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1、An Update on Obstetric Hemorrhage,Michael Y. Gao MD, Ph.D Department of Obstetrics and Gynecology Rutgers/Robert Wood Johnson Medical School New Brunswick, New Jersey Telephone: 732-246-0495 (USA) WeChat ID: michaelg8175,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update
2、on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,Maternal mortality is quite low in United States Still any increase is concerning when one recognizes the great improvements seen over the past century Likely multifactorial such as increased maternal age at delivery and associated comorbidit
3、ies, improved management of chronic disease, and increased elective interventions that result in an increased cesarean delivery rate,An Update on Obstetric Hemorrhage,The consequences of intrapartum hemorrhage are related to the degree of blood loss The key to the management is to recognize its occu
4、rrence in a timely fashion Some causes of obstetric hemorrhage include placenta previa, accreta, abruption, uterine atony, uterine injury and vaginal or cervical laceration,An Update on Obstetric Hemorrhage,Macrosomia Multiple gestation Polyhydramnios Labor induction Prolonged labor Rapid labor,An U
5、pdate on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhag
6、e,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,An Update on Obstetric Hemorrhage,Prenatal Assessment & Planning,Identify and prepare for pati
7、ents with special considerations: placenta previa and accreta, bleeding disorder, or those who decline blood products Screen and aggressively treat severe anemia: if oral iron fails, initiate IV iron protocol to reach desired Hgb/Hct, especially for at risk mothers,Admission Assessment & Planning,Ve
8、rify type & antibody screen Evaluate for risk factors Evaluate for the development of additional risk factors in labor: prolonged 2nd stage labor, prolonged oxytocin use, active bleeding, chorioamnionitis, or magnesium sulfate usage Treat multiple risk factors as high risk,OB Hemorrhage Risk Factor,
9、 low,No previous uterine incision Singleton pregnancy Less than five previous vaginal births No known bleeding disorder No history of PPH,OB Hemorrhage Risk Factor, medium,Prior cesarean birth(s) or uterine surgery Multiple gestation Four or more previous vaginal births Chorioamnionitis History of p
10、revious PPH Large uterine fibroids Estimated fetal weight greater than 4 kg Morbid obesity (BMI35),OB Hemorrhage Risk Factor, high,Placenta previa, low lying placenta Suspected placenta accreta or percreta Hematocrit 30 and other risk factors Platelets 100,000 Active bleeding (greater than show) on
11、admit Known coagulopathy,STAGE 0: All Births: Prevention & Recognition of OB Hemorrhage,Active management of 3rd stage: 10-20 units oxytocin/1000ml solution titrate infusion rate to uterine tone; or 10 units IM; do not give oxytocin as IV push Vigorous fundal massage for at least 15 seconds Ongoing
12、QBL evaluation: using formal methods, such as graduated containers, weight of blood soaked materials (1gm=1ml),STAGE 1: QBL 500ml Vag or 1000ml CS or VS unstable with continued bleeding,Activate OB hemorrhage protocol and checklist Notify obstetrician, charge nurse and anesthesiologist Establish IV
13、access, at least 18 gauge, increase IV fluid rate, and increase oxytocin rate Administer methergine per protocol Vital signs, O2 sat(95%) & level of consciousness,STAGE 1: cont,Empty bladder, monitor urinary output Type and Crossmatch for 2 units PRBCs Keep patient warm Consider potential etiology:
14、uterine atony, trauma/laceration, retained placenta, amniotic fluid embolism, uterine inversion, coagulopathy, placenta accreta and uterine rupture Once stabilized: modified postpartum management with increased surveillance,An Update on Obstetric Hemorrhage,STAGE 2: QBL 1000-1500ml with continued bl
15、eeding,Activate response team, notify perinatologist, 2ndOB, 2ndanesthesiologist Notify blood bank, assign single person to communicate with blood bank Additional uterotonic medication: hemabate and/or misoprostol Order labs STAT (CBC/Plts, chem 12, PT/aPTT, fibrinogen, ABG) Establish 2nd large bore
16、 IV,STAGE 2: cont,Transfuse PRBCs based on clinical signs and response, do not wait for lab results Vaginal birth: if vaginal or cervical trauma, visualize and repair; if retained placenta, D if uterine inversion, anesthesia and uterine relaxation drugs for manual reduction If above measures unprodu
17、ctive: selective interventional radiology embolization,STAGE 2: cont,C-section: uterine hemostatic suture, e.g., B-Lynch suture, OLeary, multiple squares; intrauterine balloon If amniotic fluid embolism: maximally aggressive respiratory, vasopressor and blood product support If VS are worse than QBL: possible uterine rupture or broad ligament tear with internal bleeding, move to laparotomy Once stabilized: modified postpartum management with increased surveillance,
