분만중 자연자궁파열의 1 예

안정례(CR Ahn),이순해(SB Rhee),전춘희(HC Chun),조면호(MH Cho) 대한산부인과학회 1967 Obstetrics & Gynecology Science Vol.10 No.2

In the 6 year period from Jan. 1961 to Dec. 1966, a single case of spontaneous rupture of intact preg- nant uterus during labor was experienced in a total of 11,111 deliveries at Ewhn Womans University Hospital, Seoul. The patient, gravida 7, para 3, 31 year of age, term pregnant woman was admitted into the labor room in Nov. 30, 1966 with ceasing pain following some 4½ hours active labor pain at home. The past history revealed that only she has had two times early spontaneous abortions and a tubal pregnancy of one year previousely. On the admission the cervix was fully dilated but without progressing and the pressenting part of the vertex was completely engaged. The B.P. was 90/0, pulse 132/min. The oxygen mask was applied to the patient although there was no any restlessness or pale appearance 2½ hour after the admission, X-ray pelvimetry was taken and showed a suggestive of borderline transvevese arrest although she has had 3 times normal vaginal deliveries previousely. She developed two times vomitings, then the B.P. suddenly dropped to 70/0 or 50/0, became pale, and evidently is in the shock. The abdomen, however, was so soft and the two different prominent parts could be palpated, suggestive of the fetal head and uterrine fundus. During the immediated laparatomy the B.P. was controlled by giving 5,000 c.c. of blood transfusion and total hysterectomy was performed in good condition for the longitudinal spontaeous rupture of left low portion of the uterus extending to the upper vaginal wall. In the spontaneous rupture of the uterus during labor or advanced stage especially in the lateral longi- tudinal rupture, the bleeding from the proximal end of the severed uterine artery seems tend to stop temporally probably due to the accumulated blood clots in the limited retroperitoneal space occuring the inital stage of the rupture. The bleeding from the lateral vesical plexus, however, was so proguse, never seemed to be stopped anatomically by the natural clotting mechanism. We would like to emphasize that searching and ligation of the silent proximal end of the uterine artery, masking in the numerous clots should never be missed since it will subseqquently pop up by the time of the clots resolution take place in 4~5 days as well as the B.P. back to normal level.

산후출혈에 관하여 ( 1963.1 - 1966.8 )

조면호(MH Cho),안정례(CR Ahn),전춘혜(CH Chun),방선옥(SO Bang) 대한산부인과학회 1967 Obstetrics & Gynecology Science Vol.10 No.4

Hemorrhage is indeed one of the leading cause of maternal death and of postpartum infection. The hemorrhagic maternal mortality in Ewha Womans University Hospital during 1960-1966 was 9.3%, as the 3rd cause. Postpartum hemorrhage is defined as blood loss in excess of 500cc.If this occurs within the first 24 hours of delivery, it is clssified as late pospartum hemorrhage. The data presented here are based on 133 cases of pospartum hemorrhage including 89% of immedite and 44% of late type among total deliveries of 6595 in Ewha Womans University Hospital and 44 cases delivered at home or general practicians clinic during 4 yrars period from 1963 to 1966. The following results have bee obtained. 1. The incidence of immediate pospartum hemorrhage among total deliveries was 1:74, and of late postpartum hemorrhage was 1:50. For past 3 years the former has been reduced to 58-81% in Ewha. 2. Majority cases(79%) of immediate postpartum hemorrhage went into shock, but all were reco- vered well with 1250cc. of blood transfusion in average, including 3 cases of hysterectomy. The patients with late hemorrhage which mostly(71%) deliveried at home or by midwife(toxem- ic cases)and wich occurred later than 12 days after delivery revealed only 21% of shock cases- However this required more blood transfusion(1500-2000c.c.) and even 2 cases of hysterectomy were inevitable. 3. The main causes of immediate postpartum hemorrhage were uterine atony (87%), cervical laceration(7%), retained placental picies(6%), and jaundice due to liver cirrhosis(1 cases). The causative predisposing conditions contributing to atony were toxemia (43%) and enlarged uterus (13%) such as twins (10%), large fetus weighing 4 or more kg.(2%), and Hydramnios. 92% of toxemic cases has caused atony-type hemorrhage within first 24 hours of delivery. For last 3 years, over all immediate postpartum hemorrhage due to atony associated with enlarged uterus has been reduced significantly to 50% of the cases by routine prophylactic oxytocic intravenous infusion. 4. More than 2/3 cases(67%) of late postpartum hemorrhage were deliveried by midwive at home or by general practicians at the clinics. The Commonest cause of late postpartum hemorrhage were retained placental picies (41%), uterine subinvolution(25%), placental-site(23%), cervical laceration(2%). However, the incidence of placental picies retained was much lesser and constant (21-36%) in group of the patients deliveried in Ewha although we do not perform routine immediate uterine exploration. The conditions contributing to late postpartum hemorrhage were also toxemic patients(35%) which was mostly due to placental site of nonjnvolution(2/3 of cases), enlarged uterus(10%) including twins and 4 or more kg. fetus and forcep deliveries(5%).

