产后出血.ppt

教学内容,胎儿窘迫、子宫破裂、产后出血约2学时脐带异常、羊水量异常、早产、胎膜早破、过期妊娠、多胎妊娠约1学时自学王正平浙江大学医学院附属妇产科医院产科Tel：870615012061,PostPartumHemorrhageUterineRupture,FetalDistress,WomenHospital,SchoolofMedical,ZheJiangUniversityWangZhengPing,Postpartumhemorrhage,Postpartumhemorrhage,Pastpartumhemorrhagedenotesexcessivebleeding(500mlinvaginaldelivery)duringthefirst24hoursafterdeliveryCommoncauseofdeathanddiseasesinpregnantwomengloballyLeadingcauseofdeathinpregnantwomeninChinaIncidence2%-3%oftotalnumberofdeliveries,Etiology,Uterineatony:70%Obstetriclacerations:20%Retainedplacentaltissue:10%Coagulation:1%,Uterineatony,Generalfactors:extremenervousness,sedative,anesthesia,tocolytics,weakObstetricfactors:prolongedlabour,fatigue,placentaprevia,placentaabruptio,severeanemiaUterinefactors:uterinemuscularfiberunderdevelopment,suchasuterinedeformityormyoma;uterineoverstretched,suchasmacrosomia,multiplepregnancy,polyhydramnios,Placentalfactors,IncompleteplacentalseparationRetainedplacentaPlacentalincarceration（嵌顿）PlacentaladhesionPlacentalimplantation(accreta,increta,percreta)Residualplacentaandamnioticmembrane,Birthcanalinjury,Lacerationduringlabourareusuallyassociatedwith:PoorvulvalelasticityStronglabourforce,emergencydelivery,macrosomiaInadequateskillsatassistedvaginaldeliveryInadequatecessationofbleedingduringepisiotomyrepair,missingouttearsatcervixorfornices,Coagulationdisorder,Complicationsassociatedwithobstetric:amnioticfluidembolism,pregnancyinducedhypertensivediseases,placentaabruptioandintrauterinedemisePregnancyliverdisease:acutefattyliver,severehepatitisHematologydiseases:primarythrombocytopenicpurpura,aplasticanemiaetc,Clinicalpresentation,Vaginalbleeding:Ifbleedingoccursimmediatelyafterdeliveryofbaby,considerbirthcanalinjuryIfbleedingoccursminutesafterdeliveryofbaby,considerplacentafactorsIfbleedingoccursminutesafterdeliveryofplacenta,mainreasonsareuterineatonyorretainedproductsofconceptionPersistentbleedingandblooddonotcoagulate,considercoagulationdisordercausingPPH,Clinicalpresentation,VaginalhematomaShock:dizziness,paleness,weakpulse,lowbloodpressureetc,Diagnosis,EstimationofbloodlossAscertaincauseofpostpartumhemorrhage,Estimationofbloodloss,Visualobservation:only50%-70%ofbloodlossContainer:kidneydish,measuringcupSurfacearea:bloodstained10cmx10cm=10mlWeighing:1.05g=1mlHct1000mlHourlyurineoutput2500mlShockindex=pulserate/systolicpressure,Shockindex(SI),SI=0.5,normalbloodvolumeSI=0.5-1,bloodloss160bpm;duringseverehypoxia120bpmCSTshowslatedeceleration,variabledecelerationfetalheartrate100bpm,withfrequentlatedecelrationsindicatingseverefetalhypoxia,maydieintrauterineanymoment,Latedeceleration,Variabledeceleration,Diagnosisofacutefetaldistress,Meconiumstainedamnioticfluid:greencolor,dirty,thickandlittlevolumeIdegree:lightgreen,IIdegree:yellowishgreen,dirty,IIIdegree:brownishyellow,thick,Diagnosisofacutefetaldistress,Fetalmovement:earlystagefrequentfetalmovement,subsequentlyreducedtoabsentFetalacidosis:fetalscalpbloodanalysispH60mmHg(normal3555mmHg),Diagnosisofchronicfetaldistress,ReducedorabsentfetalmovementAbnormalfetalmonitoringLowfetalbiophysicalprofilescoringFetalretardationReducedplacentalfunctionMeconiumstainedamnioticfluidAbnormalfetalpulseoxymetry,Reducedorabsentfetalmovement,Reducedfetalmovement10times/12hours,isanimportantmanifestationoffetalhypoxiaUsually24hoursafterabsentoffetalmovementfetalheartbeatdisappearsNormalfetalmovementcount:30-100times/12hours,Abnormalfetalelectronicmonitoring,NSTisknownasnon-reactivetype,during20minutescontinuousfetalmovementfetalheartrateacceleration=15bpm,sustaining=15s,baselinevariability5bpmOCTfrequentvariabledecelerationsorlatedecelerationsareseen,Lowbiophysicalprofilescoring,Basedonultrasoundassessmentoffetalbodymovement,breathingmovement,flexortone,amnioticfluidvolume,couplewithfetalelectronicmonitoringNSTresultscombinedscoring(eachvariablescore2,totalscoreis10)Score=3indicatesfetaldistress,score4-7suspiciousfetalhypoxia,Fetalretardation,Sustainedchronicfetalhypoxia,causefetalintrauterinegrowthretardation,reducedcellsnumberinorgans,reducedorganvolume,lowfetalweight,presentingasfundalheightandabdominalgirthbeinglowerthan10thpercentileofthesamegestationalage,Lowplacentalfunction,Decreasedurineestriol:24hoursurineE330%Estrogen:creatinine(E:C)ratio10Placentalprolactin(hPRL)4mg/LPregnancyspecific1glycoproteindecrease100mg/L,Meconiumstainedamnioticfluid,Amnioscopyexaminationshowsdirtyamnioticfluidinlightgreenorbrownishyellowcolor,Abnormalfetalpulseoxymetry,Fetalpulseoxymetryprincipallymonitorthebloodoxygenpartialpressurethroughmeasuringfetalbloodoxygensaturation(饱和度）,Management,Acutefetaldistress:emergenttreatmentChronicfetaldistress:managementplandependsonseverityofthepregnancycomplications,gestationalage,fetalmaturity,fetaldistresscondition,Managementofacutefetaldistress,Giveoxygen:facemaskornasalprongcontinuousoxygenat10L/minflowSearchforcause,activemanagement:ifpatienthassupinehypotensivesyndrome,liethepatientonleftlateralposition;ifexcessiveoxytocinleadingtouterinehyperstimulation,stopoxytocinimmediately,usetocolyticswhennecessary,Managementofacutefetaldistress,Terminatepregnancysoonestpossible:Cervixnotfullydilatedwiththefollowingconditions,immediatecaesareansection:(1)fetalheartrate180bpm,accompaniedbyIIdegreemeconiumstainedamnioticfluid;(2)IIIdegreemeconiumstainedamnioticfluid,withlowamnioticfluidamount;(3)CSTorOctshowsfrequentlatedecelerationsorseverevariabledecelerations;(4)fetalscalpbloodpH7.20,Managementofacutefetaldistress,Fullydilatedcervix:fetalbiparietaldiameter,hasdescendbelowischialspines,performassistedvaginaldeliveryPreparefornewbornresuscitation,M