婦產(chǎn)科學產(chǎn)后出血完整版課件

1、產(chǎn)后出血Postpartum HemorrhagePPH Zhangye Xu M.D. Department of Obstetrics and Gynecology 1st Affiliated Hospital, Wenzhou Medical College學習目標掌握產(chǎn)后出血的重要原因熟悉產(chǎn)后出血臨床表現(xiàn)及初步處理方法了解產(chǎn)后出血預防簡介最普遍的嚴重的產(chǎn)科并發(fā)癥產(chǎn)婦死亡的主要原因急性血液丟失經(jīng)常不可預測災難性的出血的評估比較主觀定義問題PPH 診斷的問題性出血評估的主觀性和不精確性傳統(tǒng)陰道出血 500ml 早期出血：產(chǎn)后24hr內(nèi)晚期出血：產(chǎn)后24hr后（感染、胎盤）產(chǎn)后出血止血原理

2、止血1. 斷裂血管壁肌層環(huán)形收縮 2. 凝血系統(tǒng)3. 最有效的止血方法：子宮收縮PPH: 通常在胎盤剝離后發(fā)生胎盤剝離時，胎盤附著處的母體血管的終末端發(fā)生斷裂，直接向子宮腔開放，正常分娩時出血量約為200-400ml出血病因The 4 Ts of PPHCAUSEINCIDENCE (APPROX)TONE 子宮收縮乏力Atony70%TRAUMA 軟產(chǎn)道裂傷 Laceration, hematoma, inversion, rupture20%TISSUE 胎盤因素Retained placenta, invasive placenta10%THROMBIN 凝血功能Coagulopathi

3、es1%Am Fam Physician 2007; 75:875.病因PlannedCesarean section 剖宮產(chǎn) Episiotomy 外陰側切UnplannedVaginal/cervical tear 陰道宮頸裂傷Surgical trauma 手術創(chuàng)傷Uterine rupture 子宮破裂軟產(chǎn)道裂傷診斷如果宮縮好，軟產(chǎn)道裂傷出血首先考慮出血是明顯而迅速的，在胎兒娩出后持續(xù)出血，宮縮好縫扎可以止血確定方法：軟產(chǎn)道檢查軟產(chǎn)道裂傷治療可吸收腸線全層連續(xù)或間斷縫合抗炎治療：預防感染輸血Cervical laceration repair陰道裂傷I裂傷 皮膚黏膜II裂傷肌層III裂

4、傷肛門括約肌IV裂傷直腸病因前置胎盤 胎盤殘留胎盤滯留、嵌頓胎盤植入胎盤因素出血診斷胎盤娩出 30 分危險增加：剖宮產(chǎn)，子宮感染，多次妊娠分娩人流刮宮術過度牽拉臍帶導致臍帶斷裂，子宮內(nèi)翻通常的治療方法是人工取出胎盤出血往往發(fā)生在人工剝離胎盤之時胎盤因素治療催產(chǎn)素 10U + NS 20ml 臍靜脈 iv如果失敗開放靜脈通路備血人工剝離胎盤麻醉或藥物止痛手在宮壁與胎盤之間，輕輕剝離，胎盤完整全部取出如果人工剝離胎盤失敗刮宮手術治療抗炎治療Manual removal of placentaExternal hand steadies the uterine fundusInternal hand

5、 along plane of cleavageCheck placenta is completeCheck the uterus is emptyCheck for trauma of GTAnaesthesiaAntibioticsIV lineOxytocicsUterusPlacenta病因CongenitalVon Willebrands diseaseAcquiredDIC, Obstetric disordersHELLP syndromeDIC (eclampsia, intrauterine foetal death, septicaemia, placenta abrup

6、tio, amniotic fluid embolism)Anti coagulant therapy HeparinDead male baby 4.按摩子宮是有效的簡單的刺激子宮收縮的方法產(chǎn)后出血Postpartum HemorrhagePPHTISSUE 胎盤因素Marked fall (70-80 mmHg)DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism)2mg im Q2-4 hours留置導尿，24hr出入量Prolonged lab

