妇产科学产后出血完整版课件

1、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

2、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 PPHCAUSEINCIDENCE (APPROX)TONE 子宫收缩乏力Atony70%TRAUMA 软产道裂伤 Laceration, hematoma, inversion, rupture20%TISSUE 胎盘因素Retained placenta, invasive placenta10%THROMBIN 凝血功能Coagulopathi

3、es1%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

4、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 placentaExternal hand steadies the uterine fundusInternal hand

5、 along plane of cleavageCheck placenta is completeCheck the uterus is emptyCheck for trauma of GTAnaesthesiaAntibioticsIV lineOxytocicsUterusPlacenta病因CongenitalVon Willebrands diseaseAcquiredDIC, Obstetric disordersHELLP syndromeDIC (eclampsia, intrauterine foetal death, septicaemia, placenta abrup

6、tio, amniotic fluid embolism)Anti coagulant therapy HeparinDead male baby 4.按摩子宫是有效的简单的刺激子宫收缩的方法产后出血Postpartum HemorrhagePPHTISSUE 胎盘因素Marked fall (70-80 mmHg)DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism)2mg im Q2-4 hours留置导尿，24hr出入量Prolonged lab

7、or, PIH晚期出血：产后24hr后（感染、胎盘）AntibioticsFoley, BT-Cath, Sengstaken-Blakemore TubeB-Lynch sutureWhat do you do?Massage /compressFoley, BT-Cath, Sengstaken-Blakemore Tube病因Systemic factorsSpirit, Chronic diseasesObstetric factorsProlonged labor, PIHUterine factorsHigh parity, Multiple gestation, macrosom

8、ia, LeiomyomasDrug factorstocolytic agentsPPH 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 ）UterotonicsDose/ RouteContra-IndicationsPitocin10U im20U in 500ml NS iv

9、gtt Mast dose 80UMethergine0.2mg im Q2-4 hoursHypertensionScleroderma, RaynaudsHemabate0.25 mg im Q15min to max dose 2mgAsthmaCytotec200 1000mcg Oral / Vaginal / RectalQ 6 hours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 TubeJacobs AJ,

10、Up to Date 2009Gauze 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 18COMPRESSION SUTURESCornuFallopian tubeOvaryHayman R, Arulkumar

11、an S, Steer PObstetrics & Gynecology. 2002OvaryFallopian 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Compensation Mild Moderate SevereBlood Loss500-1000 ml 10-15%1000-1500 ml 15-25%1500-2000 ml

12、25-35%2000-3000 ml 35-45%B.P.Change(SBP)NoneSlight fall(80-100 mmHg)Marked fall (70-80 mmHg)Profound fall (50-70 mmHg)Symptoms & SignsPalpitationDizzinessTachycardiaWeaknessSweatingTachycardiaRestlessnessPallorOliguriaCollapseAir hungerAnuria治疗原则2 方面复苏止血 识别和治疗4Ts治疗：及时，系统Step IInitial Assessment and

13、treatment ResuscitationAssess EtiologyManagementLarge bore IV(s)Oxygen by maskMonitor BP,P,RHead down tilt Transfuseoxygen saturation Explore uterus (tone,tissue) Explore LGT (trauma) Review history (thrombin) Observe clots Coagulation screen Group and crossmatchMassage /compressRemove placentaRepai

14、r traumaCorrect inversionCorrect coagulopathyStep IIContinuing PPH Get HelpLocal ControlBP and coagulationObstetrician / surgeonAnesthesiologistLab and ICU Manual compression +/- pack uterus +/- vasopressin +/-embolizationCrystalloidBlood productsTransferred to theatreTemporarily effectiveVaginal/ce

15、rvical tear 阴道宫颈裂伤手术介入(3 of 4)软 胎盘胎膜异常 软产道裂伤Life +ve, 24+2 wkCoagulation screenExcessive vaginal bleedingLarge bore IV(s)Local controlInternal iliac arteryStep IIISurgery RepairLacerations Local controlLigate VesselsHysterectomy Undersutering the placental bed Square suture B-Lynch sutureUterinesInt

16、ernal iliac arteryStep VPost Hysterectomy BleedingAbdominal Packing Angiographic Embolization 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！ProductContentsVolumeEffectWhole Blood500ml Hct 3%PRBCsRBCs, WBCs, few plasma proteins300ml Hct

17、3%, less feverPlateletsPooled concentrate 1 unit = 6 pack50ml PLT 5-10KFFPFibrinogen, ATIII, clotting factors, plasma250ml fibrinogen 5-10mg/dlCryoprecipitateFibrinogen, Factor VIII, XIII, vWF40ml fibrinogen 5-10mg/dlBlood Product UtilizationActive management of the third stage of labor Blood loss 1

18、000 to 1500ml massive PPHBrisk bleedingBlood pressure falling Pulse risingMassageOxytocinExplore genital tract Inspect placentaObserve clottingCoagulation screenThe Four T sSoft, boggy uterusToneResuscitationGenital tract tearTraumaPlacenta retainedTissueBlood not clottingThrombinHemabateMetherginec

19、ytotecSutureManual removeBlood product, Surgical Intervention Blood loss 500 mlPPHReplace factor Conclusions ！Be preparedPractice prevention Assess the lossAssess the maternal statusResuscitate vigorously and appropriately Diagnose the cause Summary: Remember 4 TsUnderstanding its etiology is fundam

20、ental 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 PLT 5-10K米索前列醇（Misop

21、rostol ）Huge blood clot seen in vagina.oxygen saturationExplore genital tract掌握产后出血的重要原因Blood Product UtilizationReplace factorLevel 18 wk)Internal hand along plane of cleavagePostoperative RecoveryOn admission:最普遍的严重的产科并发症On admission:依据出血时间、出血量、出血性质判断出血原因Personal History23 year old ladyMarried for

22、 3 yearsG 2nd Para 1; no livingPast Obstetric HistoryIn 2002Gestational Diabetes + Preeclampsia（PE）Delivered at 38 weeksVaginal delivery on 5/2002Dead male baby 4.5 kgCurrent PregnancyLMP 10/10/2003 Twin pregnancyRegular prenatal care in a private clinicNo document of screening for GDM in this pregn

23、ancyOn admission:History of unsatisfactory fetal movements for the last 3 daysLabor pains for 3 hoursAdmission21:00, May 3rd 2004liquor above average, uterine contractions 2/10 min, each 20 sec.PV: 4 cm dilated, 1 cm long, central, softU.S. scan Twin pregnancyMonoamniotic monochorionic1st cephalic,

24、F. Life +ve, 24+2 wk2nd transverse, F. Life ve, 22 wkPlacenta fundal anterior grade IILiquor: clear, AFI 27 cmProgressPatient spontaneously miscarried at 03:001 L male 500 gm (died later)1 SB male 1 kgVaginal bleeding associated with retained placenta.Transferred to theatreEmptying the bladderIV crystalloidsManual separation of the pl