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1、“Obstetrics is Bloody Business”*Postpartum Hemorrhage:Postpartum Hemorrhage:*Cunningham, et. al: Williams Obstetrics, 21st ed., 2001PPH is the leading cause of death related to pregnancy worldwide 1 1Major causes of death for pregnancy women （maternal mortality)lPostpartum hemorrhage（28%)lheart dise
2、aseslpregnancy-induced hypertensionl(or Amniotic fluid embolism )linfection2 2Definition of PPHlThe early PPH is defined as a blood loss exceeding 500ml after delivery of the infant2cm in length and be actively bleedingllaceration of vaginal and perineumEtiology/prediction/prevention/management1919R
3、ecord:lPulseshock indexlblood pressurelmaternal heart ratelcentral venous pressurelurine outputEtiology/prediction/prevention/management2020Lab tests:lHb,lBT(bleeding time), CT( clotting time),lplatelets countlfibrinogenlprothrombin time and patial thromboplastin timelFDPlwomens blood group and cros
4、s- matchingEtiology/prediction/prevention/management2121Treatment:lthe key is correcting the coagulation defectlresuscitation must be started as soon as possiblelinfusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusionlblood transfusion is essentiallinfusi
5、on of red cells, platelets, fresh frozen plasma, FDP , clotting factors,Etiology/prediction/prevention/management2222Perineum vaginal and cervical lacerationlonly skin and a minor part of the perineal bodylperineal body and vaginalanal sphincter and anal canalEtiology/prediction/prevention/managemen
6、t2323Stimulation of uterine contraction lMassage of uterus through the abdomen and bimanual compression lintrauterine packingEtiology/prediction/prevention/management2424Surgical therapylcausing uterine contraction or compressionltamponade the uterine cavity ldecrease blood supply to the uterusl rem
7、ove the uterusl. Etiology/prediction/prevention/management2525Surgical methodsIf massage and agents are unsuccessful:lLigation or embolization of the uterine arterieslHysterectomyEtiology/prediction/prevention/management2626adherence of placenta (accreta increta pericreta)Etiology/prediction/prevent
8、ion/management2727Potential complications of PPH lPostpartum infectionlAnemialTransfusion hepatitis,lSheehans syndromelAshermans syndromeThe best management of PPH is prevention Etiology/prediction/prevention/management2828Resuscitation for PPHlcall an assistantlresuscitate the patient vigorouslyWha
9、t is the state of her peripheral circulation?How much blood has she lost? Is it clotting normally in the receiver used to collect it? What has been done so far? Monitor the volume of blood she continues to lose her peripheries, pulse and blood pressure, and her urine output.2929Summary: remember 4 T
10、sl“TONE”lRule out Uterine AtonylPalpate fundus.lMassage uterus.lOxytocin 20U/500cc.lProstaglandinl Hemabate IM q 15min3030Summary: remember 4 Tsl“Tissue”lR/O retained placentalInspect placenta for missing cotyledons.lExplore uterus.lTreat abnormal implantation.3131Summary: remember 4 Tsl“TRAUMA”lR/o
11、 cervical or vaginal lacerations.lObtain good exposure.lInspect cervix and vagina.lWorry about slow bleeders.lTreat hematomas.3232Summary: remember 4 Tsl“THROMBIN”lCheck labs if suspicious.3333Case-2 l37ys, multiparity, was admitted in her 40+2wks for irregular contraction without any abnormal sign.
12、lTwo hrs later, the contraction became stronger and membranes ruptured when h with meconium-stained amniotic fluid Idegree.l7:33 cyanochroia happened with breathless and loss of consciousness in a second. 3434What is the diagnosisl8:20pm still-birth weight 3.2kg.lPPH emerged as soon as placenta deli
13、vered without any clot.lThe patient was in the state of unconsciousness and became pale3535HysterectomylHysterectomy was done soon after resuscitation.lThe amount was about 4000ml.lRed cell was transfused 1600ml, fresh plasma 400ml, platelet 20u, cryoprecipitate 10u. lTransfusion was continued after
14、 OP 1800ml.3636l，Hb38g/L, APTT43.4秒，PT45.0(正常11- 14sec),PT比例3.52 (正常0.85-1.15)，Fbg 0.976g (正常2-4g/L),APTT不凝， TT44.Tsec(正常14-21sec)。FDP（+），D -2聚集体（+），3P试验（+）。尿常规Pro 2+, 比重1.000, RBC 10-15/HP, 可见颗粒 管型。 3737l术后41小时拔除气管插管，并停用多巴胺，生命 体征平稳。术后40小时发现左上肢皮肤感觉减退 ，运动受限。头部MRI：左侧小脑半球、双侧枕 、顶叶及右侧丘脑多发脑梗塞，胸部CT：两肺纹 理明显
15、增多，两下肺见散在斑点状致密影，心影 增大，两则胸腔积液，两侧胸腔积液。术后18天 复查血、尿常规、凝血功能除Hb 102g/L外，均正 常。胸部CT：正常。头部MRI：梗塞灶明显缩小 。左上肢皮肤感觉功能恢复，但肌力仍低下。术 后5个月恢复正常。3838Uterine pathologyCervical blood camp expansion, congestion and the small focal-like bleeding in the small vessels seen in the amniotic fluid composition. Subclavian vein bl
16、ood smear inspection, microscopic examination shows like material and a little meconium keratosis-like material.3939l术后15天复查头部MRT表现右顶叶及丘脑 病灶范围缩小。原双侧枕叶，左顶叶及左 小脑半球病灶已吸收消散，胸部CT提示原 病灶及胸腔积液均已消失。4040Amniotic fluid embolismlClinical characterHeart and lung failure Bleeding induced by DICAcute renal failure lDiagnosis“amniotic fluid composition” in circulation or tissue4141Key wordslUterine atonylthe definition of PPHlAmniotic fluid embolism lPRO
