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1、产后出血产后出血PostpartumHemorrhagePPHZhangyeXuM.D.DepartmentofObstetricsandGynecology1stAffiliatedHospital,WenzhouMedicalCollege1 学学习目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2 3 简介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4 定义定义问题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）5 产后出
2、血止血原理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6 病因病因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
3、凝血功能Coagulopathies1%Am Fam Physician 2007; 75:875.7 病因病因PlannedCesareansection剖宫产剖宫产Episiotomy外阴侧切外阴侧切UnplannedVaginal/cervicaltear阴道宫颈裂伤阴道宫颈裂伤Surgicaltrauma手术创伤手术创伤Uterinerupture子宫破裂子宫破裂8 软产道裂伤诊断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9 软产道裂伤治疗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
4、血10 Cervical laceration repair11 阴道裂伤阴道裂伤lI裂伤 皮肤黏膜lII裂伤肌层lIII裂伤肛门括约肌lIV裂伤直肠12 13 病因病因前置胎盘前置胎盘胎盘残留胎盘残留胎盘滞留、胎盘滞留、嵌顿嵌顿胎盘植入胎盘植入14 胎盘因素出血诊断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15 胎盘因素治疗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
5、，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16 Manual removal of placentaExternal hand steadies the uterine fundusInternal hand along plane of cleavageCheck placenta is completeCheck the uterus is emptyCheck for trauma of GTAnaesthesiaAntibioticsIV lineOxytocicsUterusPlacenta17 病因病因CongenitalVonWillebrandsdiseaseA
6、cquiredDIC,ObstetricdisordersHELLP syndromeDIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism)AnticoagulanttherapyHeparin18 病因病因SystemicfactorsSpirit,ChronicdiseasesObstetricfactorsProlongedlabor,PIHUterinefactorsHighparity,Multiplegestation,macrosomia
7、,LeiomyomasDrugfactorstocolyticagentsPPH 最常见病因(70%)19 宫缩乏力的诊断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20 宫缩乏力的预防宫缩乏力的预防21 宫缩乏力治疗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 200722 宫缩乏力的治疗宫缩乏力的治疗宫缩剂宫缩剂催产素 （Oxytocin ）麦角新碱（Methergine）欣母沛（Hemabate） 米索前列醇（Misoprostol ）23 UterotonicsDose/RouteContra-Indi
8、cationsPitocin10U im20U in 500ml NS ivgtt Mast dose 80UMethergine0.2mg im Q2-4 hoursHypertensionScleroderma, RaynaudsHemabate0.25 mg im Q15min to max dose 2mgAsthmaCytotec200 1000mcg Oral / Vaginal / RectalQ 6 hours24 宫缩剂疗效不佳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25 子宫填塞子宫填塞Bakri Ball
9、oonFoley, BT-Cath, Sengstaken-Blakemore TubeJacobs AJ, Up to Date 200926 Gauze Packing27 子宫动脉栓塞子宫动脉栓塞Requires available facilities/ personnelHemodynamically Stable PatientTemporizing measure en route to OR (Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992)28 29 手术介入手术介入(1 of
10、 4)Gabbe, Ch 1830 COMPRESSIONSUTURESCornuFallopian tubeOvaryHayman R, Arulkumaran S, Steer PObstetrics & Gynecology. 2002OvaryFallopian tube31 手术介入手术介入(2 of 4)Gabbe, Ch 1832 手术介入手术介入(3 of 4)33 手术介入手术介入(4 of 4)34 出血的评估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250
11、0ml休克指数= 脉搏/收缩压35 Compensation MildModerateSevereBloodLoss500-1000ml10-15%1000-1500ml15-25%1500-2000ml25-35%2000-3000ml35-45%B.P.Change(SBP)NoneSlightfall(80-100mmHg)Markedfall(70-80mmHg)Profoundfall(50-70mmHg)Symptoms&SignsPalpitationDizzinessTachycardiaWeaknessSweatingTachycardiaRestlessnessPallor
12、OliguriaCollapseAirhungerAnuria36 治疗原则治疗原则2方面方面复苏止血 识别和治疗4Ts治疗：及时，系统37 StepIInitialAssessmentandtreatmentResuscitationResuscitationAssess EtiologyAssess EtiologyManagementManagementLarge bore IV(s)Oxygen by maskMonitor BP,P,RHead down tilt Transfuseoxygen saturation Explore uterus (tone,tissue) Expl
13、ore LGT (trauma) Review history (thrombin) Observe clots Coagulation screen Group and crossmatchMassage /compressRemove placentaRepair traumaCorrect inversionCorrect coagulopathy38 Step IIContinuing PPH GetHelpGetHelpLocalControlLocalControlBPandcoagulationBPandcoagulationObstetrician / surgeonAnest
14、hesiologistLab and ICU Manual compression +/- pack uterus +/- vasopressin +/-embolizationCrystalloidBlood products39 Step IIISurgery RepairRepairLacerationsLacerations LocalcontrolLocalcontrolLigateVesselsLigateVesselsHysterectomHysterectomyy Undersutering the placental bed Square suture B-Lynch sut
