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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：研究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，分为观察组和对照组，对照组给予注射卡前列素氨丁三醇治疗，观察组给予注射卡前列素氨丁三醇联合卡贝缩宫素治疗。观察两组治疗后临床疗效，并检测治疗前后NO、NOS、FIB、D-dimer水平以及泌乳功能。结果：治疗后，观察组子宫复旧有效率为93.2
2、%明显高于对照组子宫复旧有效率74.6%，差异显著（P0.05）；观察组NO、NOS、FIB、D-dimer水平均显著低于对照组，比较具有统计学意义（P0.05）；观察组术后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对照组，比较具有统计学意义（P0.05）；观察组泌乳时间低于对照，观察组产后1d泌乳量评分及产后2d泌乳量评分均高于对照组，比较具有统计学意义（P0.05）。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
3、乳时间，提高患者1d泌乳量评分及产后2d泌乳量评分。【关键词】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： 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 hemorrhageAbstract Objective: To study effects of caffeine tromethamine combi
4、ned 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 wereselected as research objects. According to different treatment options，those
5、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 Prostaglandin tromethamine combined with carbene oxytocin, the clinical efficacy of
6、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, which was significantly higher than that in the control group (74.6%). The
7、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 was lower than that in the control group (P 0.05), and the time of postoperative hemor
8、rhage, 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 significantly higher in the observation group than in the control group (P 0.05），具有可比性。连续使用两天。记录所有产妇术后
9、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采用免疫比浊法；D-dimer采用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，吸允后乳房依然没有排空为3分；手法挤奶存在奶乳汁溢出情况，哺乳时间超过8次/d，新生儿大便超1次/d，小便超5次/d，哺乳后婴儿较安全，乳房松软为2分；不能满足婴儿，需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
10、；（2）子宫复旧不良：产妇子宫收缩差。本研究数据选择spss18.0进行统计，比较计量资料采用t检验，计数资料采用2检验，等级资料比较则用秩和检验，当P0.05时表示差异显著。2结果两组产妇子宫复旧疗效比较:治疗后，观察组子宫复旧有效率为93.2%明显高于对照组子宫复旧有效率74.6%，差异显著（P0.05）；治疗后，观察组FIB、D-Dimer检测值均低于对照组FIB、D-Dimer检测值，差异具有比较意义（P0.05）；治疗后，观察组NO、NOS的水平均低于对照组NO、NOS的水平，差异具有比较意义（P0.05）。见表3。表3 两组患者治疗前后NO、NOS的水平比较（s）Table 3 C
11、omparison of NO、NOS levels between the two groups before and after treatment（s）GroupnTimeNO（ m mo l /L）NOS（U/mL）Observation group59Before treatmentAfter treatmentababControl group59Before treatmentAfter treatmentbbNote: Compared with the control group, aP0.05; Compared with Before treatment, bP 0.05
12、.2.4两组患者术后出血情况比较：3.12），差异具有统计学意义（P0.05）。见表4。表4 两组患者术后出血情况比较（s）Table 4 Comparison of postoperative bleeding in both groups（s）Groupn2 hours after surgery bleeding（ml）24 hours after surgery bleeding（ml）Postpartum hemorrhage rate n（%）Contractions lasted（h）The duration of the lochia（d）Observation group59
13、aa3（5.1）aaaControl group5911（18.6）Note: Compared with the control group, a2.5两组患者产后泌乳时间和泌乳量评分比较：0.25），差异具有统计学意义（P0.05）。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 lactation score between the two groups（s）GroupnLactation time（h）Postpartum 1d lactation score（Minute）
14、Postpartum 2d lactation score（Minute）Observation group59aaaControl group59Note: Compared with the control group, a3讨论产后出血是妇产科常见的并发症，发病原因较多，包括宫缩乏力、凝血功能障碍、胎盘组织功能异常等，其中宫缩乏力是常见的发病原因11,12。引起宫缩乏力的原因主要是产妇精神紧张、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重威胁
15、13。因此，预测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就会升高16。对产后出血具有一定的预测作用。通过D-dimer检测值变化，是判断剖宫产产后出血的危险因素17。FIB由肝脏合成糖蛋白，当水平升高时，容易形成血栓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，容易引起内细胞损伤。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变化，诊断出患者出
16、血发生率20。NO既是一种有细胞毒性的效应器，又是一种生物体许多部分的信号分子，具有较为复杂的生物学效应，促进毛细血管的渗出21,22。NO具有抑制宫缩的作用，与子宫平滑肌活动密切相关。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、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息息相关23。通过检测NO与NOS水平变化，观察产妇胎盘血流量、子宫平滑肌松弛度变化。泌乳是多种激素作用于已发育的乳腺引起的。产妇通过调节内分泌系统，促进乳腺中导管系统的生长发育，从而生乳有源，泌乳通畅。当产妇感到疼痛下丘脑可刺激催乳素抑制因子
17、，降低泌乳素分泌，抑制泌乳反射，从而延迟泌乳，减少泌乳量，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。剖宫产产妇使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情况，具有27,28。：（1）起效快，持续
18、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、雄激素水平密切相关等特点。对严重的产后出血卡贝缩宫素药效明显，需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。研究显示，单一使用卡前列素氨丁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水平变化不明显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%明高于单一使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水平均低于单一使用
19、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泌乳量评分均显著升高。由此可见，卡前列素氨丁三醇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，能够显著减少剖宫产产后出血，降低产后出血发生率，促进产后恢复，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: i
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