婦產(chǎn)科學(xué)教學(xué)課件：Post Partum Hemorrhage Uterine Rupture, Fetal Distress

1、Post Partum Hemorrhage Uterine Rupture, Fetal Distress Post partum hemorrhage Post partum hemorrhage nPast partum hemorrhage denotes excessive bleeding (500ml in vaginal delivery) during the first 24 hours after delivery；Cesarean section 1000ml nCommon cause of death and diseases in pregnant women g

2、lobally nLeading cause of death in pregnant women in China nIncidence 2%-3% of total number of deliveries 19.3219.32 4.014.01 53.0 53.0 26.126.1 0 10 20 30 40 50 60 2000200120022003200420052006200720082009201020112012 浙江浙江MMRMMR 全國全國MMRMMR 2000-20122000-2012年浙江省和全國孕產(chǎn)婦死亡率比較（年浙江省和全國孕產(chǎn)婦死亡率比較（1/101/10萬）

3、萬） Etiology nUterine atony: 70% nObstetric lacerations: 20% nRetained placental tissue: 10% nCoagulation:1% Uterine atony nGeneral factors: extreme nervousness, weak， severe anemia nObstetric factors: prolonged labour, placenta previa, placenta abruptio nUterine factors: uterine muscular fiber under

4、development, such as uterine deformity or myoma; uterine overstretched, such as macrosomia, multiple pregnancy, polyhydramnios nDrug factors: sedative, anesthesia, tocolytics Placental factors nRetained placenta nPlacental incarceration（嵌頓嵌頓 ） nIncomplete placental separation nPlacental adhesion nPl

5、acental implantation (accreta, increta, percreta) nResidual placenta and amniotic membrane Implantation of placenta Birth canal injury nLaceration during labour are usually associated with: Poor vulval elasticity Strong labour force, emergency delivery, macrosomia Inadequate skills at assisted vagin

6、al delivery Inadequate cessation of bleeding during episiotomy repair, missing out tears at cervix or fornices Coagulation disorder nComplications associated with obstetric: amniotic fluid embolism, pregnancy induced hypertensive diseases, placenta abruptio and intrauterine demise nPregnancy liver d

7、isease: acute fatty liver, severe hepatitis nHematology diseases: primary thrombocytopenic purpura, aplastic anemia etc Clinical presentation nVaginal bleeding: If bleeding occurs immediately after delivery of baby, consider birth canal injury If bleeding occurs minutes after delivery of baby, consi

8、der placenta factors If bleeding occurs minutes after delivery of placenta, main reasons are uterine atony or retained products of conception Persistent bleeding and blood do not coagulate, consider coagulation disorder Clinical presentation nVaginal hematoma nShock: dizziness, paleness, weak pulse,

9、 low blood pressure etc Diagnosis nEstimation of blood loss nAscertain cause of post partum hemorrhage Estimation of blood loss nVisual observation: only 50%-70% of blood loss nContainer: kidney dish, measuring cup nSurface area: blood stained 10cmx10cm = 10ml nWeighing: 1.05g = 1ml nHct1000ml nHour

10、ly urine output 2500ml nShock index = pulse rate/systolic pressure Shock index (SI) nSI =0.5, normal blood volume nSI = 0.5-1, blood loss 160bpm; during severe hypoxia 110bpm CST shows late deceleration, severe variable deceleration fetal heart rate 100bpm, with frequent late decelrations indicating

11、 severe fetal hypoxia, may die intrauterine any moment Late deceleration Variable deceleration Diagnosis of acute fetal distress nMeconium stained amniotic fluid: green color, dirty, thick and little volume I degree: light green, II degree: yellowish green, dirty, III degree:brownish yellow, thick D

12、iagnosis of acute fetal distress nFetal movement: early stage frequent fetal movement, subsequently reduced to absent nFetal acidosis: fetal scalp blood analysis pH 7.2 (normal 7.25 7.35) PO2 60mmHg (normal 35 55mmHg) Diagnosis of chronic fetal distress nReduced or absent fetal movement nAbnormal fe

13、tal monitoring nLow fetal biophysical profile scoring nAbnormal umbilical artery blood flow nMeconium stained amniotic fluid Reduced or absent fetal movement nReduced fetal movement 6 times/2 hours, 50% drooprate nHeart beat disappears：usually 24 hours after absent of fetal movement fetal nNormal fe

14、tal movement count: 30-100 times/12hours Abnormal fetal electronic monitoring nNST is known as non-reactive type, during 20 minutes continuous fetal movement fetal heart rate acceleration15bpm, sustaining15s, baseline variability 5bpm nOCT frequent severe variable decelerations or late decelerations

15、 are seen Low biophysical profile scoring nBased on ultrasound assessment of fetal body movement, breathing movement, flexor tone, amniotic fluid volume, couple with fetal electronic monitoring NST results combined scoring (each variable score 2, total score is 10) nScore 3 indicates fetal distress,

16、 score 4-7 suspicious fetal hypoxia Abnormal umbilical artery blood flow numbilical artery diastolic blood flow reducing absence inversion Meconium stained amniotic fluid nAmnioscopy examination shows dirty amniotic fluid in light green or brownish yellow color Management nAcute fetal distress: emer

17、gent treatment nChronic fetal distress: management plan depends on severity of the pregnancy complications, gestational age, fetal maturity, fetal distress condition Management of acute fetal distress nGive oxygen: face mask or nasal prong continuous oxygen at 10L/min flow nSearch for cause, active

18、management supine hypotensive syndrome：lie the patient on left lateral position excessive oxytocin leading to uterine hyperstimulation：stop oxytocin immediately use tocolytics when necessary Management of acute fetal distress Terminate pregnancy soonest possible: qCervix not fully dilated with the f

19、ollowing conditions, immediate caesarean section: (1)fetal heart rate 180bpm, accompanied by II degree meconium stained amniotic fluid (2) CST or OCT shows frequent late decelerations or severe variable decelerations, sine wave (3) fetal scalp blood pH 7.20 (4) III degree meconium stained amniotic f

20、luid, with low amniotic fluid amount Management of acute fetal distress qFully dilated cervix: fetal biparietal diameter, has descend below ischial spines, perform assisted vaginal delivery nPrepare for newborn resuscitation Management of chronic fetal distress nRoutine management: left lateral position, give oxygen regularly (30mins, 2-3times/day) nActive treatment of pregnancy complications nTerminate pregnancy: pregnancy nearing term with less fetal movement or OCT shows late decelerations, severe variab