产后出血2010（北医三院八年制临床医学课件）

“Obstetrics is Bloody Business”* Postpartum Hemorrhage:Postpartum Hemorrhage: *Cunningham, et. al: Williams Obstetrics, 21st ed., 2001 PPH is the leading cause of death related to pregnancy worldwide 1 1 Major causes of death for pregnancy women （maternal mortality) lPostpartum hemorrhage（28%) lheart diseases lpregnancy-induced hypertension l(or Amniotic fluid embolism ) linfection 2 2 Definition of PPH lThe early PPH is defined as a blood loss exceeding 500ml after delivery of the infant2cm in length and be actively bleeding llaceration of vaginal and perineum Etiology/prediction/prevention/management 1919 Record: lPulseshock index lblood pressure lmaternal heart rate lcentral venous pressure lurine output Etiology/prediction/prevention/management 2020 Lab tests: lHb, lBT(bleeding time), CT( clotting time), lplatelets count lfibrinogen lprothrombin time and patial thromboplastin time lFDP lwomens blood group and cross- matching Etiology/prediction/prevention/management 2121 Treatment: lthe key is correcting the coagulation defect lresuscitation must be started as soon as possible linfusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion lblood transfusion is essential linfusion of red cells, platelets, fresh frozen plasma, FDP , clotting factors, Etiology/prediction/prevention/management 2222 Perineum vaginal and cervical laceration lonly skin and a minor part of the perineal body lperineal body and vagina lanal sphincter and anal canal Etiology/prediction/prevention/management 2323 Stimulation of uterine contraction lMassage of uterus through the abdomen and bimanual compression lintrauterine packing Etiology/prediction/prevention/management 2424 Surgical therapy lcausing uterine contraction or compression ltamponade the uterine cavity ldecrease blood supply to the uterus l remove the uterus l. Etiology/prediction/prevention/management 2525 Surgical methods If massage and agents are unsuccessful: lLigation or embolization of the uterine arteries lHysterectomy Etiology/prediction/prevention/management 2626 adherence of placenta (accreta increta pericreta) Etiology/prediction/prevention/management 2727 Potential complications of PPH lPostpartum infection lAnemia lTransfusion hepatitis, lSheehans syndrome lAshermans syndrome The best management of PPH is prevention Etiology/prediction/prevention/management 2828 Resuscitation for PPH lcall an assistant lresuscitate the patient vigorously What is the state of her peripheral circulation? How much blood has she lost? Is it clotting normally in the receiver used to collect it? What has been done so far? Monitor the volume of blood she continues to lose her peripheries, pulse and blood pressure, and her urine output. 2929 Summary: remember 4 Ts l“TONE” lRule out Uterine Atony lPalpate fundus. lMassage uterus. lOxytocin 20U/500cc. lProstaglandin l Hemabate IM q 15min 3030 Summary: remember 4 Ts l“Tissue” lR/O retained placenta lInspect placenta for missing cotyledons. lExplore uterus. lTreat abnormal implantation. 3131 Summary: remember 4 Ts l“TRAUMA” lR/o cervical or vaginal lacerations. lObtain good exposure. lInspect cervix and vagina. lWorry about slow bleeders. lTreat hematomas. 3232 Summary: remember 4 Ts l“THROMBIN”lCheck labs if suspicious. 3333 Case-2 l37ys, multiparity, was admitted in her 40+2wks for irregular contraction without any abnormal sign. lTwo hrs later, the contraction became stronger and membranes ruptured when h with meconium-stained amniotic fluid I degree. l7:33 cyanochroia happened with breathless and loss of consciousness in a second. 3434 What is the diagnosis l8:20pm still-birth weight 3.2kg. lPPH emerged as soon as placenta delivered without any clot. lThe patient was in the state of unconsciousness and became pale 3535 Hysterectomy lHysterectomy was done soon after resuscitation. lThe amount was about 4000ml. lRed cell was transfused 1600ml, fresh plasma 400ml, platelet 20u, cryoprecipitate 10u. lTransfusion was continued after OP 1800ml. 3636 l，Hb38g/L, APTT43.4秒，PT45.0(正常11- 14sec),PT比例3.52 (正常0.85-1.15)，Fbg 0.976g (正常2-4g/L),APTT不凝， TT44.Tsec(正常14-21sec)。FDP（+），D -2聚集体（+），3P试验（+）。尿常规Pro 2+, 比重1.000, RBC 10-15/HP, 可见颗粒 管型。 3737 l术后41小时拔除气管插管，并停用多巴胺，生命 体征平稳。术后40小时发现左上肢皮肤感觉减退 ，运动受限。头部MRI：左侧小脑半球、双侧枕 、顶叶及右侧丘脑多发脑梗塞，胸部CT：两肺纹 理明显增多，两下肺见散在斑点状致密影，心影 增大，两则胸腔积液，两侧胸腔积液。术后18天 复查血、尿常规、凝血功能除Hb 102g/L外，均正 常。胸部CT：正常。头部MRI：梗塞灶明显缩小 。左上肢皮肤感觉功能恢复，但肌力仍低下。术 后5个月恢复正常。 3838 Uterine pathology Cervical blood camp expansion, congestion and the small focal-like bleeding in the small vessels seen in the amniotic fluid composition. Subclavian vein blood smear inspection, microscopic examination shows like material and a little meconium keratosis-like material. 3939 l术后15天复查头部MRT表现右顶叶及丘脑 病灶范围缩小。原双侧枕叶，左顶叶及左 小脑半球病灶已吸收消散，胸部CT提示原 病灶及胸腔积液均已消失。 4040 Amniotic fluid embolism lClinical character Heart and lung failure Bleeding induced by DIC Acute renal failure lDiagnosis “amniotic fluid composition” in circula