浙江大學(xué)醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院

ObstetricalHemorrhage浙江大學(xué)醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院胡文勝

ObstetricHaemorrhage◆Obstetricsis“bloodybusiness〞◆Definitionsofobstetricalhemorrhage:?Hematocritdropof10volumepercent?Needfortransfusion

◆CDC:nonabortion-relatedmaternaldeaths30%◆Hemorrhagemaybeantepartumorpostpartum.Hemorrhageisadescriptionofanevent,andnotadiagnosis.◆Becauseofinexactdefinitionsused,theincidenceofobstetricalhemorrhagecannotbedeterminedpreciselyWilliamsObstetrics(21stedition)Table1:Causesof764pregnancy-relateddeathsduetohemorrhageCauseofhemorrhageNumber(%)Abruptioplacentae141(19)Laceration/uterinerupture125(16)Uterineatony115(15)Coagulopathies108(14)Placentafactors76(10)Placentaprevia50(7)Uterinebleeding47(6)Formchichakilandcolleagues.USA,CDC,1999ClassificationofHemorrhageClassAcuteBloodLoss%Lost1900cc1521200-1500cc20-2531800-2100cc30-3542400cc40BakerR,ObstetGynecolAnnu,1997highriskofobstetricHaemorrhage◆Abnormalplacentation◆Traumaduringlaboranddelivery◆Smallmatermalbloodvolume◆Uterineatony◆Coagulationdefects◆OtherfactorsAntepartumhemorrhageCommoncasusesofthirdtrimesterbleedingObstetricCausesNonobstetricCausesBloodyshowCervicalcancerordysplasiaPlacentapreviaCervicalpolypsplacentalabruptionCervicitisVasapreviaCervicaleversionDisseminatedintravascularcoagulopathy(DIC)VaginallacerationUterusrupture

VaginitisMarginalsinusbleedInitialEvaluationPrinciplesofManagement：Anywomenexperiencingvaginalbleedinginlatepregnancymustbeevaluatedinahospitalcapableofdealingwithmaternalhemorrhageandacompromisedperinate.Avaginalorrectalexaminationmustnotbeperformeduntilplacentapreviahasbeenruledoutanduntilpreparationsarecompleteformanagementofmassivehemorrhageandmaternalorperinatalcomplication.Life-ThreateningHemorrhage:Intheunstablepatient,thestandardABCDsofresuscitionshoudbeinitiated.NonemergencyBleeding:HistoryandabdominalexaminationLaboratoryevaluationUltrasoundexaminationVaginalexaminationManagementofbleeding

Placentalabruption

EssentialsofDiagnosisUnremittentabdominal(uterine)orbackpainIrritable,tender,andoftenhypertonicuterusVisibleorconcealedhemorrhageEvidenceoffetaldistressmayormaynotbepresentdependingontheseverityoftheprocessDefinitions

:Prematureseparationoftheplacentaisdefinedasseparationfromthesiteofuterineimplantationbeforedeliveryofthefetus(about1in77-89deliveries).Types：ApparentbleedingConcealedbleedingRelativelyconcealedbleedingOccultHemorrhagein

AbruptionAbruptionPlacentaRiskFactorsforAbruptionHypertensivedisordersofpregnancyMgSO4totreatpreeclampsiareducesabruptionby27%Smokingorsubstanceabuse(e.g.cocaine)TraumaOver-distentionoftheuterusPreviousabruptionUnexplainedelevationofMSAFPPlacentalinsufficiencyThrombophilias/metabolicabnormalities

GabbeSG,Obstetrics4thEd.,2002Acceleration/DecelerationinjurywithautoaccidentBleedingfromAbruptionExternalizedhemorrhageBloodyamnioticfluidRetroplacentalclot20%occult“uteroplacentalapoplexy〞LookforconsumptivecoagulopathyPatientHistory-AbruptionPain=hallmarksymptomVariesfrommildcrampingtoseverepainBackpain–thinkposteriorabruptionBleedingMaynotreflectamountofbloodlossDifferentiatefromexuberantbloodyshowRiskfactorsTrauma,hypertension,drugs18PhysicalExam-AbruptionSignsofcirculatoryinstabilityMildtachycardianormalSignsandsymptomsofshockrepresent>30%bloodlossMaternalabdomenFundalheightEstimatedfetalweight,fetallieLocationoftendernessTetaniccontractionsPlacentaPreviaEssentialsofDiagnosisSpottingduringfirstandsecondtrimestersSudden,painless,profusebleedinginthirdtrimesterInitialcrampingin10%ofcasesPlacentaPreviaDiagnosebyUltrasoundResuscitate,monitorBPandamountofbleedingPersistentbleedingrequiresdeliverywhateverthegestation34weeks-bytimeforsteroidspreventcontractionswithindocid

