卡前列素氨丁审稿三醇联合卡贝缩宫素对剖宫产后出血患者no、nos、fib、d-dimer及泌乳功能影响1（1）.docx

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1、卡前列素氨丁审稿三醇联合卡贝缩宫素对剖宫产后出血患者no、nos、fib、d-dimer及泌乳功能影响1（1）卡前列素氨丁三醇联合卡贝缩宫素对剖宫产后出血患者NO、NOS、FIB、D-dimer及泌乳功能的影响 摘要目的：探讨卡前列素氨丁三醇联合卡贝缩宫素对剖宫产后出血患者一氧化氮（NO）、一氧化氮合酶（NOS）、纤维蛋白原( FIB)、D-二聚体( D-dimer)及泌乳功能的影响。方法：选取我院2015年6月至2017年6月具有剖宫产手术指证的孕产妇119例，分为视察组和比照组，比照组赐予注射卡前列素氨丁三醇治疗，视察组赐予注射卡前列素氨丁三醇联合卡贝缩宫素治疗。视察两组治疗后临床疗效，并

2、检测治疗前后NO、NOS、FIB、D-dimer水平以及泌乳功能。结果：治疗后，视察组子宫复旧有效率为93.2%明显高于比照组子宫复旧有效率74.6%，差异显著（P<0.05）；视察组NO、NOS、FIB、D-dimer水平均显著低于比照组，比较具有统计学意义（P<0.05）；视察组术后2h出血量、术后24h出血量、产后出血率、宫缩持续时间及恶露持续时间均低于比照组，比较具有统计学意义（P<0.05）；视察组泌乳时间低于比照，视察组产后1d泌乳量评分及产后2d泌乳量评分均高于比照组，比较具有统计学意义（P<0.05）。结论:卡前列素氨丁三醇联合卡贝缩宫素治疗剖宫产产后出

3、血患者，有效降低患者NO、NOS、FIB、D-dimer水平及2h出血量、术后24h出血量、产后出血率、宫缩持续时间及恶露持续时间，改善患者泌乳时间，提高患者1d泌乳量评分及产后2d泌乳量评分。卡前列素氨丁三醇；卡贝缩宫素；NO；FIB；D-dimer；NOS；剖宫产产后出血 中图分类号：R714.62 文献标识码：A 文章编号： Effects of caffeine tromethamine combined with carbene oxytocin on NO, NOS, FIB, D-dimer and lactation in patients with postpartum he

4、morrhage Abstract Objective: To study effects of caffeine tromethamine combined with carbene oxytocin on NO, NOS, FIB, D-dimer and lactation in patients with postpartum hemorrhage. Methods: 118 patients of cesarean section bleeding whoreceived therapy from June 2015 to June 2017in our hospital weres

5、elected as research objects. According to different treatment options，those patients were divided into the control group ( n = 59) and the observation group ( n = 59)，the control group was treated withCard prostaglandin tromethamine drug therapy, while the observation group was treated with Prostagl

6、andin tromethamine combined with carbene oxytocin, the clinical efficacy of the two groups was observed and the levels of NO, NOS, FIB, D-dimer and lactation were measured before and after treatment. Results: After treatment, the effective rate of uterine recovery was 93.2% in the observation group,

7、 which was significantly higher than that in the control group (74.6%). The difference was significant (P <0.05).the levels of NO, NOS, FIB and D-dimer in the observation group were significantly lower than those in the control group (P <0.05). the time of lactation in the observation group wa

8、s lower than that in the control group (P <0.05), and the time of postoperative hemorrhage, postpartum hemorrhage rate, duration of uterine contusion and duration of lochia were lower than those of the control group (P <0.05). The scores of lactation and postpartum 2d lactation were significan

9、tly higher in the observation group than in the control group (P <0.05).Conclusion: the levels of NO, NOS, FIB, D-dimer and 2h bleeding in patients with postpartum hemorrhage were significantly lower than those in patients with postpartum hemorrhage. Duration and duration of lochia, improve the t

10、ime of lactation, improve the 1d lactation score and postpartum 2d lactation score. key words Pentoprostin; Cobia oxytocin; NO; FIB; D-dimer; NOS; cesarean section postpartum hemorrhage Chinese Library Classification(CLC): R714.62 Document code: A Article ID: 产后出血是产妇死亡的重要因素1。引起产妇出血的缘由有：（1）产妇过于惊慌的精神状

