產(chǎn)科學(xué)英文課件：14-PPH-產(chǎn)后出血

POSTPARTUMHEMORRHAGEPPH產(chǎn)后出血POSTPARTUMHEMORRHAGEPPH12005

MaternalMortality（1/100000）World

400USA

11UK8Sweden

3Ireland

1Japan6Korea

14China

45SierraLeone21002005MaternalMortality（1/10002INCIDENCETheleadingcauseofmaternalmortalitynearly14,000,000cases/year127,000deathsannuallyworldwide99%indevelopingcountry50%～55%casesshouldavoidINCIDENCETheleadingcauseof3DEFINITION

ExcessivebloodLoss（>500ml)duringthefirst24hoursafterdelivery(earlyPPH)Bloodlossbetween24hoursand6weeksafterdelivery(latePPH－mostlyduetoinfectionandretainedplacentatissue)BloodlossthatneedtransfusionDEFINITION4ETIOLOGY–4“T”Tone：Uterineatony

-70％Tissue：Retainedplacenta-20%Trauma：Lacerations-10%Thrombin：Coagulopathy-1%ETIOLOGY–4“T”Tone：Uterin51.UterineAtonyGeneralconditionDrugLaborprocessObstetricalcomplicationsUterinedisorder1.UterineAtonyGeneralconditi6DualBloodSupplyDualBloodSupply7Myometriumhasnotcontractedtocutofftheuterinespiralarteriesthataresupplyingtheplacentalbed.PATHOLOGYMyometriumhasnotcontracted8DiagnosisSoftuterus(i.e,likedough)thatispalpableabovetheumblicusBoggyuterusDiagnosisSoftuterus(i.e,lik92.RetainedPlacentalTISSUEPlacentaretainedPlacentaaccetePlacentaincretaMembraneadherenceSuccenturiateplacenta2.RetainedPlacentalTISSUEPla10DiagnosisDelayedspontaneousseparetionofplacentaInspectionofplacentaUltrasoundMRIDiagnosisDelayedspontaneouss11PlacentaincretaPlacentaAccreta:PlacentaadherenttomyometriumPlacentaIncreta:myometrialinvasionPlacentaPercreta:penetrationofmyometriumtoorbeyondserosa.PlacentaincretaPlacentaAccre123.LacerationofGenitalTractPerineum/vaginal/cervicallacerationHematomaUterinesectionlacerationUterinerupture3.LacerationofGenitalTractP13PathologyInstrumenteddelivery(forceps)Manipulativedelivery(breechextraction,precipitouslabor,macrosomia)SofttissuedisorderPathologyInstrumenteddelivery14DiagnosisBleedingwithafirmcontracteduterus.Thebloodisbrightred.Thevaginalsidewallsandcervixshouldbeespeciallycarefullyinspected.DiagnosisBleedingwithafirm15Vulvalaceration

ⅠⅡ

Ⅲ

ⅣVulvalacerationⅠ16VaginalhematomacervicallacerationVaginalhematomacervicallacer174.CoagulationdefectsAcquiredabnormalityinbloodclottingabruptionplacentaamnioticfluidembolismseverepre－eclampsiaCongenitalabnormalityinbloodclottingthrombocytopeniaseverehepaticdiseasesleukemia4.CoagulationdefectsAcquired18DiagnosisContinuousgeneralizedoozingfromtheskin,subcutaneousandfascialtissuesSuchevidencealsomaybegainedbyobservingcontinuousoozingfromepisiotomyincisionsorperineallacerations.ExcessivebleedingatsitesofmodesttraumacharacterizesdefectivehemostasisNobloodclot.DiagnosisContinuousgeneralize19PROGNOPSISAnemiaSubsequentpuerperalinfectionTransfusiontherapy(hepatitis,HIV,transfusionreaction)Postpartumpanhypopituitarism

（Sheehan’ssyndrome）AcuterenalfailureSterilityMaternalmortality↑PROGNOPSISAnemia20Key-pointtodiagnosis:

EstimateofBloodLossThevelocityofbloodlossBloodloss＞150ml/minBloodlosswithin3H>50%generalamountBloodlosswithin24H>generalamountDiscretionofthePPHcauseRightafterfetaldelivery-TRAUMAFewerminafterfetaldelivery-TISSUEBleedingafterplacentadelivery–TONE/TISSUEContineously/noclotting-THROMBINKey-pointtodiagnosis:

