Obstetric-Postpartum-Hemorrhage-产科-产后出血.pptx

PostpartumHemorrhage Reporter Peng Sijing Stone In1990 atechnicalworkinggroupoftheWorldHealthOrganization WHO definedPPHasbloodlossof500mlormorefromthegenitaltractaftervaginaldelivery PrimaryPPHislossofbloodestimatedtobe 500ml fromthegenitaltract within24hoursofdelivery themostcommonobstetrichemorrhage 1 MinorPPHisestimatedbloodlossofupto1000mls MajorPPHisanyestimatedbloodlossover1000mls SecondaryPPHisdefinedasabnormalbleedingfromthegenitaltract from24hoursafterdeliveryuntilsixweekspostpartum 1 Preventionandmanagementofpostpartumhaemorrhage RoyalCollegeofObstetriciansandGynaecologists May2009withrevisionsApril2011 Tone Tissue Trauma Thrombin AbnormalityOfUterineContractionUTERINEATONY RetainedProductsOfConception OfGenitalTract AbnormalityOfCoagulation The FourTs ofCausesofPostpartumHemorrhage The FourTs MnemonicDeviceCausesofPostpartumHemorrhage JANICEM ANDERSON M D PreventionandManagementofPostpartumHemorrhage AmFamPhysician2007 75 875 82 Antenatalriskfactors Antepartumhaemorrhageinthispregnancy Placentapraevia Risk Suspectedorprovenplacentalabruption Multiplepregnancy Risk Alsoothercausesofuterineover distentionsuchaspolyhydramniosormacrosomia Pre eclampsiaorpregnancy inducedhypertension Risk Grandmultiparity fourormorepregnancies PreviousPPH Risk orprevioushistoryofretainedplacenta Asianethnicorigin Risk Maternalobesity Bodymassindex 35kg m2 Risk Existinguterineabnormalities Maternalage 40yearsorolder Maternalanaemia Hb 9g dL Risk Factorsrelatingtodelivery Emergencycaesareansection Risk Electivecaesareansection Risk especiallyif 3repeatprocedures Retainedplacenta Risk Mediolateralepisiotomy Risk Inductionoflabour Risk Operativevaginaldelivery Risk Labourof 12hours Risk 4kgbaby Risk Maternalpyrexiainlabour Risk Pre existingmaternalhemorrhagicconditions Factor8deficiency haemophiliaAcarrier Factor9deficiency haemophiliaBcarrier VonWillebrand sDisease Note VonWillebranddisease VWD isageneticdisordercausedbymissingordefectivevonWillebrandfactor VWF aclottingprotein VWFbindsfactorVIII akeyclottingprotein andplateletsinbloodvesselwalls whichhelpformaplateletplugduringtheclottingprocess TheconditionisnamedafterFinnishphysicianErikvonWillebrand awhofirstdescribeditinthe1920s TheusualpresentationofPPHisoneofheavyvaginalbleedingthatcanquicklyleadtosignsandsymptomsofhypovolemicshock AmericanCollegeofObstetriciansandGynecologists ACOGeducationalbulletin Hemorrhagicshock Number235 April1997 replacesno 82 December1984 AmericanCollegeofObstetriciansandGynecologists IntJGynaecolObstet 1997May 57 2 219 26 ActivemanagementofthethirdstageoflaborOxytocin Pitocin administeredwithorfollowingdeliveryControlledcordtractionUterinemassageafterdeliveryofplacenta Bloodloss 500mLPostpartumhemorrhage BriskbleedingBloodpressurefallingPulserising BimanualuterinemassageOxytocin20IU LofnormalsalineInfuseupto500mLover10minutes ExplorelowergenitaltractConsiderexploringuterus Inspectplacenta ObserveclottingConsiderCBC typeandcross coagulationscreen Resuscitation2large boreIVneedlesOxygenbymaskMonitorbloodpressure pulse urineoutputTeamapproach TheFourTs Soft boggy uterusTONE GenitaltracttearInversionofuterusTRAUMA PlacentaretainedTISSUE BloodnotclottingTHROMBIN Carboprost Hemabate 0 25mgIMMisoprostol Cytotec 1 000mcgrectallyMethylergonovine Methergine 0 2mgIM SuturelacerationsDrainhematomas 3cmReplaceinverteduterus ManualremovalCurettageMethotrexate ReplacefactorsFreshfrozenplasmaRecombinantfactorVIIaPlatelettransfusion Bloodloss 1 000to1 500mLMassivehemorrhage TransfuseRBCs platelets andclottingfactors Supportbloodpressurewithvasopressors ICUforanesthesia hematology surgery Uterinepacking tamponadeprocedureVesselembolization ligation andcompressionsutures Hysterectomy 3 1 COMMUNICATION 3 1 1 Alertallrelevantprofessionals3 1 2 FormajorPPH activate REDALERT 3 1 3 Communicatewithpatientandthepartnerwithclearinformationofwhathappening CallexperiencedMidwifeCallSpecialistAlertConsultantCallAnaesthetist