7、or, PIH晚期出血：產(chǎn)后24hr后（感染、胎盤）AntibioticsFoley, BT-Cath, Sengstaken-Blakemore TubeB-Lynch sutureWhat do you do?Massage /compressFoley, BT-Cath, Sengstaken-Blakemore Tube病因Systemic factorsSpirit, Chronic diseasesObstetric factorsProlonged labor, PIHUterine factorsHigh parity, Multiple gestation, macrosom

8、ia, LeiomyomasDrug factorstocolytic agentsPPH 最常見病因(70%)宮縮乏力的診斷腹部檢查：子宮軟，無張力陰道出血在胎盤娩出之后陣發(fā)性出血宮縮乏力的預防宮縮乏力治療人工按摩雙手按摩：按摩子宮是有效的簡單的刺激子宮收縮的方法Anderson JM, AFP 2007宮縮乏力的治療宮縮劑 催產(chǎn)素 （Oxytocin ）麥角新堿（Methergine）欣母沛（Hemabate） 米索前列醇（Misoprostol ）UterotonicsDose/ RouteContra-IndicationsPitocin10U im20U in 500ml NS iv

9、gtt Mast dose 80UMethergine0.2mg im Q2-4 hoursHypertensionScleroderma, RaynaudsHemabate0.25 mg im Q15min to max dose 2mgAsthmaCytotec200 1000mcg Oral / Vaginal / RectalQ 6 hours宮縮劑療效不佳尋找其他原因! 開放靜脈通路血交叉，備血，輸血留置導尿，24hr出入量監(jiān)測生命體征凝血功能監(jiān)測子宮填塞Bakri BalloonFoley, BT-Cath, Sengstaken-Blakemore TubeJacobs AJ,

10、Up to Date 2009Gauze Packing子宮動脈栓塞Requires available facilities/ personnelHemodynamically Stable PatientTemporizing measure en route to OR (Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992)手術介入(1 of 4)Gabbe, Ch 18COMPRESSION SUTURESCornuFallopian tubeOvaryHayman R, Arulkumar

11、an S, Steer PObstetrics & Gynecology. 2002OvaryFallopian tube手術介入(2 of 4)Gabbe, Ch 18手術介入(3 of 4)手術介入(4 of 4)出血的評估肉眼觀察:容器: 量杯表面積: blood stained 10cmx10cm = 10ml稱重: 1.05g = 1mlHct1000ml每小時尿量2500ml休克指數(shù)= 脈搏/收縮壓Compensation Mild Moderate SevereBlood Loss500-1000 ml 10-15%1000-1500 ml 15-25%1500-2000 ml

12、25-35%2000-3000 ml 35-45%B.P.Change(SBP)NoneSlight fall(80-100 mmHg)Marked fall (70-80 mmHg)Profound fall (50-70 mmHg)Symptoms & SignsPalpitationDizzinessTachycardiaWeaknessSweatingTachycardiaRestlessnessPallorOliguriaCollapseAir hungerAnuria治療原則2 方面復蘇止血 識別和治療4Ts治療：及時，系統(tǒng)Step IInitial Assessment and

13、treatment ResuscitationAssess EtiologyManagementLarge bore IV(s)Oxygen by maskMonitor BP,P,RHead down tilt Transfuseoxygen saturation Explore uterus (tone,tissue) Explore LGT (trauma) Review history (thrombin) Observe clots Coagulation screen Group and crossmatchMassage /compressRemove placentaRepai

14、r traumaCorrect inversionCorrect coagulopathyStep IIContinuing PPH Get HelpLocal ControlBP and coagulationObstetrician / surgeonAnesthesiologistLab and ICU Manual compression +/- pack uterus +/- vasopressin +/-embolizationCrystalloidBlood productsTransferred to theatreTemporarily effectiveVaginal/ce

