产科出血的新进展高原

An Update on Obstetric Hemorrhage,Michael Y. Gao MD, Ph.DDepartment of Obstetrics and GynecologyRutgers/Robert Wood Johnson Medical School New Brunswick, New JTelephone: 732-246-0495 (USA)WeChat ID: michaelg8175,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,Maternal mortality is quite low in United StatesStill any increase is concerning when one recognizes the great improvements seen over the past centuryLikely multifactorial such as increased maternal age at delivery and associated comorbidities, improved management of chronic disease, and increased elective interventions that result in an increased cesarean delivery rate,An Update on Obstetric Hemorrhage,The consequences of intrapartum hemorrhage are related to the degree of blood lossThe key to the management is to recognize its occurrence in a timely fashionSome causes of obstetric hemorrhage include placenta previa, accreta, abruption, uterine atony, uterine injury and vaginal or cervical laceration,An Update on Obstetric Hemorrhage,MacrosomiaMultiple gestationPolyhydramniosLabor inductionProlonged laborRapid labor,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,Prenatal Assessment & Planning,Identify and prepare for patients with special considerations: placenta previa and accreta, bleeding disorder, or those who decline blood productsScreen and aggressively treat severe anemia: if oral iron fails, initiate IV iron protocol to reach desired Hgb/Hct, especially for at risk mothers,Admission Assessment & Planning,Verify type & antibody screenEvaluate for risk factorsEvaluate for the development of additional risk factors in labor: prolonged 2nd stage labor, prolonged oxytocin use, active bleeding, chorioamnionitis, or magnesium sulfate usageTreat multiple risk factors as high risk,OB Hemorrhage Risk Factor, low,No previous uterine incisionSingleton pregnancyLess than five previous vaginal birthsNo known bleeding disorderNo history of PPH,OB Hemorrhage Risk Factor, medium,Prior cesarean birth(s) or uterine surgeryMultiple gestationFour or more previous vaginal birthsChorioamnionitisHistory of previous PPHLarge uterine fibroidsEstimated fetal weight greater than 4 kgMorbid obesity (BMI35),OB Hemorrhage Risk Factor, high,Placenta previa, low lying placentaSuspected placenta accreta or percretaHematocrit 30 and other risk factorsPlatelets 500ml Vag or 1000ml CS or VS unstable with continued bleeding,Activate OB hemorrhage protocol and checklistNotify obstetrician, charge nurse and anesthesiologistEstablish IV access, at least 18 gauge, increase IV fluid rate, and increase oxytocin rateAdminister methergine per protocolVital signs, O2 sat(95%) & level of consciousness,STAGE 1: cont,Empty bladder, monitor urinary outputType and Crossmatch for 2 units PRBCsKeep patient warmConsider potential etiology: uterine atony, trauma/laceration, retained placenta, amniotic fluid embolism, uterine inversion, coagulopathy, placenta accreta and uterine ruptureOnce stabilized: modified postpartum management with increased surveillance,An Update on Obstetric Hemorrhage,STAGE 2: QBL 1000-1500ml with continued bleeding,Activate response team, notify perinatologist, 2ndOB, 2ndanesthesiologistNotify blood bank, assign single person to communicate with blood bankAdditional uterotonic medication: hemabate and/or misoprostolOrder labs STAT (CBC/Plts, chem 12, PT/aPTT, fibrinogen, ABG)Establish 2nd large bore IV,STAGE 2: cont,Transfuse PRBCs based on clinical signs and response, do not wait for lab resultsVaginal birth: if vaginal or cervical trauma, visualize and repair; if retained placenta, D&C; if uterine atony or lower uterine segment bleeding, intrauterine balloon; if uterine inversion, anesthesia and uterine relaxation drugs for manual reductionIf above measures unproductive: selective interventional radiology embolization,STAGE 2: cont,C-section: uterine hemostatic suture, e.g., B-Lynch suture, OLeary, multiple squares; intrauterine balloonIf amniotic fluid embolism: maximally aggressive respiratory, vasopressor and blood product supportIf VS are worse than QBL: possible uterine rupture or broad ligament tear with internal bleeding, move to laparotomyOnce stabilized: modified postpartum management with increased surveillance,STAGE 3: QBL exceeds 1500ml,Notify advanced gyn surgeon, adult intensivistNotify blood bank for massive hemorrhage pack, stay aheadNotify ICUMove to OR if not already thereCentral hemodynamic monitoring, CVP or PA line, arterial line, vasopressor support, and intubation,STAGE 3: cont,Apply upper body warmer, use fluid warmer and/or rapid infuser for fluid & blood productPrevent hypothermia, acidemiaApply sequential compression stockings to lower extremitiesConsider selective embolization, conservative or definitive surgery: uterine artery ligation or hysterectomy,STAGE 3: cont,Aggressively transfuse, based on VS, QBL with PRBCs: FFP: Platelets at ratio of either 6:4:1 or 4:4:1Unresponsive coagulopathy: after 8-10 units PRBCs and coagulation factor replacement may consider risk/benefit of rFacto