產(chǎn)后出血-熊鈺課件

JinyingYangObstetric&GynecologyDepartmentPostpartumHemorrhageDefinition:Bloodlossinexcessofvaginalbirth

≥500mlcesareanbirth≥1000mlwithin

thefirst24hours

ofdelivery

SeriousandcommonintrapartumcomplicationThemostsignificantcauseofmaternaldeathworldwidemortality（worldwide）:140000peryear(1maternaldeathevery4minutes)mortality（China）:8.0/100000,thefirstreason(27.1%)ofmaternaldeathIncidence:4–6%ofpregnanciesActualincidence:morehigherbecauseofinaccurate,significantunderreporting4“T”Tone:uterineatonyTissue:retainedplacentaTrauma:vaginal,cervical,oruterineinjuryThrombin:coagulopathy(pre-existingoracquired)

——SOGCguideline(number235,October2009):ActiveManagementoftheThirdStageofLabor:PreventionandTreatmentofPostpartumHemorrhage.ThemostcommonandimportantcauseofPPHTheprimaryprotectivemechanismforimmediatehemostasisafterdelivery:Myometrialcontractioncausingocclusionofuterinebloodvessels——livingligaturesoftheuterusBloodflowfromthevascularspacetotheuterinecavityviathemyometriumisimpededEtiologiccategoryandprocessHighriskfactorsOverdistensionofuterusPolyhydramnios,Multiplegestation,MacrosomiaUterinemuscleexhaustionRapidlabor,Prolongedlabor,Highparity,OxytocinuseIntra-amnioticinfectionFever,ProlongedruptureofmembranesFunctional/anatomicdistortionofuterusFibroids,Adenomyosis,Placentaprevia,UterineanomaliesUterine-relaxingmedicationsHalogenatedanesthetics,NitroglycerinBladderdistensionPlacentaabruption胎兒子宮內(nèi)膜胎盤臍帶宮頸出血PlacentapreviaCaseApatientwaspregnancywithtwinsandhadplacentaprevia.At36w,shewakedupwithastarttofindherselflyinginpoolofblood.EmergenctCSwasdone.Inoperation,uterineatonyoccurredandwasn’tcorrectedbyutrotonicdrugs.Finallythebleedingwasceasedbyusinguterinetampon.Thenextday,thepatientbledagainwhentamponwasextracting.Soextractionwasstoppedandshewasundergoneembolism.Thetamponwasextractedtotally24hourslater,andthepatientnomorebled.SuccenturiatelobeEtiologiccategoryandprocessClinicalriskfactorsLacerationsofthecervix,vaginal,orperineumPrecipitousdeliveryOperativedeliveryPuerperalHematomasNulliparity,episiotomy,andforcepsdeliveryLacerationofcervixIIIIII

LacerationsofperineumSkinandmucosamuscleExternalanussphincterEtioiogiccategoryandprocessClinicalriskfactorsPre-existingstatesPrimarythrombocytopeniaAplasticanemiaAcquiredinpregnancy

HELLPsyndromeAbruptionplacentaProlongedintrauterinefetaldemiseSepsisAmnioticfluidembolism

SignificanthemorrhageElevatedbloodpressureAntepartumhemorrhageFetaldemiseFeverSuddencollapseVaginalbleedingBleedingwithcharacteristicsoft,poorlycontracted(“boggy”)uterusonbimanualpelvicexamination

——uterineatonyBleedingwhiletheuterusisfirmlycontracted

——retainedplacenta——genitaltractlaceration

Bleedingwithoutclot

——coagulopathyPelvicorrectalpressureandpain

——genitaltracthematomasHypovolemicshockIrritablepallorandclamminessofskintachycardianarrowpulsepressure

TheinitialgoalIdentifyingandtreatingthecauseofbloodlossInstitutingresuscitativemeasurestomaintainhemodynamicstabilityandoxygenperfusionofthetissuesCallforhelpResuscitationAssessthe“ABC”MonitorBP,P,REmptybladder,monitorurineoutputIVlineCrystalloid,isotonicfluidreplacementOxygenbymask

LaboratorytestsCompletebloodcountCoagulationscreenBloodgroupingandcross

——SOGC2009DrugDose/RouteFrequencyCommentOxytocinIV:10–40unitsin1liternormalsalineorlactatedRinger’ssolutionIM:10unitsContinuousAvoidundilutedrapidIVinfusion,whichcauseshypotensionCarbetocinIV/IM：100μgErgometrineIM:0.2mgEvery2–4hAvoidifpatientishypertensiveDrugDose/RouteFrequencyComment15-methylPGF2α(Hemabate)IM:0.25mgEvery15–90min,8dosesmaximumAvoidinasthmaticpatientsDiarrhea,fever,tachycardiacanoccurDinoprostone(PGE2)Suppository:vaginalorrectal20mgEvery2hAvoidifpatientishypotensive.Feveriscommon.Misoprostol(PGE1)800–1,000mcgrectallyIndication：uterotonicsfailtocausesustaineduterinecontractionsandsatisfactorycontrolofhemorrhageaftervaginaldeliveryTechniqueComment—Packing—4-inchgauze;cansoakwith5,000unitsofthrombinin5mLofsterilesaline—Foleycatheter—Insertoneormorebulbs;instill60–80mLofsaline—Sengstaken–Blakemoretube—SOSBakritamponadeballoon—Insertballoon;instill300–500mLofsalinePackingBakriBalloontamponade

Indication：WhenuterotonicagentswithorwithouttamponademeasuresfailtocontrolbleedinginapatientwhohasgivenbirthvaginallyTechniquesCompressionsuturesArteryligationHysterectomyB-LynchtechniqueFirstreportedbyB-lynchin1993CompresstheuterinecorpusanddecreasebleedingRareComplication：uterineischemicnecrosiswithperitonitisModifiedB-Lynche.g.HemostaticmultiplesquaresuturingForpostpartumhemorrhagecausedbyuterineatony,placentaprevia,orplacentaaccretaEliminateingspaceintheuterinecavitybysuturingbothanteriorandposterioruterinewalls

BilateraluterinearteriesligationBilateralinternaliliacarteriesligationBilateralovarianarteriesligationUterinearteriesligationInternaliliacarteriesligationDiminishthepulsepressureofbloodflowingtotheuterusThetimingofthisinterventionisimportant:itmustbedonewithoutdelay,beforeexcessivebloodlosshasoccurredSurgicalskillisrequiredtoavoidfailureandcomplicationssuchasdamagetoothervascularstructuresandtheuretersIndication:massivehemorrhagehasnotrespondedtopreviousinterventionsNotice:Ifhysterectomyisperformedforuterineatony,thereshouldbedocumentationofothertherapyattemptsoverybladderuterusvaginacervixcavitycavitysalpinxendometriummyometriumsubtotal

total

HysterectomyIndication:stablevitalsigns,persistentbleeding,especiallyiftherateoflossisnotexcessiveUsedforbleedingthatcontinuesafterhysterectomyUsedasanalternativetohysterectomytopreservefertilityRadiographicidentificationofbleedingvesselsEmbolizationwithgelfoam,coils,orglue,orballoonocclusionH.A.E.M.O.S.T.A.S.I.S.H:AskforhelpA:Assess(vitalparameters,bloodloss)andresuscitateE:Establishetiologyandcheckmedicationsupply(oxytosin,ergometrine)andavailabilityofbloodM:MassageuterusO:Oxytocininfusion,prostaglandins(intravenous,rectal,intramuscular,intramyometrial)S:Shifttooperatingroom,excluderetainedproductsandtrauma,bimanualcompressionT:Tamponadeballoon,uterinepackingA:ApplycompressionsuturesS:Systematicpelvicdevascularization(uterine,ovarian,internaliliac)I:Interventionradiologist,uterinearteryembolizationifappropriateS:Subtotalortotalabdominalhysterectomy

——ICM/FIGOguideline2006:Postpartumhemorrhagetoday:initiative2004—2006Diagnosis:detectionofanechogenicmassintheuterusbyultrasonographyDirectedtherapyWholeplacentainuterus：manualremovalIncompleteseparation（avulsedlobule,succenturiatelobe）：gentlecurettagePlacentaaccreta

curettagewedgeresectionmedicalmanagementhysterectomyLacerationsofperineum,vagina,orcervixGenitaltracthematomasIdentificationandproperrepairoflacerationsTransfertoawell-equippedoperatingroomProperpatientpositioningAdequateoperativeassistanceGoodlightingAppropriateinstrumentation(eg,SimpsonorHeaneyretractors)AdequateanesthesiaMaynotberecognizeduntilhoursafterthedeliverySometimesoccurintheabsenceofvaginalorperineallacerationsThemainsymptomsarepelvicorrectalpressureandpainDirectedtherapyDrainingthebloodwithinthehematoma(sometimesplacingadraininsitu)SuturingtheincisionPackingthevaginaInterventionalradiologyDirectedtherapyAppropriatetestingBloodproductsinfusedasindicatedSimultaneoussurgeryifthecoagulopathycausedorperpetuatedbythehemorrhageBaselinestudiesCompletebloodcountwithplateletsProthrombintimeActivatedpartialthromboplastintimeFibrinogenAtypeandcrossorderBeorderedwhenexcessivebloodlossissuspectedandshouldberepeatedperiodicallyasclinicalcircumstanceswarrantResponsetohemorrhagebeforelaboratoryresultsareknownAsimplemeasureoffibrinogenAvolumeof5mLofthepatient’sbloodisplacedintoaclean,red-toppedtubeandobservedfrequently.Normally,bloodwillclotwithin8–10minutesandwillremainintact.Ifthefibrinogenconcentrationislow,generallylessthan150mg/dL,thebloodinthetubewillnotclot,ifitdoes,itwillundergopartialorcompletedissolutionin30–60minutes.AMTSL(activemanagementofthethirdstageoflabor)RoutineuseofuterotonicsEarlycordclamping,controlledcordtractionAppropriateuterinemassageafterdeliveryoftheplacentaSubinvolutionofplacentalsiteRetainedproductsofconceptionInfectionInheritedcoagulationdefectsTheextentofbleed