11、况，引起子宫收缩力变差，导致产后出血；（2）胎盘滞留，包括胎盘剥落不全，胎盘粘连等；（3）凝血功能障碍，产妇有血液病、肝炎等要高度高危因素2。因此，须做好产前检查，对有血液病、肝炎以及有多次刮宫史的产妇提前入院视察，备好血，预防在分娩时出现意外3。剖宫产后出血与正常阴道分娩比较，剖宫产产妇产后出血发生率较高，产后出血的病因中，大部分是由于子宫收缩乏力引起，因此，预防子宫乏力性出血具有重要的临床意义4,5。卡前列素氨丁三醇能够提高钙离子浓度从而刺激促进子宫平滑肌收缩，对预防产后出血和治疗有肯定的疗效6。卡贝缩宫素属于一种催产素，特地用于预防和治疗宫缩乏力引起的产后出血，与传统的缩宫素制剂比较，具

12、有起效快、效果长久和便捷等特点7,8。卡前列素氨丁三醇联合卡贝缩宫素治疗剖宫产产后出血患者，具有良好的临床疗效，有效提高患者康复率，降低产妇FIB、D-Dimer检测值和NO与NOS水平，对产后出血量降到最低，提高产妇泌乳量评分。本文旨在探讨卡前列素氨丁三醇联合卡贝缩宫素对剖宫产后出血患者NO、NOS、FIB、D-dimer及泌乳功能的影响，现将结果报道如下。1材料与方法 1.1一般资料 选取我院2015年6月至2017年6月具有剖宫产手术指证的孕产妇119例，纳入标准9：（1）本人及家属知情并签署同意书；（2）全部产妇均符合剖宫产诊断指标。解除标准：（1）患有高血压、心脏病者；（2）患有重肝

13、炎者及血液疾病者。将入选患者依据治疗方案不同分为视察组（n=59），年龄2236岁，平均年龄（31.494.49）岁；孕周3744周，平均（39.425.53）周；剖宫产手术指证：巨大儿33例，羊水过多11例，多胎妊娠及双胎15例。比照组（n=59），年龄2138岁，平均年龄（29.193.39）岁；孕周3541周，平均（37.524.93）周；剖宫产手术指证：巨大儿27例，羊水过多19例，多胎妊娠及双胎13例。两组产妇年龄、孕周等方面比较无统计学意义（P>0.05），具有可比性。1.2方法 全部产妇均采纳子宫下段横切口剖宫产术，胎儿娩出后，比照组赐予卡前列素氨丁三醇注射液（生产厂家：P

14、harmacia Upjohn company ，1ml：250g，进口药物注册证号：H20120388）250 g 宫体内注射，术后2h再注射一次。视察组在比照组治疗基础上联合运用卡贝缩宫素（辉凌制药有限公司， 每支100g：1ml ，20150101）100g：(1ml)，静脉注射，连续运用两天。1.3视察指标 记录全部产妇术后2、24h出血量，产后出血发生率、子宫收缩持续时间、恶露持续时间。FIB采纳免疫比浊法；D-dimer采纳ELISA法检测。产后出血量计算方法：出血量=胎儿娩出后接血敷料湿重( g)接血前敷料干重( g) /1. 05( 血液比重， g/mL) 。泌乳时间为胎盘娩出

15、后至乳房第一次溢乳时间；泌乳量评分：挤奶乳汁表现为喷射状，吸允后乳房依旧没有排空为3分；手法挤奶存在奶乳汁溢出状况，哺乳时间超过8次/d，新生儿大便超1次/d，小便超5次/d，哺乳后婴儿较平安，乳房松软为2分；不能满意婴儿，须要添加一些代乳品为1分；没有乳汁分泌为0分。疗效标准参照相关文献进行10：（1）子宫复旧良好：产妇子宫收缩好；（2）子宫复旧不良：产妇子宫收缩差。1.4统计学分析 本探讨数据选择spss18.0进行统计，比较计量资料采纳t检验，计数资料采纳2检验，等级资料比较则用秩和检验，当P<0.05时表示差异显著。2结果 2.1两组产妇子宫复旧疗效比较:治疗后，视察组子宫复旧有

16、效率为93.2%明显高于比照组子宫复旧有效率74.6%，差异显著（P<0.05），见表1。表1 两组产妇子宫复旧疗效比较n/(%) Table 1 Comparison of efficacy of two groupsn/(%) Group n The uterus is well restored Improved uterine healing Uterine bad old Efficient Observation group 59 35（59.3） 20（33.9） 4（6.8） 93.2 a Control group 59 29（49.2） 15（25.4） 15（25.

