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1、1,“Obstetrics is Bloody Business”*,Postpartum Hemorrhage:,*Cunningham, et. al: Williams Obstetrics, 21st ed., 2001,PPH is the leading cause of death related to pregnancy worldwide,2,Major causes of death for pregnancy women （maternal mortality),Postpartum hemorrhage（28%) heart diseases pregnancy-ind
2、uced hypertension (or Amniotic fluid embolism ) infection,3,Definition of PPH,The early PPH is defined as a blood loss exceeding 500ml after delivery of the infant 24 h The late PPH: occurs after 24 hour of delivery to 6 weeks,4,Major causes,Uterine atony (90%) Lacerations of the genital tract(6%) R
3、etained placenta(3%-4%) Coagulation defects (blood dyscrasia) (4T: tone, tissue, trauma, thrombin),Etiology/prediction/prevention/management,5,1. Uterine atony,Local factors: Overdistention of the uterine Condition that interfere with contraction (leiomyoma) Complications (PIH, anemia, placenta prev
4、ia) Systemic factors: Nervous Drugs Abnormal labor History of previous PPH Preeclampsia, abnormal placentation,Etiology/prediction/prevention/management,6,Pathology,Contraction constricting the spiral arteries Preventing the excessive bleeding from the placenta implantation site Uterine atony give r
5、ise to PPH when no contraction occur,Etiology/prediction/prevention/management,7,Main complain,Have heart palpitations Feel faint Lightheaded Breathless,Etiology/prediction/prevention/management,8,2. Lacerations of the genital tract,Causes: Instrumented delivery (forceps) manipulative delivery (bree
6、ch extraction, precipitous labor, macrosomia) Types: perineum laceration vaginal laceration cervical laceration,Etiology/prediction/prevention/management,9,3. Retained placenta,Separation and explosion of placenta is caused by strong uterine contraction Placenta tissue remaining in the uterus preven
7、t adequate contraction and predispose to excessive bleeding,Etiology/prediction/prevention/management,10,4. Coagulation defects,Acquired abnormality in blood clotting: abruption placenta, amniotic fluid embolism severe preeclampsia Congenital abnormality in blood clotting: thrombocytopenia severe he
8、patic diseases leukemia,Etiology/prediction/prevention/management,11,disseminated intravascular coagulopathy (DIC),if bleeding persists in spite of all other treatment described, DIC should be suspected the blood passing from the genital tract is not clotting shock: reduction of effective circulatio
9、n inadequate perfusion of all tissues oxygen depletion depression of functions,12,D.D. with PPH,Color, order, amount Risk reasons Clot,“Bloody”,Etiology/prediction/prevention/management,13,Consequences of PPH,Hypovolemic shock Blood transfusion and its attendant complications Surgical injury, fever,
10、 renal and hepatic failure Acute respiratory distress syndrome Disseminated intravascular coagulopathy Loss of fertility, and Sheehans syndrome,14,CASE,36ys Primiparity, accepted C-section because of marginal placenta and fibroids After birth, PPH happened immediately caused by uterine atony, Oxytoc
11、in was used while stitching, but hemorrhage was continue,15,Risk factors for PPH,Advanced maternal age Multifetal gestations Prolonged labor Polyhydramnios Instrumental delivery Fetal demise Placental abruption Anticoagulation therapy,Multiparity Fibroids Prolonged use of oxytocin Macrosomia Cesarea
12、n delivery Placenta previa and accreta Chorioamnionitis General anesthesia,16,Risk factors for PPH,Advanced maternal age Multifetal gestations Prolonged labor Polyhydramnios Instrumental delivery Fetal demise Placental abruption Anticoagulation therapy,Multiparity Fibroids Prolonged use of oxytocin
13、Macrosomia Cesarean delivery Placenta previa and accreta Chorioamnionitis General anesthesia,17,Prevention and treatment,The placenta should be examined carefully manual removal of placenta hysterectomy is required for placenta uterine contraction drugs,Etiology/prediction/prevention/management,18,P
14、revention uterine atony,Administration of medicine: promotes contraction of the uterine corpus decreases the likelihood of uterine atony Oxytocin agents Prostaglandin,Etiology/prediction/prevention/management,19,management,Vaginal examination soon after delivery repair: cervical laceration 2cm in le
15、ngth and be actively bleeding laceration of vaginal and perineum,Etiology/prediction/prevention/management,20,Record: Pulseshock index blood pressure maternal heart rate central venous pressure urine output,Etiology/prediction/prevention/management,21,Lab tests: Hb, BT(bleeding time), CT( clotting t
16、ime), platelets count fibrinogen prothrombin time and patial thromboplastin time FDP womens blood group and cross-matching,Etiology/prediction/prevention/management,22,Treatment: the key is correcting the coagulation defect resuscitation must be started as soon as possible infusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion blood transfusion is essential infusion of red cells, platelets, fresh frozen plasma, FDP , clotting factors,Etiology
