妇产科学 产后出血

产后出血Postpartum HemorrhagePPH,Zhangye Xu M.D. Department of Obstetrics and Gynecology 1st Affiliated Hospital, Wenzhou Medical College,学习目标,掌握产后出血的重要原因熟悉产后出血临床表现及初步处理方法了解产后出血预防,简介,最普遍的严重的产科并发症产妇死亡的主要原因急性血液丢失经常不可预测灾难性的出血的评估比较主观,定义,问题PPH 诊断的问题性出血评估的主观性和不精确性传统阴道出血 500ml 早期出血：产后24hr内晚期出血：产后24hr后（感染、胎盘）,产后出血止血原理,止血,1. 断裂血管壁肌层环形收缩,2. 凝血系统,3. 最有效的止血方法：子宫收缩,PPH: 通常在胎盘剥离后发生,胎盘剥离时，胎盘附着处的母体血管的终末端发生断裂，直接向子宫腔开放，正常分娩时出血量约为200-400ml,出血,病因The 4 Ts of PPH,Am Fam Physician 2007; 75:875.,病因,PlannedCesarean section 剖宫产 Episiotomy 外阴侧切,UnplannedVaginal/cervical tear 阴道宫颈裂伤Surgical trauma 手术创伤Uterine rupture 子宫破裂,软产道裂伤诊断,如果宫缩好，软产道裂伤出血首先考虑出血是明显而迅速的，在胎儿娩出后持续出血，宫缩好缝扎可以止血确定方法：软产道检查,软产道裂伤治疗,可吸收肠线全层连续或间断缝合抗炎治疗：预防感染输血,Cervical laceration repair,阴道裂伤I裂伤 皮肤黏膜II裂伤肌层III裂伤肛门括约肌IV裂伤直肠,病因,前置胎盘,胎盘残留,胎盘滞留、嵌顿,胎盘植入,胎盘因素出血诊断,胎盘娩出 30 分危险增加：剖宫产，子宫感染，多次妊娠分娩人流刮宫术过度牵拉脐带导致脐带断裂，子宫内翻通常的治疗方法是人工取出胎盘出血往往发生在人工剥离胎盘之时,胎盘因素治疗,催产素 10U + NS 20ml 脐静脉 iv如果失败开放静脉通路备血人工剥离胎盘麻醉或药物止痛手在宫壁与胎盘之间，轻轻剥离，胎盘完整全部取出如果人工剥离胎盘失败刮宫手术治疗抗炎治疗,Manual removal of placenta,External hand steadies the uterine fundus,Internal hand along plane of cleavage,Check placenta is completeCheck the uterus is emptyCheck for trauma of GT,AnaesthesiaAntibioticsIV lineOxytocics,Uterus,Placenta,病因,CongenitalVon Willebrands disease,AcquiredDIC, Obstetric disordersHELLP syndromeDIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism)Anti coagulant therapy Heparin,病因,Systemic factorsSpirit, Chronic diseasesObstetric factorsProlonged labor, PIHUterine factorsHigh parity, Multiple gestation, macrosomia, LeiomyomasDrug factorstocolytic agents,PPH 最常见病因(70%),宫缩乏力的诊断,腹部检查：子宫软，无张力阴道出血在胎盘娩出之后阵发性出血,宫缩乏力的预防,宫缩乏力治疗,人工按摩双手按摩：按摩子宫是有效的简单的刺激子宫收缩的方法,Anderson JM, AFP 2007,宫缩乏力的治疗宫缩剂,催产素 （Oxytocin ）麦角新碱（Methergine）欣母沛（Hemabate） 米索前列醇（Misoprostol ）,宫缩剂疗效不佳,寻找其他原因! 开放静脉通路血交叉，备血，输血留置导尿，24hr出入量监测生命体征凝血功能监测,子宫填塞,Bakri BalloonFoley, BT-Cath, Sengstaken-Blakemore Tube,Jacobs AJ, Up to Date 2009,Gauze Packing,子宫动脉栓塞,Requires available facilities/ personnelHemodynamically Stable PatientTemporizing measure en route to OR (Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992),手术介入(1 of 4),Gabbe, Ch 18,COMPRESSION SUTURES,Cornu,Fallopian tube,Ovary,Hayman R, Arulkumaran S, Steer PObstetrics & Gynecology. 2002,Ovary,Fallopian tube,手术介入(2 of 4),Gabbe, Ch 18,手术介入(3 of 4),手术介入(4 of 4),出血的评估,肉眼观察:容器: 量杯表面积: blood stained 10cmx10cm = 10ml称重: 1.05g = 1mlHct1000ml每小时尿量2500ml休克指数= 脉搏/收缩压,治疗原则,2 方面复苏止血 识别和治疗4Ts治疗：及时，系统,预防,产前评估停止治疗性的肝素，阿司匹林积极管理第三产程温和牵拉脐带宫缩剂的预防应用缩宫素第三产程常规使用可以预防60%PPH仔细检查软产道，胎盘,血制品的应用,不用等待实验室结果!大量出血没有输入凝血因子将导致凝血功能异常！