17、4） 74.6 Note: Compared with the control group, a P0.05. 2.2两组患者治疗前后FIB、D-Dimer的检测值比较：治疗前，两组FIB、D-Dimer检测值均无比较意义（P>0.05）；治疗后，视察组FIB、D-Dimer检测值均低于比照组FIB、D-Dimer检测值，差异具有比较意义（P<0.05）。见表2。表2 两组患者治疗前后FIB、D-Dimer的检测值比较（s） Table 2 Comparison of FIB, D-Dimer between the two groups before and after trea

18、tment（s） Group n Time FIB（g/L） D-Dimer（mg/L） Observation group 59 Before treatment 4.690.58 3.550.38 After treatment 3.470.45ab 1.220.25ab Control group 59 Before treatment 4.660.50 3.540.37 After treatment 4.620.49b 3.460.35b Note: Compared with the control group, aP0.05; Compared with Before treat

19、ment bP 0.05. 2.3两组患者治疗前后NO、NOS的水平比较：治疗前两组NO、NOS的水平均无比较意义（P>0.05）；治疗后，视察组NO、NOS的水平均低于比照组NO、NOS的水平，差异具有比较意义（P<0.05）。见表3。表3 两组患者治疗前后NO、NOS的水平比较（s） Table 3 Comparison of NO、NOS levels between the two groups before and after treatment（s） Group n Time NO（ m mo l /L） NOS（U/mL） Observation group 59 B

20、efore treatment 105.2411.37 38.324.71 After treatment 41.325.27ab 18.282.58ab Control group 59 Before treatment 103.3311.21 37.674.77 After treatment 88.199.38b 31.564.01b Note: Compared with the control group, aP0.05; Compared with Before treatment, bP <0.05. 2.4两组患者术后出血状况比较：视察组术后2h出血量为（235.3235

21、.19）、术后24h出血量为（301.3434.11）、产后出血率为（5.1%）、宫缩持续时间为（1.550.23）及恶露持续时间为（15.332.87）均低于比照组术后2h出血量为（367.8340.89）、术后24h出血量为（453.1949.35）、产后出血率为（18.6%）、宫缩持续时间为（3.270.42）及恶露持续时间为（21.193.12），差异具有统计学意义（P<0.05）。见表4。表4 两组患者术后出血状况比较（s） Table 4 Comparison of postoperative bleeding in both groups（s） Group n 2 hour

22、s after surgery bleeding（ml） 24 hours after surgery bleeding（ml） Postpartum hemorrhage rate n（%） Contractions lasted（h） The duration of the lochia（d） Observation group 59 235.3235.19a 301.3434.11a 3（5.1）a 1.550.23a 15.332.87a Control group 59 367.8340.89 453.1949.35 11（18.6） 3.270.42 21.193.12 Note:

23、 Compared with the control group, aP0.05 2.5两组患者产后泌乳时间和泌乳量评分比较：视察组泌乳时间为（20.383.18）低于比照组泌乳时间（27.083.53）；视察组产后1d泌乳量评分为（1.570.26）及产后2d泌乳量评分为（1.970.31）均高于比照组产后1d泌乳量评分为（1.210.19）及产后2d泌乳量评分为（1.530.25），差异具有统计学意义（P<0.05）。见表5。表5 两组患者产后泌乳时间和泌乳量评分比较（s） Table 5 Comparison of postpartum lactation time and lac

24、tation score between the two groups（s） Group n Lactation time（h） Postpartum 1d lactation score（Minute） Postpartum 2d lactation score（Minute） Observation group 59 20.383.18a 1.570.26a 1.970.31a Control group 59 27.083.53 1.210.19 1.530.25 Note: Compared with the control group, aP0.05 3探讨 产后出血是妇产科常见的并

25、发症，发病缘由较多，包括宫缩乏力、凝血功能障碍、胎盘组织功能异样等，其中宫缩乏力是常见的发病缘由11,12。引起宫缩乏力的缘由主要是产妇精神惊慌、体质虚弱、子宫肌壁损伤及患有慢性疾病等。剖宫产与正常阴道分娩比较，剖宫产产妇一般存在巨大儿、多胎妊娠、前置胎盘等高危因素，加上麻醉、手术等影响，产后出血率显著提高，对剖宫产产妇及新生儿造成严峻威逼13。因此，预料剖宫产产后出血史剖宫产手术过程中的一个重要环节14。D-dimer是交联纤维蛋白的一种降解产物，主要反映纤维蛋白溶解功能15。机体血管内有活化的血栓形成及纤维溶解活动，D-dimer就会上升16。对产后出血具有肯定的预料作用。通过D-dime

