发成都产后出血指南解读

国内外产后出血最新诊治指南解读,四川大学华西第二医院刘兴会E-mail:,海纳百川 有容乃大,一、产后出血的定义和诊断,中国（WHO）：胎儿娩出后24小时内阴道出血量500ml国外：阴道分娩产后出血：产后24小时出血量500ml剖宫产产后出血：出血量1000ml中华医学会妇产科学分会产科学组.产后出血预防与处理指南（草案）.中华妇产科杂志，2009,44:554-557.Leduc D, Senikas V, Lalonde AB, et al. Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. Journal of Obstetrics 31(10): 980-93.,严重产后出血（severe postpartum hemorrhage，sPPH：将产后出血量1000ml难治性产后出血（intractable postpartum hemorrhage，iPPH）：子宫收缩药物、子宫按摩或按压等保守措施无法有效止血，需要外科手术或介入治疗甚至切除子宫的严重产后出血Bulik CM, Torgersen L, Reichborn-Kjennerud T, Gendall K, Von Holle A. The surgical management of intractable postpartum hemorrhage. Acta Obstetricia Et Gynecologica Scandinavica 2009; 88(4): 489-.490.Maassen MS, Lambers MDA, Tutein Nolthenius RP, van der Valk PHM, Elgersma OE. Complications and failure of uterine artery embolisation for intractable postpartum haemorrhage. Bjog-Int J Obstet Gy 2009; 116(1): 55-61.,产后出血（PPH）发生率,国内：大多报道PPH5%，sPPH1%国外：PPH为5-13%，sPPH为1-2%全国多中心前瞻性研究（华西二院）：产后出血：12.3%Gungor T, Simsek A, Ozdemir AO, et al. Surgical treatment of intractable postpartum hemorrhage and changing trends in modern obstetric perspective. Arch Gynecol Obstet, 2009,280(3):351-355.Metin Gulmezoglu A, Lumbiganon P, Landoulsi S, et al. Active management of the third stage of labour with and without controlled cord traction: A randomised, controlled, non-inferiority trial. The Lancet 2012; 379(9827): 1721-7.Laas E, Bui C, Popowski T, Mbaku OM, Rozenberg P. Trends in the rate of invasive procedures after the addition of the intrauterine tamponade test to a protocol for management of severe postpartum hemorrhage. Am J Obstet Gynecol 2012; 207(4): 281 e1-7.,估计出血量的方法,肉眼估计：准吗称重法或容积法监测生命体征、尿量和精神状态休克指数法血红蛋白测定,?,低估3050%,二、产后出血的原因及预防,产后出血的四大原因：宫缩乏力（70%90%）产道损伤（20%）胎盘因素（10%）凝血功能障碍（1%）American College of Obstetricians and Gynecologists. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 76, October 2006: postpartum hemorrhage. Obstet Gynecol, 2006,108:1039-1047,不要忽略引起产后出血的高危因素,产后出血的原因和高危因素,产后出血的预防,预防性使用缩宫素及时钳夹并剪断脐带有控制地牵拉脐带协助胎盘娩出胎盘娩出后按摩子宫,缩宫素（催产素）,预防和治疗PPH的一线药物长效缩宫素：剖宫产预防用（加拿大指南）半衰期长、作用时间长、更方便高危患者：如双胎、巨大儿、前置胎盘等加用前列腺素制剂,合理的断脐时机,近年来循证医学证据表明:及时断脐并不能减少PPH的发生，反而可能增加新生儿贫血、脑室出血等风险WHO产后出血防治指南:2007年：已偏向于延迟钳夹和剪断脐带2012年：胎儿娩出后的1-3分钟钳夹和剪断脐带WHO. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva：World Health Organizaion 2012,控制性牵拉脐带协助胎盘娩出,国外多中心随机对照研究：控制性牵拉脐带并不能降低PPH的发生率2012年WHO产后出血防治指南：并不推荐常规预防性按摩子宫华西二院组织的多中心随机对照临床研究：亦表明阴道分娩后子宫按摩并不能减少产后出血Metin GA,Lumbiganon P, Landoulsi S, et al.Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet,2012,379:1721-1727.Catherine D. Effect of routine controlled cord traction as part of theactive management of the third stage of labour onpostpartum haemorrhage: multicentre randomisedcontrolled trial (TRACOR). BMJ, 2013,346:f1541-1551.,？,三、产后出血的处理流程,预警期：一级急救处理期：二级急救危重期：三级急救中华医学会妇产科学分会产科学组.产后出血预防与处理指南（草案）.中华妇产科杂志，2009,44:554-557.,四、产后出血的处理原则,最根本的方法：积极针对病因进行处理,1、宫缩乏力的处理,原则：先简单、后复杂；先无创，后有创。