were defined as pelvic adhesions group (133 cases in total); there were 778 normal cases without pelvic organ adhesion. SPSS26.0 was used to analyze the data of the two groups of patients on whether the muscular layer was continuous, whether they had hypertensive disorder complicating pregnancy, whether they had diabetes complicating pregnancy, the interval between two cesarean sections, the number of uterine cavity operations, whether they had fever after the first operation, the body mass of the newborn, the number of cesarean sections, age, the opening of the uterine orifice during the first operation, the amount of bleeding during the second operation, and the time of the second operation. Results: Of the 911 patients, 778 had no pelvic adhesions, 133 had pelvic adhesions. Among the 778 patients without pelvic adhesions, 60 had pregnancy induced hypertension, 72 had cesarean section more than twice, and 233 were older than 35 years; Among the 133 patients with pelvic adhesions, 20 had pregnancy induced hypertension, 25 had cesarean section more than twice, and 50 were older than 35 years old. The differences were statistically significant (P = 0.006, 0.001, 0.038, 0.004). Among 778 patients without pelvic adhesions, 578 patients underwent reoperation for more than 40 minutes, and among 133 patients with pelvic adhesions, 114 patients underwent reoperation for more than 40 minutes, the difference was statistically significant (P = 0.004). Conclusion: Patients with pregnancy related hypertension, those with more than two caesarean sections and those over 35 years old are prone to pelvic adhesions, and the reoperation time after pelvic adhesions is longer than that of ordinary caesarean sections.
Keywords:Lower Uterine Section Cesarean Section, Scarred Uterus, Pelvic Adhesions, Reoperation
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剖宫产的出现解决了难产、产道裂伤等风险，但部分患者手术后会出现盆腔粘连的情况。盆腔粘连的情况一旦发生，不仅可能造成慢性盆腔疼痛、排尿困难等症状，严重影响患者生活质量，部分患者可能出现不孕、异位妊娠、肠梗阻等后果，对患者身体健康造成影响 [
收集我院2019年1月~2021年12月期间在我院行子宫下段剖宫产术的患者共计911例，并根据盆腔粘连情况将其分为盆腔粘连组及无盆腔粘连组。回顾其年龄、剖宫产次数、术前是否有高血压疾病、糖尿病疾病、剖宫产时间间隔、宫腔操作次数、初次手术后是否有发热、初次手术新生儿体重、初次手术宫口开大情况等信息，同时记录术中肌层是否连续、术中出血量、本次手术时间等数据。所有产妇及家属均已签署知情同意书，本研究经青岛大学附属医院伦理委员会批准。
参照《妇科手术后盆腹腔粘连预防及诊断的专家共识(2020年版)》 [
纳入标准：① 均有剖宫产手术史，符合瘢痕子宫诊断标准；② 孕36周~41周，单胎；③ 临床资料完整。排除标准：① 患有血液系统疾病；② 合并严重脏器功能不全；③ 彩超提示胎儿发育异常。
将所收集的所有患者资料进行整理，并录入Excal表格，将收集的每项内容进行编码，导入SPSS26.0软件进行数据分析，计量资料均经Shapiro-Wilk非正态性检验，分类变量采用c2，相关因素检验水准α = 0.05。采用多元Logistic回归分析盆腔粘连相关高危因素。
911例患者中发生盆腔粘连的患者有133例，发生比例为14.60%，未发生盆腔粘连患者有778例，比例为85.40%。
778例无盆腔粘连患者中有60例高血压患者，133例盆腔粘连患者中有20例高血压患者，P = 0.006，差别有统计学意义。
778例无盆腔粘连患者中有72例剖宫产次数 > 2次，133例盆腔粘连患者中有25例剖宫产次数 > 2次，P = 0.001，差别有统计学意义。
778例无盆腔粘连患者中有233例年龄大于35岁，133例盆腔粘连患者中有50例年龄 > 35岁，P = 0.038，差别有统计学意义(见表1)。
患者剖宫产次数大于2次及合并高血压疾病是盆腔粘连的独立危险因素(P均为0.011)，OR分别为1.961和2.039，95%CI分别为1.163~3.304和1.175~3.538 (见表2及图1)。
| 盆腔粘连[例(%)] | 统计值 | P | ||
|---|---|---|---|---|
| 无(n 778) | 有(n 133) | |||
| 妊娠期糖尿病相关 | ||||