specialist AlertConsultantclinicalHaemotologistoncallAlertbloodbankCallPPKfordeliveryofspecimens bloodRecordtheevents fluid drugsandvitalsign 3 2 RESUSCITATION 3 2 1 Themeasurementforresuscitationdependonconditionanddegreeofshock3 2 2 AssessAirwayandBreathingGiveoxygen10 15L minviafacemaskregardlessthematernal O2 Ifairwayiscompromisedduetoimpairedconsciouslevel needtointubatewithanaestheticassistance 3 2 RESUSCITATION 3 2 3 EvaluateCirculation2large borebranula 14 16gauge TakebloodforFBC coagulationprofile BUSE Cr LFT Fibrinogen GXM4units Positionflat lateraltiltKeeppatientwarmGivecrystalloidinfusion Hartmann 3 2 4 InMajorPPH addTranfusebloodasap Untilbloodisavailable totalvolumeof3 5litrescrystalloidinfuseupto2LofwarmedcrystalloidHartmannsolutionand orcolloid 1 2L asrapidlyasrequiredifbloodstillnotavailable MayrequireDIVCregime 3 2 RESUSCITATION 3 2 5 Aimtorestorethebothbloodvolumeandoxygen carryingcapacity3 2 6 Volumereplacementmustbeundertakenonthebasisthatbloodlossisoftengrosslyunderestimated 3 2 7 Thetherapeuticgoalsofmanagementofmassivebloodlossistomaintain3 2 8 RoleofrecombinantfactorVIIatherapy rFVIIa 3 2 9 Roleofantifibrinolyticdrugs thereisroleofmanagementofobstetrichemorrhage 3 3 MONITORING INVESTIGATION 3 3 1 Takebloodasmentioned3 3 2 MonitorBP PRevery15minuteisMinorPPH3 3 3 ContinousBP PR RRinMajorPPH usingoximeter cardiacmonitoring automatedBPrecording 3 3 4 PutFoleycathetertomonitorurineoutput 3 3 5 Incertaincases considerarteriallinemonitoringbyexperiencedstaff3 3 6 TransfertoICUorHDWoncebleedingiscontrolled3 3 7 Documentationoffluidbalance blood bloodproductsandprocedure 3 4 ARRESTTHEBLEEDING 3 4 1 Dependsonthecauseofthemassivebleeding3 4 2 Commoncause UterineAtonyMechanicalPharmacologicalSurgical 3 4 2 1 Mechanical Bimanualuterinecompressiontostimulateuterustocontract External Internal 3 4 2 1 Mechanical AorticCompression Preventionandmanagementofpostpartumhaemorrhage RoyalCollegeofObstetriciansandGynaecologists May2009withrevisionsApril2011 3 4 2 2 Pharmacology RepeatIMSyntocinonorSyntometrineIVPitocin40unitsin500mlHartmann ssolution runat125ml hrIMCarboprost Haemabate 0 25mg mayrepeatedatintervalnotlessthan15mintoamaximum8doses contraindicatedinAsthma IntramyometrialofCarboprost0 25 0 5mgMisoprostol1000mcgrectallyorcervagemperrectally 3 4 2 3 Surgery IffailpharmacologicalDependsontheclinicalcircumstancesandavailableexpertiseFirstlineisBalloonTamponadeVarioustypesofhydrostaticballooncatheterFoleycatheter Bakriballoon Sengstaken Blakemoreoesophagealcatheterandacondomcatheter 3 4 2 3 Surgery Preventionandmanagementofpostpartumhaemorrhage RoyalCollegeofObstetriciansandGynaecologists May2009withrevisionsApril2011 3 4 2 3 Surgery NoevidenceofhowlongtheballoontamponadeshouldbeleftinplaceMostcases 4 6hoursoftamponadeisadequatetoachievehaemostasisShouldberemoveduringdaytimehourswithpresenceofappropriateseniorstaffasfurtherinterventionmaybenecessary The tamponadetest A positivetestA negativetest 3 4 3 CaseofRETAINEDPLACENTAemptybladder attemptCCTIffail proceedwithManualRemovalofPlacenta MRP eitherundersedationorGATakeconsentIfundersedation giveIVPethidine25 50mgstat IVMidazolam2 5 5 0mgstatContinousSPO2monitoring Litothomyposition IVAmpicillin1gstat IVFlagyl500mgstatFullygown mask long sleeveglove Introduceonehandintovaginaalongthecord JANICEM ANDERSON M D PreventionandManagementofPostpartumHemorrhage AmFamPhysician2007 75 875 82 JANICEM ANDERSON M D PreventionandManagementofPostpartumHemorrhage AmFamPhysician2007 75 875 82 OtherhandgraspthefundalofuterusandthehandjustnowmovethroughthecervixtotheintrauterinecavityDetachingtheplacentabysidewaysslicingmovementofthefingers Onceabletodetachtheplacentapartfromtheintrauterinewall grasptheplacentaandbringoutinpieceThenrecheckagaininsidetheuterusforanyremnantpartofplacenta 1 Preventionandmanagementofpostpartumhaemorrhage RoyalCollegeofObstetriciansandGynaecologists May2009withrevisionsApril2011 2 FIGOGui