15、ureUterinesInternal iliac arteryStep VPost Hysterectomy BleedingAbdominalPackingAbdominalPackingAngiographicEmbolizationAngiographicEmbolization 40 预防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41 血制品的应用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！42 ProductContentsVolumeEffectW
16、hole Blood500ml Hct 3%PRBCsRBCs, WBCs, few plasma proteins300ml Hct 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 U
17、tilization43 44 Active management of the third stage of labor Blood loss 1000 to 1500ml massive PPHBrisk bleedingBlood pressure falling Pulse risingMassageOxytocinExplore genital tract Inspect placentaObserve clottingCoagulation screenTheFourTsSoft, boggy uterusToneResuscitationGenital tract tearTra
18、umaPlacenta retainedTissueBlood not clottingThrombinHemabateMetherginecytotecSutureManual removeBlood product, Surgical Intervention Blood loss 500 mlPPHReplace factor45 Conclusions ！Be preparedPractice prevention Assess the lossAssess the maternal statusResuscitate vigorously and appropriately Diag
19、nose the cause Summary: Remember 4 TsUnderstanding its etiology is fundamental to effectively managingTreat the causeActive management of the third stage of labor is also a key component in its prevention.46 软软软软 胎盘胎膜异常胎盘胎膜异常胎盘胎膜异常胎盘胎膜异常 软产道裂伤软产道裂伤软产道裂伤软产道裂伤 暗红暗红暗红暗红 鲜红鲜红鲜红鲜红阵发性阵发性阵发性阵发性 持续性持续性持续性持续
20、性胎盘剥离后胎盘剥离后胎盘剥离后胎盘剥离后 胎盘娩出前胎盘娩出前胎盘娩出前胎盘娩出前 胎儿娩出后胎儿娩出后胎儿娩出后胎儿娩出后 宫缩乏力宫缩乏力宫缩乏力宫缩乏力 胎盘因素胎盘因素胎盘因素胎盘因素 产道裂伤产道裂伤产道裂伤产道裂伤凝血功能障碍：出血晚，血液不凝凝血功能障碍：出血晚，血液不凝凝血功能障碍：出血晚，血液不凝凝血功能障碍：出血晚，血液不凝不同病因阴道出血特点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产后出血原因互为因果出血时间出血时间出血性质出血性质出血颜色出血颜色检查检查47 CasePresentat
21、ionPersonalHistory23 year old ladyMarried for 3 yearsG 2nd Para 1; no livingPastObstetricHistoryIn 2002In 2002Gestational Diabetes + PreeclampsiaGestational Diabetes + Preeclampsia（PEPE）Delivered at 38 weeksDelivered at 38 weeksVaginal delivery on 5/2002Vaginal delivery on 5/2002Dead male baby 4.5 k
22、gDead male baby 4.5 kgCurrentPregnancyLMP 10/10/2003 Twin pregnancyRegular prenatal care in a private clinicNo document of screening for GDM in this pregnancyOn admission:History of unsatisfactory fetal movements for History of unsatisfactory fetal movements for the last 3 daysthe last 3 daysLabor p
23、ains for 3 hoursLabor pains for 3 hoursAdmission21:00,May3rd2004liquor above average, uterine contractions 2/10 min, each 20 sec.PV: 4 cm dilated, 1 cm long, central, softU.S.scanTwin pregnancyMonoamniotic monochorionic1st cephalic, F. Life +ve, 24+2 wk2nd transverse, F. Life ve, 22 wkPlacenta funda
24、l anterior grade IILiquor: clear, AFI 27 cmProgressPatient spontaneously miscarried at 03:001 L male 500 gm (died later)1 L male 500 gm (died later)1 SB male 1 kg1 SB male 1 kgVaginal bleeding associated with retained placenta.Transferred to theatreEmptying the bladderIV crystalloidsManual separatio
25、n of the placentaExcessive vaginal bleeding Uterine massage and bimanual compressionUterus stayed atonic (F.Level 18 wk)Received 3 units of whole blood in last 20 minutesUterotonics:1000 ug Misoprostol rectal (5 tabs)60 units oxytocin (IVI)500ug Hemabate Temporarily effectiveRe-accumulation of blood
26、 clots in the uterusBleeding ControlledUterine artery embolizationPostoperativeRecoveryF.U.: vital data stableF.U.: vital data stableU.O.P adequateU.O.P adequateDrain 150 mlDrain 150 mlUterine massageUterine massageCase 1Healthy, age: 32, G2P1.Augmented vaginal delivery, no tears.Nurse calls you one hour after delivery because of heavy bleeding.What do you do?What do you order?57 Case 226 years G4 now P4.You leave the room to answer a page while waiting for placenta to deliver, but are called back overhead.Huge blood clot seen in vagina.What is this, and what do you do next? 58 59