15、rvical tear 陰道宮頸裂傷手術介入(3 of 4)軟 胎盤胎膜異常 軟產(chǎn)道裂傷Life +ve, 24+2 wkCoagulation screenExcessive vaginal bleedingLarge bore IV(s)Local controlInternal iliac arteryStep IIISurgery RepairLacerations Local controlLigate VesselsHysterectomy Undersutering the placental bed Square suture B-Lynch sutureUterinesInt

16、ernal iliac arteryStep VPost Hysterectomy BleedingAbdominal Packing Angiographic Embolization 預防產(chǎn)前評估停止治療性的肝素，阿司匹林積極管理第三產(chǎn)程溫和牽拉臍帶宮縮劑的預防應用縮宮素第三產(chǎn)程常規(guī)使用可以預防60%PPH仔細檢查軟產(chǎn)道，胎盤血制品的應用不用等待實驗室結果!大量出血沒有輸入凝血因子將導致凝血功能異常！ProductContentsVolumeEffectWhole Blood500ml Hct 3%PRBCsRBCs, WBCs, few plasma proteins300ml Hct

17、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 UtilizationActive management of the third stage of labor Blood loss 1

18、000 to 1500ml massive PPHBrisk bleedingBlood pressure falling Pulse risingMassageOxytocinExplore genital tract Inspect placentaObserve clottingCoagulation screenThe Four T sSoft, boggy uterusToneResuscitationGenital tract tearTraumaPlacenta retainedTissueBlood not clottingThrombinHemabateMetherginec

19、ytotecSutureManual removeBlood product, Surgical Intervention Blood loss 500 mlPPHReplace factor Conclusions ！Be preparedPractice prevention Assess the lossAssess the maternal statusResuscitate vigorously and appropriately Diagnose the cause Summary: Remember 4 TsUnderstanding its etiology is fundam

20、ental to effectively managingTreat the causeActive management of the third stage of labor is also a key component in its prevention. 軟 胎盤胎膜異常 軟產(chǎn)道裂傷 暗紅 鮮紅陣發(fā)性 持續(xù)性胎盤剝離后 胎盤娩出前 胎兒娩出后 宮縮乏力 胎盤因素 產(chǎn)道裂傷凝血功能障礙：出血晚，血液不凝不同病因陰道出血特點依據(jù)出血時間、出血量、出血性質判斷出血原因產(chǎn)后出血原因互為因果出血時間出血性質出血顏色檢查Case Presentation PLT 5-10K米索前列醇（Misop

21、rostol ）Huge blood clot seen in vagina.oxygen saturationExplore genital tract掌握產(chǎn)后出血的重要原因Blood Product UtilizationReplace factorLevel 18 wk)Internal hand along plane of cleavagePostoperative RecoveryOn admission:最普遍的嚴重的產(chǎn)科并發(fā)癥On admission:依據(jù)出血時間、出血量、出血性質判斷出血原因Personal History23 year old ladyMarried for

22、 3 yearsG 2nd Para 1; no livingPast Obstetric HistoryIn 2002Gestational Diabetes + Preeclampsia（PE）Delivered at 38 weeksVaginal delivery on 5/2002Dead male baby 4.5 kgCurrent PregnancyLMP 10/10/2003 Twin pregnancyRegular prenatal care in a private clinicNo document of screening for GDM in this pregn

23、ancyOn admission:History of unsatisfactory fetal movements for the last 3 daysLabor pains for 3 hoursAdmission21:00, May 3rd 2004liquor above average, uterine contractions 2/10 min, each 20 sec.PV: 4 cm dilated, 1 cm long, central, softU.S. scan Twin pregnancyMonoamniotic monochorionic1st cephalic,

24、F. Life +ve, 24+2 wk2nd transverse, F. Life ve, 22 wkPlacenta fundal anterior grade IILiquor: clear, AFI 27 cmProgressPatient spontaneously miscarried at 03:001 L male 500 gm (died later)1 SB male 1 kgVaginal bleeding associated with retained placenta.Transferred to theatreEmptying the bladderIV crystalloidsManual separation of the pl