RiskFactorsforPlacentaPrevia

PreviouscesareandeliveryPreviousuterineinstrumentationHighparityAdvancedmaternalageSmokingMultiplegestation

Ultrasound–PlacentaPreviaCanconfirmdiagnosisLow-lyingplacentaseenin50%ofultrasoundscansat16-20weeks90%willhavenormalimplantationwhenscanrepeatedat>30weeks

Treatment–PlacentaPreviaWithnoactivebleedingExpectantmanagementNointercourse,digitalexamsWithlatepregnancybleedingAssessoverallstatus,circulatorystabilityConsidermaternaltransferifpremature

Mayneedcorticosteroids,tocolysis,amniocentesis PlacentaPrevia:

ObstetricManagementIfpossible,delaydeliveryuntilfetusismatureIndicationsfordelivery:activelabordocumentedfetallungmaturity37weeksgestationalageexcessivebleedingdevelopmentofanotherobstetriccomplicationmandatingdeliveryRuptureofuterusEssentialsofDiagnosisIncreasedsuprapubicpainandtendernesswithlaborSuddencessationofuterinecontractionswitha“tear〞sensationVaginalbleeding(orbloodyurine)RecessionofthefetalpresentingpartDisappearanceoffetalhearttoneUterineRuptureOccultdehiscencevs.symptomaticrupture0.03-0.08%ofallwomen0.3-1.7%ofwomenwithuterinescarPreviouscesareanincisionmostcommonreasonforscardisruptionOthercauses:previousuterinecurettageorperforation,inappropriateoxytocinusageRiskFactors–UterineRupturePreviousuterinesurgeryUterineorfetalanomalyUterineover-distentionortraumaPlacentalfactorsHistoryofdifficultplacentalremovalPlacentaincretaConsiderUSorMRItoevaluateuterinewallGestationaltrophoblasticneoplasiaClinicalFindings-UterineRuptureSuddendeteriorationofFHRpatternismostfrequentfindingVaginalbleedingPainCessationofcontractionsPalpablefetalpartsthroughmaternalabdomenProfoundmaternaltachycardiaandhypotension

ComparisonofPresentationof

Abruptionv.Previav.Rupture

abruption previa ruptureabd.pain present absent variablevag.blood old fresh freshDIC common rare rareacutefetal common rare common

distress

VasapreviaVasaPreviaAssociatedwithvelamentousinsertionoftheumbilicalcord(1%ofdeliveries)Bleedingoccurswithruptureoftheamnioticmembranes(theumbilicalvesselsareonlysupportedbyamnionBleedingisFETAL(notmaternalaswithplacentaprevia)FetaldeathmayoccurwithtrivialsymptomsVasaPreviaPlacentaldiskUmbilicalcordMembranesVelamentousInsertionAntepartumDiagnosis–VasaPreviaAmnioscopyUltrasoundVasapreviaishighlyassociatedwithplacentapreviaon2ndtrimesterUSPerformfollow-upUSwithcolor-flowDopplerPalpatevesselsduringvaginalexaminationManagement–VasaPreviaApttesttodeterminepresenceoffetalbloodBasedoncolorimetricresponseoffetalhemoglobinDon’tdelayurgentdeliveryforthistestImmediatecesareandeliveryiffetalheartratenon-reassuring

Administernormalsaline10-20cc/kgbolustonewbornifinshockafterdeliverySummaryLatepregnancybleedingmayheralddiagnoseswithsignificantmorbidity/mortalityDeterminingdiagnosisimportant,astreatmentdependentoncauseAvoidvaginalexamwhenplacentallocationnotknown

PostpartumhemorrhageDifinitionpostpartumhemorrhagedenotedexcessivebleeding(>500mlinvaginaldelivery〕followingdeliver.Theincidenceofexcessivebloodlossfollowingvaginaldeliveryis5-8%PostpartumHemorrhageEarlypostpartumhemorrhageiswithin1st24hours(alsomaybejustcalled“postpartumhemorrhage〞)Latepostpartumhemorrhage(notaddressedinthistalk)islesscommonandoccursafterthe1st24hourspostpartum

ThecausesofpostpartumhemorrhagecanbethoughtofasthefourTs:tone：70％trauma：20％tissue：10％thrombin：1％EtiologyofPPHUterineatonyMultiplegestation,highparity,prolongedlaborchorioamnionitis,

tocolyticagentsObstetricLacerationEtiologyofPPHVaginal/cervicaltear

Uterineinversion,uterinerupture

Lacerationsandtrauma

PlannedCesareansection,episiotomy

UnplannedVaginal/cervicaltear,surgicaltraumaEtiologyofPPHEtiologyofPPHRetaineduterinecontentsProductsofconception,bloodclotsPlacentalabnormalitiesCongenital