| 否 | 597 (76.7%) | 97 (72.9%) | c2= 0.905 | 0.341 |
| 是 | 181 (23.3%) | 36 (27.1%) | ||
| 妊娠期高血压相关 | ||||
| 否 | 718 (92.3%) | 113 (85.0%) | c2= 7.609 | 0.006 |
| 是 | 60 (7.7%) | 20 (15.0%) | ||
| 剖宫产时间间隔 | ||||
| <2年 | 15 (1.9%) | 6 (4.5%) | c2= 3.366 | 0.067 |
| ≥2 | 763 (98.1%) | 127 (95.5%) | ||
| 宫腔操作次数 | ||||
| 0次 | 488 (92.2%) | 81 (60.9%) | c2= 0.161 | 0.688 |
| ≥1次 | 290 (7.8%) | 52 (39.1%) | ||
| 术后发热 | ||||
| 否 | 717 (92.2%) | 120 (90.2%) | c2= 0.569 | 0.451 |
| 是 | 61 (7.8%) | 13 (9.8%) | ||
| 新生儿体重 | ||||
| <3500 g | 399 (43.6%) | 60 (45.1%) | c2= 1.731 | 0.188 |
| ≥3500 g | 379 (56.4%) | 73 (54.9%) | ||
| 剖宫产次数 | ||||
| 2次 | 706 (90.7%) | 108 (81.2%) | c2= 10.871 | 0.001 |
| >2次 | 72 (9.3%) | 25 (18.8%) | ||
| 初次手术宫口开大 | ||||
| 未开 | 693 (89.1%) | 118 (88.7%) | c2= 0.014 | 0.904 |
| ≥1 cm | 85 (10.9%) | 15 (11.3%) | ||
| 初次手术宫口开大 | ||||
| 1~4 cm | 697 (89.6%) | 123 (92.5%) | c2= 1.057 | 0.304 |
| >4 cm | 81 (10.4%) | 10 (7.5%) | ||
| 初次手术宫口开大 | ||||
| <10 cm | 743 (95.5%) | 128 (96.2%) | c2= 0.148 | 0.701 |
| 10 cm | 35 (4.5%) | 5 (3.8%) | ||
| 年龄 | ||||
| <35岁 | 555 (71.3%) | 83 (62.4%) | c2= 4.317 | 0.038 |
| ≥35岁 | 233 (28.7%) | 50 (37.6%) | ||
表1. 盆腔粘连相关因素分析
| 自变量 | β | S.E | Wald | P | OR | 95%CI |
|---|---|---|---|---|---|---|
| 病人年龄 ≥ 35岁 | 0.293 | 0.205 | 2.036 | 0.154 | 1.341 | 0.896~2.005 |
| 剖宫产次数 > 2次 | 0.673 | 0.266 | 6.390 | 0.011 | 1.961 | 1.163~3.304 |
| 高血压 | 0.712 | 0.281 | 6.419 | 0.011 | 2.039 | 1.175~3.538 |
表2. 盆腔粘连多因素Logistic回归分析
图1. 盆腔粘连多因素logistic回归分析
两组患者肌层连续性及本次手术出血量之间无明显差异(P分别为0.771、0.231)。
778例无盆腔粘连患者中有200例手术时间 > 40分钟，133例盆腔粘连患者中有114例手术时间 > 40分钟，P = 0.004，差别有统计学意义(见表3)。
| 盆腔粘连[例(%)] | 统计值 | P | ||
|---|---|---|---|---|
| 无(n 778) | 有(n 133) | |||
| 肌层连续性 | ||||
| 否 | 20 (2.6%) | 758 (97.4%) | c2= 0.084 | 0.771 |
| 是 | 4 (3.0%) | 129 (97.0%) | ||
| 出血量 | ||||
| <1000 ml | 679 (87.3%) | 111 (83.5%) | c2= 1.436 | 0.231 |
| ≥1000 ml | 99 (12.7%) | 22 (16.5%) | ||
| 手术时间 | ||||
| ≤40 min | 200 (25.7%) | 19 (14.3%) | c2= 8.114 | 0.004 |
| >40 min | 578 (74.3%) | 114 (85.7%) | ||
表3. 盆腔粘连患者本次手术数据对比
剖宫产的出现确实解决了部分难产问题，保证了母儿安全，是临床上不可或缺的操作。盆腔粘连作为剖宫产术后常见的并发症之一，不仅可能导致慢性盆腔痛，影响患者生活质量，甚至可能出现肠梗阻等严重后果。术前及时预测患者可能出现盆腔粘连，从而在术中或术后尽快采取应对措施，可以降低盆腔粘连的发生率 [
孙利业 [
妊娠期高血压相关疾病其病理机制为全身小血管痉挛，此种状况下血管对瘢痕恢复提供血供减少，不利于瘢痕恢复，且妊娠相关高血压患者术后可能存在血压波动，关腹腔后瘢痕处或腹壁、腹膜处有再次出血可能，此种情况下大网膜及肠道可能粘连于此，增加剖宫产后盆腔粘连发生几率。而且部分妊娠期高血压疾病如子痫前期患者合并低蛋白血症，或术后应用硫酸镁导致下地活动减少，更增加了其发生盆腔粘连的风险 [
既往也有多次研究表明剖宫产后盆腔粘连的发生率随剖宫产次数增多而不断提高，Hesselman Susanne [
具有盆腔粘连的患者虽然术中出血量未见明显增多，但手术时间明显延长，术后感染等并发症也会相应增加。
综上所述，患者术前合并高血压疾病、剖宫产次数 > 2次、年龄 > 35岁，是剖宫产术后发生盆腔粘连的高危因素。手术医生对该类产妇术前需提高警惕，此类患者出现盆腔粘连可能性高，术中应仔细操作，避免周围器官损伤。术中可以选择放置防粘连材料，术后嘱患者及早、适度下地活动。有盆腔粘连患者其手术时间相对较长，应适当延长抗生素使用时间。
徐圣龙,王 慧,郑富民,张高娜,詹 瑛. 剖宫产术后发生盆腔粘连的相关因素分析Analysis of Correlative Factors of Pelvic Adhesions after Cesarean Section[J]. 临床医学进展, 2022, 12(12): 12166-12172. https://doi.org/10.12677/ACM.2022.12121752
https://doi.org/10.1055/s-0042-101545
https://doi.org/10.1111/1471-0528.14708