,Blood Product Utilization,Active management of the third stage of labor,Blood loss 1000 to 1500ml massive PPH,Brisk bleedingBlood pressure falling Pulse rising,MassageOxytocin,Explore genital tract,Inspect placenta,Observe clottingCoagulation screen,The Four T s,Soft, boggy uterusTone,Resuscitation,Genital tract tearTrauma,Placenta retainedTissue,Blood not clottingThrombin,HemabateMetherginecytotec,Suture,Manual remove,Blood product, Surgical Intervention,Blood loss 500 mlPPH,Replace factor,Conclusions ！,Be preparedPractice prevention Assess the lossAssess the maternal statusResuscitate vigorously and appropriately Diagnose the cause Summary: Remember 4 TsUnderstanding its etiology is fundamental to effectively managingTreat the causeActive management of the third stage of labor is also a key component in its prevention.,软 胎盘胎膜异常 软产道裂伤,暗红 鲜红,阵发性 持续性,胎盘剥离后 胎盘娩出前 胎儿娩出后,宫缩乏力 胎盘因素 产道裂伤,凝血功能障碍：出血晚，血液不凝,不同病因阴道出血特点,依据出血时间、出血量、出血性质判断出血原因,产后出血原因互为因果,出血时间,出血性质,出血颜色,检查,Case Presentation,Personal History,23 year old ladyMarried for 3 yearsG 2nd Para 1; no living,Past Obstetric History,In 2002Gestational Diabetes + Preeclampsia（PE）Delivered at 38 weeksVaginal delivery on 5/2002Dead male baby 4.5 kg,Current Pregnancy,LMP 10/10/2003 Twin pregnancyRegular prenatal care in a private clinicNo document of screening for GDM in this pregnancyOn admission:History of unsatisfactory fetal movements for the last 3 daysLabor pains for 3 hours,Admission21:00, May 3rd 2004,liquor above average, uterine contractions 2/10 min, each 20 sec.PV: 4 cm dilated, 1 cm long, central, soft,U.S. scan,Twin pregnancyMonoamniotic monochorionic1st cephalic, F. Life +ve, 24+2 wk2nd transverse, F. Life ve, 22 wkPlacenta fundal anterior grade IILiquor: clear, AFI 27 cm,Progress,Patient spontaneously miscarried at 03:001 L male 500 gm (died later)1 SB male 1 kgVaginal bleeding associated with retained placenta.,Transferred to theatre,Emptying the bladderIV crystalloids,Manual separation of the placenta,Excessive vaginal bleeding Uterine massage and bimanual compression,Uterus stayed atonic (F.Level 18 wk),Received 3 units of whole blood in last 20 minutes,Uterotonics:1000 ug Misoprostol rectal (5 tabs)60 units oxytocin (IVI)500ug Hemabate,Temporarily effective,Re-accumulation of blood clots in the uterus,Bleeding Controlled,Uterine artery embolization,Postoperative Recovery,F.U.: vital data stableU.O.P adequateDrain 150 mlUterine massage,Case 1,Healthy, age: 32, G2P1.Augmented vaginal delivery, no tears.Nurse calls you one hour after