BicornuateuterusLocationPlacentapreviaAttachmentAccretaAcquiredstructuralLeiomyoma,previoussurgeryPeripartumUterineinversion,uterinerupture,placentalabruptionEtiologyofPPHCoagulation

disordersEtiologyofPPHCongenitalVonWillebrand'sdiseaseAcquiredDIC,dilutional

coagulopathy,heparinAntenatalassessmentHistory:Theexistenceofsomeoftheobstetricriskfactorsmaybeknownearlyinpregnancyfromhistoryandexamination.AnemiaCoagulationstudiesImaginginvestigationsManagementofPPHHemorrhagesuspectedExplorationofUterusRetainedplacenta(?Accreta)Emptyuterus(NextSlide)ManagementofPPH(2)EmptyUterusOxytocinAtony?Yes-2ndarymedicaltx.ConsidersurgeryforfailureNo-Inspectvaginaandcervix(nextslide)ManagementofPPH(3)LacerationYes=RepairNo=otherclues?ConsiderDIC,AFE,uterineruptureManagementofPPH

Ifvaginalbleedingpersistsafterdeliveryoftheplacenta,thefollowingstepsshouldbeundertakenwithoutdelay:ManuallycompresstheuterusObtainassistanceIfnotalreadydone,obtainbloodfortypingandcross-matchingObservebloodforclottingtoruleoutcoagulapathyBeginfluidorbloodreplacementCarefullyexploretheuterinecavityCompletelyinspectthecervixandvaginaInsertasecondintravenouscatheterforadministrationofbloodorfluidsManagementofPPHUterinemassageInspectforlacerationsMedicalManagement:oxytocin\ergotderivatives\prostaglandinsSurgicalManagementofPPHemorrhageRoleofdilationandcurettageUterinearteryligationHypogastricarteryligationB-LynchSuturesHysterectomySelectiveAngiographicEmbolization(SAE)GabbeSGObstetrics4thEd.,2002UterinearteryligationWilliamsObstetrics,21stEd.,2001HypogastricarteryligationFoleyMR,ObstetricIntensiveCareManual,2ndEd.,2004B-LynchSuture

Guidelines

bytheScottishExecutiveCommitteeof

theRCOG

COMMUNICATE.RESUSCITATE.

MONITORMONITOR/INVESTIGATE/INVESTIGATE.STOPSTOPTHEBLEEDINGTHESTOPTHEBLEEDINGBLEEDING.謝謝

Abnormalplacentation

◆Placentaprevia

◆Placentalabruption

◆

Placentalaccreta/increta/percreta

◆Etopicpregnancy

◆HydatidiformmoleTraumaduringlaboranddelivery

◆Episiotomy

◆Complicatedvaginaldelivery

◆Low-ormid-forcepsdelivery

◆Cesareandeliveryorhysterectomy

◆HighrisksofUterinerupture:PreviouslyscarreduterusHyperstimulationObstructedlaborIntrauterinemanipulationMidforcepsrotationSmallmatermalbloodvolume◆Smallwomen

◆Pregnancyhypervolemianotyetmaximal

◆PregnancyhypervolemiaconstrictedSeverepreeclampsiaEclampsiaUterineatony◆

Overdiatenteduterus:largefetusmutiplefetuseshydramnios◆Anesthesiaoranalgesia◆Exhaustedmyometrium:rapidlaborprolongedlaboroxytocinorprostaglandinstimulation◆Previousuterineatony

Coagulationdefects◆Placentalabruption◆Prolongedretentionofdeadfetus◆Amnionicfluidembolism◆Sepsiswithendotoxemia◆Severeintravascularhemolysis◆Massivetransfusion◆Severepreeclampsiaandeclampsia◆Congenitalcoagulopathies◆AnticoagulanttreatmentObstetricalDICAmnioticfluidembolismPlacentalabruption(Pre)eclampsiaDeadfetussyndromeIntrauterineinfectionAcutefattyliverofpregnancy(AFLP)ScreeningTestsofDisseminatedIntravascularCoagulation:GuidelinesforRapidandspecificLaboratoryDiagnosis

CritCareMed2000vol28,No6

GoldstandardisbiopsyprovenfibrinthrombiinmicrovasculatureOrdiffusebleedinginappropriateclinicalsetting(latefinding)Surrogatecriteria:Appropriateclinicalsetting 1ptThrombohemorrhagicevent 1ptIncreasedPT,PTT,TT 1ptThrombocytopenia 1ptDecreasedFibrinogen 1ptIncreasedFDP 1ptIncreasedD-Dimer 1ptLowATlevel 1ptTOTAL 8DICCriteriaNEED5ptsTreatmentofOBDICDIC:asecondaryphenomenon,andthemainstayofmanagementistoremovetheinitiati