美国ACOG产后大出血治疗策略PostPartumHemorrhage学习教案

1、会计学1美国美国ACOG产后大出血治疗策略产后大出血治疗策略PostPartumHemorrhage第一页，编辑于星期二：六点 四十六分。第1页/共33页第二页，编辑于星期二：六点 四十六分。第2页/共33页第三页，编辑于星期二：六点 四十六分。第3页/共33页第四页，编辑于星期二：六点 四十六分。第4页/共33页第五页，编辑于星期二：六点 四十六分。第5页/共33页第六页，编辑于星期二：六点 四十六分。第6页/共33页第七页，编辑于星期二：六点 四十六分。Zymogens of Serine ProteasesActivitiesFactor XIIbinds to exposed coll

2、agen at site of vessel wall injury, activated by high-MW kininogen and kallikreinFactor XIactivated by factor XIIaFactor IXactivated by factor XIa in presence of Ca2+Factor VIIactivated by thrombin in presence of Ca2+Factor Xactivated on surface of activated platelets by tenase complex and by factor

3、 VIIa in presence of tissue factor and Ca2+Factor IIactivated on surface of activated platelets by prothrombinase complexCofactorsActivitiesFactor VIIIactivated by thrombin; factor VIIIa is a cofactor in the activation of factor X by factor IXaFactor Vactivated by thrombin; factor Va is a cofactor i

4、n the activation of prothrombin by factor XaFactor III (tissue factor)a subendothelial cell-surface glycoprotein that acts as a cofactor for factor VIIFibrinogenActivityFactor Icleaved by thrombin to form fibrin clotTransglutaminaseActivityFactor XIIIactivated by thrombin in presence of Ca2+; stabil

5、izes fibrin clot by covalent cross-linkingRegulatory and other proteinsActivitiesvon Willebrand factorassociated with subendothelial connective tissue; serves as a brigde between platelet glycoprotein GPIb/IX and collagenProtein Cactivated to protein Ca by thrombin bound to thrombomodulin; then degr

6、ades factors VIIIa and VaProtein Sacts as a cofactor of protein C; both proteins contain gla residuesThrombomodulinprotein on the surface of endothelial cells; binds thrombin, which then activates protein CAntithrombin IIImost important coagulation inhibitor, controls activities of thrombin, and fac

7、tors IXa, Xa, XIa and XIIa第7页/共33页第八页，编辑于星期二：六点 四十六分。第8页/共33页第九页，编辑于星期二：六点 四十六分。第9页/共33页第十页，编辑于星期二：六点 四十六分。第10页/共33页第十一页，编辑于星期二：六点 四十六分。第11页/共33页第十二页，编辑于星期二：六点 四十六分。第12页/共33页第十三页，编辑于星期二：六点 四十六分。第13页/共33页第十四页，编辑于星期二：六点 四十六分。第14页/共33页第十五页，编辑于星期二：六点 四十六分。第15页/共33页第十六页，编辑于星期二：六点 四十六分。Etiology ProcessCli

8、nical Risk FactorsToneOverdistended UterusPolyhydramnios, Multiple GestationMacrosomiaUterine Muscle Fatigue Rapid Labor, Prolonged LaborHigh ParityIntra Amniotic InfectionFever, Prolonged ROMFunctional/Anatomic Distortion of the UterusFibroid UterusPlacenta PreviaUterine AnomaliesTissueRetained Pro

9、ductsAbnormal PlacentaIncomplete Placenta at DeliveryPrevious Uterine ScarHigh ParityRetained Blood ClotsAtonic UterusTraumaLacerationsPrecipitous or Operative DeliveryExtensions at C/SMalposition, Deep EngagementUterine RupturePrevious Uterine SurgeryUterine InversionHigh Parity, Fundal PlacentaThr

10、ombinPre-existingCoagulopaties, Liver DiseaseAcquired in PregnancyITP, DICTherapeutic Anti-coagHistory of clots第16页/共33页第十七页，编辑于星期二：六点 四十六分。第17页/共33页第十八页，编辑于星期二：六点 四十六分。第18页/共33页第十九页，编辑于星期二：六点 四十六分。第19页/共33页第二十页，编辑于星期二：六点 四十六分。第20页/共33页第二十一页，编辑于星期二：六点 四十六分。Blood Loss (%)Blood PressureSigns & Sym

11、ptoms500-1000ml (10-15)normalPalpitations, dizziness, tachycardia1000-1500ml (15-25)Slightly lowWeakness, sweating, tachycardia1500-2000ml (25-35)70-80Restlessness, pallor, oliguria2000-3000ml (35-45)50-70Collapse, air hunger, anuria 2500cc blood loss 50% mortality if not managed urgently & appr

12、opriately第21页/共33页第二十二页，编辑于星期二：六点 四十六分。第22页/共33页第二十三页，编辑于星期二：六点 四十六分。第23页/共33页第二十四页，编辑于星期二：六点 四十六分。DrugDoseSide EffectsContraindicationsOxytocin10 IU IM/IMM5 IU iv bolus10-40 IU/L-Usually none-ctx-N&V-water intoxication-hypersensitivityErgot0.25mg IM0.125 mg IVQ5mins X 5 doses-peripheral vasospa

13、sm-HTN-N&V-HTN-peripheral disease-Raynaulds-hypersensitivityHemabate(PGF2)0.25 mg IM/IMMQ15mins X 8 doses-flushing-diarrhea/N&V-O2 desats-bronchospasm-restlessness-hypersensitivity-asthma-active cardiac, pulmonary, renal, or hepatic diseaseMisoprostol(PGE1)400-1000mcg PR/PV/PO X 1 dose-pyrex

14、ia/flushing-N&V/diarrhea-abd pain-HA-hypersensitivity-pregnancyVasopressin20U/100ml salineInject 1ml at bleeding site-acute HTN-bronchospasm-N&V/cramps-HA, vertigo-angina-death if iv-coronary artery disease-hypersensitivity第24页/共33页第二十五页，编辑于星期二：六点 四十六分。第25页/共33页第二十六页，编辑于星期二：六点 四十六分。第26页/共33页

15、第二十七页，编辑于星期二：六点 四十六分。第27页/共33页第二十八页，编辑于星期二：六点 四十六分。第28页/共33页第二十九页，编辑于星期二：六点 四十六分。第29页/共33页第三十页，编辑于星期二：六点 四十六分。第30页/共33页第三十一页，编辑于星期二：六点 四十六分。Step 1 Initial AssessmentResuscitation-Large bore ivs-O2-Vitals-foley catheterDx Etiology-explore uterus (tone/tissue)-explore genital tract (trauma)-review his

16、tory (thrombin)-observe clotsLabs-CBC-coag profile-cross matchStep 2 Directed TherapyTone-massage-compress-drugsTissue-manual removal-curettageTrauma-correct inversion-repair laceration-identify ruptureThrombin-reverse anticoagulation-replace factorsStep 3 Intractable PPHGet Help-OB/Surgery-Anesthesia-Lab/Blood Bank-ICULocal Control-manual compression-pack uteru