子宫按摩或按压 + 宫缩剂（催产素+强有力宫缩剂如欣母沛）,2、保留子宫的手术止血方法,宫腔填塞B-Lynch缝合及其改良缝合术盆腔动脉结扎血管栓塞,（1）宫腔填塞（uterine packing）,宫腔水囊填塞,宫腔纱条填塞：针对子宫收缩乏力,宫腔纱条填塞：针对凶险性前置胎盘只填塞子宫下段宫体以强有力的宫缩剂让其收缩止血,（2）B-Lynch缝合法：针对宫缩乏力,针对前置胎盘的改良子宫缝合法-,Hayman RG,Arulkumaran S,Steer PJ. Uterine compression sutures:surgical management of postpartum hemorrhage. Obstet Gynecol.2002;99(3):502-506,改良的B-Lynch缝合法：国内,Zheng J, Xiong X, Ma Q, Zhang X, Li M. A new uterine compression suture for postpartum haemorrhage with atony. BJOG 2011; 118(3): 370-4.,Dr Christopher B-Lynch于2013年4月到四川大学华西第二医院交流,（3）盆腔动脉结扎,子宫动脉结扎（uterine artery ligation）髂内动脉结扎（hypogastric artery ligation, internal iliac artery ligation） 要求熟悉胜任各种骨盆妇科手术的资深医生 子宫动脉结扎对控制产后出血可能有效,髂内动脉结扎：,目前文献多为病例报道，有效率为42%100%Papathanasiou K, Tolikas A, Dovas D,et al. Ligation of internal iliac artery for severe obstetric and pelvic haemorrhage: 10 year experience with 11 cases in a university hospital. J Obstet Gynaecol. 2008;28(2):183-184Sziller I, Hupuczi P, Papp Z. Hypogastric artery ligation for severe hemorrhage in obstetric patients. J Perinat Med. 2007;35(3):187-192,（4）血 管 栓 塞,适应症：各种难治性产后出血。禁忌症：合并有DIC生命体征不稳定不宜搬动者注意事项：及早准备，提前通知 操作者娴熟的技能,Vegas G, Illescas T, Muoz M,et al. Selective pelvic arterial embolization in the management of obstetric hemorrhage. Eur J Obstet Gynecol Reprod Biol. 2006;127(1):68-72,经皮腹主动脉内球囊导管置入术,四川大学华西第二医院资料：,20072011年间需要采用手术治疗的96例难治性PPH病例，比较几种手术治疗方法的效果评价Luo FY, Chen M, Zhang L, et al. A comparison of the effectiveness of five types of hemostatic surgeries for intactable postpartum haemorrhage and the factors of failed hemostasis. Chin J Obstet Gynecol, 2012, 47(09): 641-645.,四川大学华西第二医院难治性产后出血保守手术治疗经验,罗方媛, 刘兴会等. 难治性产后出血的五种止血手术疗效的比较及止血失败原因分析. 中华妇产科杂志. 2012; (9): 641-645.,难治性产后出血保守手术治疗结局,罗方媛, 刘兴会等. 难治性产后出血的五种止血手术疗效的比较及止血失败原因分析. 中华妇产科杂志. 2012; (9): 641-645.,不同原因难治性产后出血保守治疗的效果观察,成功率%,罗方媛, 刘兴会等. 难治性产后出血的五种止血手术疗效的比较及止血失败原因分析. 中华妇产科杂志. 2012; (9): 641-645.,3、围产期子宫切除（PH）,在药物和手术治疗都失败的情况下挽救孕产妇生命的重要措施PH的死亡率为0.6%4.2%Shah M, Wright JD. Surgical Intervention in the Management of Postpartum Hemorrhage. Semin Perinatol, 2009, 33(2): 109-115.,围产期子宫切除现状,文献报道：0.3-1.5/1000中 国：1.5-2.2/1000四川省：1.9/1000-华西第二医院研究结果以1的围产期子宫切除率计算我国每年将有超过1万名孕产妇因为PPH而失去子宫Chen M, Zhang L, Wei Q, et al. Peripartum hysterectomy between 2009 and 2010 in Sichuan, China. Int J Gynecol Obstet, 2012,120(2013): 183-186.Bateman BT, Mhyre JM, Callaghan WM, et al. Peripartum hysterectomy in the United States: nationwide 14 year experience. Am J Obstet Gynecol 2012;206:63.e1-8.Yalinkaya A, Guzel AI, Kangal K. Emergency peripartum hysterectomy: 16-year experience of a medical hospital. J Chin Med Assoc 2010;73:360-3.Yang ZY, Huang SL. Clinical analysis of 43 cases of peripartum hysterectomy. In Chinese. Maternal 20:2515-6.,四川大学华西第二医院进行的PH研究,主持单位：四川大学华西第二医院参研单位（四川省）：泸州医学院附属第一医院遂宁市中心医院攀枝花市妇幼保健院自贡市妇幼保健院,成都市第五人民医院彭州市妇幼保健院南充市中心医院,资料：2009 年1月1日至2010年12月31日分娩且分娩孕周超过20周的孕产妇进行分析分娩总数：34014例子宫切除：64例（1.9/1000孕产妇）Chen M, Zhang L, Wei Q, Fu X, Gao Q, Liu X. Peripartum hys