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1、产后出血 Postpartum Hemorrhage PPH,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
2、24hr后（感染、胎盘）,产后出血止血原理,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 PPH,Am Fam Physician 2007; 75:875.,病因,Planned Cesarean section 剖宫产 Episiotomy 外阴侧切,Unplanned Vaginal/cervical tear 阴道宫颈裂伤 Surgical trauma 手术创伤 Uter
3、ine 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
4、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 placenta,External hand steadies the uterine fundus,Internal hand along plane of cleavage,Check placenta is complete Check the uterus is empty Check for trauma of
5、GT,Anaesthesia Antibiotics IV line Oxytocics,Uterus,Placenta,病因,Congenital Von Willebrands disease,Acquired DIC, Obstetric disorders HELLP syndrome DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism) Anti coagulant therapy Heparin,病因,Systemic factors S
6、pirit, Chronic diseases Obstetric factors Prolonged labor, PIH Uterine factors High parity, Multiple gestation, macrosomia, Leiomyomas Drug factors tocolytic agents,PPH 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,
7、催产素 （Oxytocin ） 麦角新碱（Methergine） 欣母沛（Hemabate） 米索前列醇（Misoprostol ）,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 Balloon Foley, BT-Cath, Sengstaken-Blakemore Tube,Jacobs AJ, Up to Date 2009,Gauze Packing,子宫动脉栓塞,Requires available facilities/ personnel Hemodynamically Stable
8、Patient Temporizing 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 18,COMPRESSION SUTURES,Cornu,Fallopian tube,Ovary,Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology. 2002,Ovary,Fallopian tube,手术介入(2 of 4),Gabbe, Ch 1
9、8,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 = 1ml Hct1000ml 每小时尿量2500ml 休克指数= 脉搏/收缩压,治疗原则,2 方面 复苏 止血 识别和治疗4Ts 治疗：及时，系统,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！,Blood Produ
10、ct Utilization,Active management of the third stage of labor,Blood loss 1000 to 1500ml massive PPH,Brisk bleeding Blood pressure falling Pulse rising,Massage Oxytocin,Explore genital tract,Inspect placenta,Observe clotting Coagulation screen,The Four T s,Soft, boggy uterus Tone,Resuscitation,Genital
11、 tract tear Trauma,Placenta retained Tissue,Blood not clotting Thrombin,Hemabate Methergine cytotec,Suture,Manual remove,Blood product, Surgical Intervention,Blood loss 500 ml PPH,Replace factor,Conclusions ！,Be prepared Practice prevention Assess the loss Assess the maternal status Resuscitate vigo
12、rously and appropriately Diagnose the cause Summary: Remember 4 Ts Understanding its etiology is fundamental to effectively managing Treat the cause Active 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,
13、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,Personal History,23 year old lady Married for 3 years G 2nd Para 1; no living,Past Obstetric History,In 2002 Gestational Diabetes + Preeclampsia（PE） Delivered at 38 weeks Vaginal delivery on 5/2002 Dead m
14、ale baby 4.5 kg,Current Pregnancy,LMP 10/10/2003 Twin pregnancy Regular prenatal care in a private clinic No document of screening for GDM in this pregnancy On admission: History of unsatisfactory fetal movements for the last 3 days Labor pains for 3 hours,Admission 21:00, May 3rd 2004,liquor above
15、average, uterine contractions 2/10 min, each 20 sec. PV: 4 cm dilated, 1 cm long, central, soft,U.S. scan,Twin pregnancy Monoamniotic monochorionic 1st cephalic, F. Life +ve, 24+2 wk 2nd transverse, F. Life ve, 22 wk Placenta fundal anterior grade II Liquor: clear, AFI 27 cm,Progress,Patient spontan
16、eously miscarried at 03:00 1 L male 500 gm (died later) 1 SB male 1 kg Vaginal bleeding associated with retained placenta.,Transferred to theatre,Emptying the bladder IV crystalloids,Manual separation of the placenta,Excessive vaginal bleeding Uterine massage and bimanual compression,Uterus stayed atonic (F.Level 18 wk),Received 3 units of whole blood in last 20 minutes,Uterotonics: 1000 ug Misoprostol rectal (5 tabs) 60 units oxytocin (IVI) 500ug Hemabate,