26、r检测值改变，是推断剖宫产产后出血的危急因素17。FIB由肝脏合成糖蛋白，当水平上升时，简单形成血栓18。是一种由是一种由A、B和v链组成的二聚体，存在于吸附血浆中19。具有促进血小板聚集、平滑肌的生长、内皮细胞的收缩、增加血液粘滞性等作用，简单引起内细胞损伤。对预防和治疗剖宫产出血患者具有重要临床意义，通过检测产妇FIB改变，诊断出患者出血发生率20。NO既是一种有细胞毒性的效应器，又是一种生物体很多部分的信号分子，具有较为困难的生物学效应，促进毛细血管的渗出21,22。NO具有抑制宫缩的作用，与子宫平滑肌活动亲密相关。NOS是机体内的一氧化合成的限速酶，其活性与NO水平相关。产妇的子宫肌层

27、、胎盘组织等存在不同的NOS活性，产妇在妊娠中期检测到NOS的稳定表达，与宫缩乏力性产后出血的发生休戚相关23。通过检测NO与NOS水平改变，视察产妇胎盘血流量、子宫平滑肌松弛度改变。泌乳是多种激素作用于已发育的乳腺引起的。产妇通过调整内分泌系统，促进乳腺中导管系统的生长发育，从而生乳有源，泌乳通畅。当产妇感到难受下丘脑可刺激催乳素抑制因子，降低泌乳素分泌，抑制泌乳反射，从而延迟泌乳，削减泌乳量，降低乳汁中的蛋白质含量。新生儿吸吮乳头的刺激和挤奶时人工按摩乳房的刺激，都可影响泌乳活动，组织乳腺的发育，切断乳腺神经24。卡前列素氨丁三醇又称为欣母沛，是前列腺2a的一种衍生物，通过提高肌细胞内钙离

28、子浓度形成诱发平滑肌收缩的机制达到刺激子宫肌层协调有力收缩的作用25。可有效预防产妇产后出血状况，生物活性明显高于传统前列腺素类药物。剖宫产产妇运用该药可促进子宫肌肉收缩，在胎盘处发挥止血效果，一旦注入宫体，即可快速通过血液循环发挥药效，一刻钟后达到最高药物浓度26。卡贝缩宫素在临床用于防治产后出血状况，具有27,28。：（1）起效快，持续时间短，需反复多次用药；（2）对子宫上段收缩有刺激作用；（3）子宫平滑肌的敏感性与孕激素、雄激素水平亲密相关等特点。对严峻的产后出血卡贝缩宫素药效明显，须要加用其他子宫收缩剂。但价钱比其他传统缩宫素贵，不属于常规用药29,30。探讨显示，单一运用卡前列素氨丁

29、三醇治疗剖宫产后出血患者，有效率较低，且患者FIB、D-Dimer检测值及NO和NOS水平改变不明显30。卡前列素氨丁三醇联合卡贝缩宫素产妇子宫复旧有效率93.2%明高于单一运用卡前列素氨丁三醇产妇子宫复旧有效率74.6%，效果显著，具有比较意义。卡前列素氨丁三醇联合卡贝缩宫患者中FIB、D-Dimer检测值及NO、NOS水平均低于单一运用卡前列素氨丁三醇的患者；联合用药者的术后2h出血量和术后24h出血量及产后出血率均低于单一用药者，且宫缩持续时间与恶露持续时间均明显高于单一用药者；联合用药者泌乳时间低于单一用药者，产后1d泌乳量评分与产后2d泌乳量评分均显著上升。由此可见，卡前列素氨丁三醇

30、联合卡贝缩宫素治疗剖宫产后出血患者效果显著，具有临床意义。综上所述，卡前列素氨丁三醇联合卡贝缩宫素对剖宫产后出血患者是一种预防方案，能够显著削减剖宫产产后出血，降低产后出血发生率，促进产后复原，值得在临床上推广应用。参考文献： 1 Straface G,Bassi E,De Santis M,et al. Tranfusion risk: is “two-step“ vaginal delivery a risk for postpartum hemorrhage J. The journal of maternal-fetal neonatal medicine : the official

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