瘢痕妊娠险象环生 宫腹腔镜联合狙击出血Scar, pregnancy, risk, environs, laparoscopy, combined sniper bleeding.转载2008-8-2

2008年8月2日12点，40岁的余女士，曾经有2次剖宫产史，现停经50天，B超提示胎停育，行清宫术，术中出血达到1500ml，压迫，催产素，止血药无效，输血400ml，急用球囊50ml压迫止血，出血停止。18时为慎重起见，争得患者和家属同意，行宫腹联合检查：

At 12 o'clock on August 2, 2008, Ms. Yu, who was 40 years old, had two Caesarean sections. She was currently suspended for 50 days. B Super suggested that the fetus should be stopped, and the operation of the palace was performed. The bleeding reached 1500ml, oppression, and oxytocin. The hemostatic drug is invalid, blood transfusion is 400ml, and emergency vesicles are 50ml pressed to stop bleeding. Bleeding stops. At 18:00, for the sake of prudence, the patient and his family agreed to jointly check the abdomen of the palace:

术中见切口网膜征，子宫前壁广泛肌性粘连在腹前壁上，分离粘连后见子宫下段膨隆，宫体形态正常，整个子宫哑铃型。释放水囊，宫下段膨隆消失子宫恢复常态，进宫腔镜见:子宫底及其侧壁，无出血面，子宫内口上方附着血块，去掉后有活动出血，用电滚反复凝固出血点，效果不佳，总有上方空旷无底感，怀疑已经透顶，腹腔镜下打开膀胱腹膜反折，暴露子宫下段，果然见到下段有1cm的极薄透顶现象，1号可吸收线八字缝合3针，修复薄弱宫壁，出血立刻停止，随后关闭腹膜。

During the operation, the incision membrane was characterized, and the anterior wall of the uterus was extensively muscle-bonded to the anterior wall of the abdomen. After separation and adhesion, it was seen that the lower segment of the uterus was dilated, the uterine form was normal, and the entire uterus was dumbbell. Release the water sac, the lower part of the palace to disappear the uterus to restore the normal state, into the uterine cavity mirror: the bottom of the uterus and its side wall, no hemorrhagic surface, the upper part of the uterus mouth attached to the blood clot, after removal of active bleeding, the use of electric roll repeatedly solidified bleeding point, poor effect, There is always an empty and bottomless feeling above. It is suspected that the bladder peritoneum has been turned upside down under laparoscopy and exposed to the lower segment of the uterus. It is true that there is a very thin phenomenon of 1cm in the lower segment. 3 stitches, repair the weak palace wall, bleeding will stop immediately, Then close the peritoneum.

术后诊断：剖腹产术后子宫下段瘢痕妊娠。Postoperative diagnosis: post-caesarean section post-uterine scar pregnancy.

体会：止血宫缩剂纯属扯淡，诊断不清治疗不灵。宫腹联合狙击瘢痕妊娠效果优良。水囊压迫效果也很好，此例看到水囊正好压在出血处，分析是因为此处薄弱水囊易进入所致。宫腹腔镜检查去除粘连修复瘢痕损伤更是一劳永逸。

Experience: Hemostasis agent is pure nonsense, the diagnosis is unclear treatment is not effective. The combination of uterine abdomen and sniper scar pregnancy has a good effect. The pressure effect of the water sac is also very good. In this case, the water sac is just pressed in the bleeding area. The analysis is due to the fact that the weak water sac is easy to enter here. Palace laparoscopy to remove adhesion repair scar injury is once and for all.

讨论：剖宫产术后瘢痕妊娠在临床上十分罕见,其发生率为0.45‰，近年来随着剖宫率逐年提高,此类病变的发生也有上升趋势,而目前对其临床表现,诊断,治疗尚无统一标准.为此,作者发表报道,旨在提高对剖宫产术后瘢痕妊娠的认识及诊治水平.

Discussion: post-cesarean section scar pregnancy is very rare in clinic, its incidence rate is 0.45 ‰, with the cesarean section rate increasing year by year in recent years, the occurrence of such lesions also has an increasing trend, and at present there is no unified standard for clinical performance, diagnosis, and treatment. For this reason, The author reported to improve the diagnosis and treatment of scar pregnancy after cesarean section.