产后出血2010(北医三院八年制临床医学课件).ppt

1 ObstetricsisBloodyBusiness PostpartumHemorrhage Cunningham et al WilliamsObstetrics 21sted 2001 PPHistheleadingcauseofdeathrelatedtopregnancyworldwide 2 Majorcausesofdeathforpregnancywomen maternalmortality Postpartumhemorrhage 28 heartdiseasespregnancy inducedhypertension orAmnioticfluidembolism infection 3 DefinitionofPPH TheearlyPPHisdefinedasabloodlossexceeding500mlafterdeliveryoftheinfant 24hThelatePPH occursafter24hourofdeliveryto6weeks 4 Majorcauses Uterineatony 90 Lacerationsofthegenitaltract 6 Retainedplacenta 3 4 Coagulationdefects blooddyscrasia 4T tone tissue trauma thrombin Etiology prediction prevention management 5 1 Uterineatony Localfactors OverdistentionoftheuterineConditionthatinterferewithcontraction leiomyoma Complications PIH anemia placentaprevia Systemicfactors NervousDrugsAbnormallaborHistoryofpreviousPPHPreeclampsia abnormalplacentation Etiology prediction prevention management 6 Pathology ContractionconstrictingthespiralarteriesPreventingtheexcessivebleedingfromtheplacentaimplantationsiteUterineatonygiverisetoPPHwhennocontractionoccur Etiology prediction prevention management 7 Maincomplain HaveheartpalpitationsFeelfaintLightheadedBreathless Etiology prediction prevention management 8 2 Lacerationsofthegenitaltract Causes Instrumenteddelivery forceps manipulativedelivery breechextraction precipitouslabor macrosomia Types perineumlacerationvaginallacerationcervicallaceration Etiology prediction prevention management 9 3 Retainedplacenta SeparationandexplosionofplacentaiscausedbystronguterinecontractionPlacentatissueremainingintheuteruspreventadequatecontractionandpredisposetoexcessivebleeding Etiology prediction prevention management 10 4 Coagulationdefects Acquiredabnormalityinbloodclotting abruptionplacenta amnioticfluidembolismseverepreeclampsiaCongenitalabnormalityinbloodclotting thrombocytopeniaseverehepaticdiseasesleukemia Etiology prediction prevention management 11 disseminatedintravascularcoagulopathy DIC ifbleedingpersistsinspiteofallothertreatmentdescribed DICshouldbesuspectedthebloodpassingfromthegenitaltractisnotclottingshock reductionofeffectivecirculationinadequateperfusionofalltissuesoxygendepletiondepressionoffunctions 12 D D withPPH Color order amountRiskreasonsClot Bloody Etiology prediction prevention management 13 ConsequencesofPPH HypovolemicshockBloodtransfusionanditsattendantcomplicationsSurgicalinjury fever renalandhepaticfailureAcuterespiratorydistresssyndromeDisseminatedintravascularcoagulopathyLossoffertility andSheehan ssyndrome 14 CASE 36ysPrimiparity acceptedC sectionbecauseofmarginalplacentaandfibroidsAfterbirth PPHhappenedimmediatelycausedbyuterineatony Oxytocinwasusedwhilestitching buthemorrhagewascontinue 15 RiskfactorsforPPH AdvancedmaternalageMultifetalgestationsProlongedlaborPolyhydramniosInstrumentaldeliveryFetaldemisePlacentalabruptionAnticoagulationtherapy MultiparityFibroidsProlongeduseofoxytocinMacrosomiaCesareandeliveryPlacentapreviaandaccretaChorioamnionitisGeneralanesthesia 16 RiskfactorsforPPH AdvancedmaternalageMultifetalgestationsProlongedlaborPolyhydramniosInstrumentaldeliveryFetaldemisePlacentalabruptionAnticoagulationtherapy MultiparityFibroidsProlongeduseofoxytocinMacrosomiaCesareandeliveryPlacentapreviaandaccretaChorioamnionitisGeneralanesthesia 17 Preventionandtreatment Theplacentashouldbeexaminedcarefullymanualremovalofplacentahysterectomyisrequiredforplacentauterinecontractiondrugs Etiology prediction prevention management 