임산부사망에 관하여 ( 1961 - 1966.9 )

전춘혜(CH Chun),이순배(SB Rhee),안정례(CR Ahn),조면호(MH Cho) 대한산부인과학회 1967 Obstetrics & Gynecology Science Vol.10 No.10

The data presented here are based on 19 cases of hospital maternal death and 15 cases of maternal D.O.A. among total live births of 10290 in Ewha Woman`s University Hospital, Seoul during 6 years period from 1961 to 1966. The following results have been obtained. 1. For past 6 years from 1961 to 1966 the hospital maternal mortality has greately been lowered, the rate dropping from 29 to 9 per 10,000 live births. However the maternal D.O.A. mostely due to immediate postpartum hemorrhage(89%) from the home the home delivery (63%) or other clinics showed an increasing tendency. 2.The leading causes of maternal deaths in Ewha at present (1964-1966. 9) are toxemia (28.6%), hemorrhage(28.6%) and some others such as post cesarean section sepsis, choriocarcinoma, leukemia,(14.3% respecively). Until 4 years ago(1961-1963) toxemia deaths were exactly 100% of all maternal death. 3. It is interestiong to compare the maternal mortality and it`s significant difference between 2 group or ears; chloropromazine(1961-1962) and Magnesium sulfate(1963-1966) used for treating toxemias, the mortalit rate during MgSo4 era was reduced to 5 per 10,000 live births, or 1/5 of former eras`(26). Its was our experience that chloropromazine tent to develop or aggrivate dyspnea or pulmonary edema(83%) and to increase the inc- idence of failure of uterine contraction or of spontaneous delivery(67%) which sugestive of potent depression of all the important vital organs that consist of involuntary muscles. 4. Hemorrhagic death constituted the highest incidence of physician responsivility(50%) or preventable death and D.O.A. Showed even higher incidence of preventable death (78%). More than half or 63% of D.O.A. happened right after delivered at the home with or without midwife and 25% of them at general practioners clinic. Toxemia death in Ewha showed relatively less incidence of physicians responsibility (1/3 of cases) because more in patient responsibility due to the delayed visit(71%) or no single visit(86% no prenatal care). Infection death was only a case of Ceserean section-sepsis that operated on by a trained obstetrician, but at a general practioner`s clinic without regular sterilizing facilities, aseptic surgical suites or regular nurses. 5. In order to prevent maternal death every expectant mother should be deliveried at hosital or at movile car facilities supporting by special fund. Every general practioners should be educated regularly and at least familiar with managing the immediate post- partum hemorrhage and aseptic delivery. The post graduate educaton program is urgently required. Inteligent prenatal care and nurtritional support for pregnant woman are import socio-ecomonical measures to nation free of toxemic death.