18 Preventionuterineatony Administrationofmedicine promotescontractionoftheuterinecorpusdecreasesthelikelihoodofuterineatonyOxytocinagentsProstaglandin Etiology prediction prevention management 19 management Vaginalexaminationsoonafterdeliveryrepair cervicallaceration 2cminlengthandbeactivelybleedinglacerationofvaginalandperineum Etiology prediction prevention management 20 Record Pulse shockindexbloodpressurematernalheartratecentralvenouspressureurineoutput Etiology prediction prevention management 21 Labtests Hb BT bleedingtime CT clottingtime plateletscountfibrinogenprothrombintimeandpatialthromboplastintimeFDPwomen sbloodgroupandcross matching Etiology prediction prevention management 22 Treatment thekeyiscorrectingthecoagulationdefectresuscitationmustbestartedassoonaspossibleinfusionofcrystalloid saline andDextranisstartedfirstlywhilearrangingthebloodtransfusionbloodtransfusionisessentialinfusionofredcells platelets freshfrozenplasma FDP clottingfactors Etiology prediction prevention management 23 Perineumvaginalandcervicallaceration onlyskinandaminorpartoftheperinealbodyperinealbodyandvaginaanalsphincterandanalcanal Etiology prediction prevention management 24 Stimulationofuterinecontraction Massageofuterusthroughtheabdomenandbimanualcompressionintrauterinepacking Etiology prediction prevention management 25 Surgicaltherapy causinguterinecontractionorcompressiontamponadetheuterinecavitydecreasebloodsupplytotheuterusremovetheuterus Etiology prediction prevention management 26 Surgicalmethods Ifmassageandagentsareunsuccessful LigationorembolizationoftheuterinearteriesHysterectomy Etiology prediction prevention management 27 adherenceofplacenta accretaincretapericreta Etiology prediction prevention management 28 PotentialcomplicationsofPPH PostpartuminfectionAnemiaTransfusionhepatitis Sheehan ssyndromeAsherman ssyndromeThebestmanagementofPPHisprevention Etiology prediction prevention management 29 ResuscitationforPPH callanassistantresuscitatethepatientvigorouslyWhatisthestateofherperipheralcirculation Howmuchbloodhasshelost Isitclottingnormallyinthereceiverusedtocollectit Whathasbeendonesofar Monitorthevolumeofbloodshecontinuestoloseherperipheries pulseandbloodpressure andherurineoutput 30 Summary remember4Ts TONE RuleoutUterineAtony Palpatefundus Massageuterus Oxytocin20U 500cc ProstaglandinHemabateIMq15min 31 Summary remember4Ts Tissue R Oretainedplacenta Inspectplacentaformissingcotyledons Exploreuterus Treatabnormalimplantation 32 Summary remember4Ts TRAUMA R ocervicalorvaginallacerations Obtaingoodexposure Inspectcervixandvagina Worryaboutslowbleeders Treathematomas 33 Summary remember4Ts THROMBIN Checklabsifsuspicious 34 Case 2 37ys multiparity wasadmittedinher40 2wksforirregularcontractionwithoutanyabnormalsign Twohrslater thecontractionbecamestrongerandmembranesrupturedwhenhwithmeconium stainedamnioticfluidIdegree 7 33cyanochroiahappenedwithbreathlessandlossofconsciousnessinasecond 35 Whatisthediagnosis 8 20pmstill birthweight3 2kg PPHemergedassoonasplacentadeliveredwithoutanyclot Thepatientwasinthestateofunconsciousnessandbecamepale 36 Hysterectomy Hysterectomywasdonesoonafterresuscitation Theamountwasabout4000ml Redcellwastransfused1600ml freshplasma400ml platelet20u cryoprecipitate10u TransfusionwascontinuedafterOP1800ml 37 Hb38g L APTT43 4秒 PT45 0 正常11 14sec PT比例3 52 正常0 85 1 15 Fbg0 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Pro2 比重1 000 RBC10 15 HP 可见颗粒管型 38 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