Estim21EvaluationofBloodLossWeightVolumeDimension：GauzebloodareaShockindex=Pulse/SystolicpressureHemoglobin：↓10g/L≈400-500mlbloodloss。Vitalsign、urineamountEvaluationofBloodLossWeight22TREATMENTPROCESSwarning＞400mlmanagement500~1500mlcrisis＞1500mlPrimarySecondaryTertiary產(chǎn)后出血預(yù)防與處理指南（2014）－中華醫(yī)學(xué)會(huì)TREATMENTPROCESSwarning＞400ml23Primary(Bloodloss＞400ml）HelpVesselOxygensupplyVitalsignmonitorLabExamination(CBC+Coagulation)PreparefortransfusionInvestigate4“T”Primary(Bloodloss＞400ml）Help24Secondary（500~1500ml）EtiologicaltreatmentAnti-ShocktreatmentTONE按摩子宮使用宮縮劑宮腔填塞B-lynch血管結(jié)扎TRAUMA縫合裂傷清除血腫恢復(fù)解剖TISSUE人工剝離清宮THROMBIN補(bǔ)充凝血因子：新鮮冰凍血漿、血小板、凝血酶原復(fù)合物Secondary（500~1500ml）Etiologic25UterineAtony--MassageUterineAtony--Massage26Tone--UterotonicagentsOxytocin：im.／iv.gttHemobate（欣母沛）：im.Misoprostol:rectalororalCarbetocin（巧特欣）:im.Tone--UterotonicagentsOxyto27Tone–UterinepackingGauzeTemponadeTone–UterinepackingGauzeTem28Tone–B-lynchsuture正面觀背面觀正面觀Tone–B-lynchsuture正面觀背面觀正面觀29Trauma--RepairVaginallacerationCervicallacerationTrauma--RepairVaginallacera30Tissue–ManualremoveTissue–Manualremove31Tissue–dilation&curettageTissue–dilation&curettage32Tissue–PlacentaAccreta（胎盤植入）ConservativetreatmentHysterectomy產(chǎn)前應(yīng)作充分評(píng)估向孕婦和家屬交待有子宮切除和輸血的可能準(zhǔn)備血制品和凝血物質(zhì)充分的人員安排和器械準(zhǔn)備Tissue–PlacentaAccreta（胎盤植入33Thrombin－TransfusionCorrectthecoagulationdefectResuscitationInfusionofcrystalloidandcolloidBloodtransfusionInfusionofplatelets＋coagulationfactorsThrombin－TransfusionCorrectt34Coagulationfactors補(bǔ)充相應(yīng)凝血因子Platelet：＜20~50×109/LFreshfrozenplasma：凝血因子、血漿蛋白、纖維蛋白原Fibrogin：1克=血中25mg/dl冷沉淀：凝血因子Ⅷ、vWF、纖維蛋白原、因子ⅩⅢ凍干人凝血酶原復(fù)合物：因子Ⅱ、Ⅶ、Ⅸ、Ⅹ

Coagulationfactors補(bǔ)充相應(yīng)凝血因子35

TertiaryManagementOxygenMaintaincirculationDICtreatmentProtectvitalorgansIntensivecareunitIntensivemaneuverTertiaryManagementOxy36Arteryligation盆腔血管結(jié)扎術(shù)結(jié)扎子宮動(dòng)脈Arteryligation盆腔血管結(jié)扎術(shù)結(jié)扎子宮動(dòng)脈37ArterialEmbolizationArterialEmbolization38子宮次全切子宮全切Hysterectomy子宮次全切子宮全切Hysterectomy39休克搶救流程－REACTResuscitationEvaluationArresthemorrhageConsultTreatcomplication休克搶救流程－REACTResuscitation402013WHOrecommendationsUniversalpreventionofPPHFirstchoice:Oxytocin10IUIV/IMIdentificationofPPHUterinemassageIVoxytocinIVergometrineOxytocin-ergometrinefixeddoseSublingualmisoprostolIntrauterineballoontamponadeUterinearteryembolizationSurgicalintervantions(Laparotomy)Oxytocinunavailable/persistentPPHPersistentPPHPersistentPPHPersistentPPH2013WHOrecommendationsUniver41Prevention—

PrenatalEvaluationRiskfactorMedical&ObstetricalComplicationsReferralsystem－ICUcenterPrevention—

PrenatalEvaluat42原因或病因?qū)?yīng)的高危因素子宮收縮乏力全身因素產(chǎn)婦體質(zhì)虛弱、合并慢性全身性疾病或精神因素藥物過(guò)多使用麻醉劑、鎮(zhèn)靜劑或?qū)m縮抑制劑等產(chǎn)程因素急產(chǎn)、產(chǎn)程延長(zhǎng)或滯產(chǎn)、試產(chǎn)失敗等產(chǎn)科并發(fā)癥子癇前期等羊膜腔內(nèi)感染胎膜破裂時(shí)間長(zhǎng)、發(fā)熱等子宮過(guò)度膨脹羊水過(guò)多、多胎妊娠、巨大兒等子宮肌壁損傷多產(chǎn)、剖宮產(chǎn)史、子宮肌瘤剔除術(shù)后等子宮發(fā)育異常雙子宮、雙角子宮、殘角子宮等產(chǎn)道損傷子宮頸、陰道或會(huì)陰裂傷急產(chǎn)、手術(shù)產(chǎn)、軟產(chǎn)道彈性差、水腫或瘢痕形成等胎位不正、胎頭位置過(guò)低等剖宮產(chǎn)子宮切口延伸或裂傷子宮破裂子宮手術(shù)史子宮體內(nèi)翻多產(chǎn)、子宮底部胎盤、第三產(chǎn)程處理不當(dāng)胎盤因素胎盤異常多次人工流產(chǎn)或分娩史、子宮手術(shù)史、前置胎盤胎盤、胎膜殘留胎盤早剝、胎盤植入、多產(chǎn)、既往有胎盤粘連史凝血功能障礙血液系統(tǒng)疾病遺傳性凝血功能疾病、血小板減少癥肝臟疾病重癥肝炎、妊娠期急性脂肪肝產(chǎn)科DIC羊水栓塞、Ⅱ~Ⅲ度胎盤早剝、死胎滯留時(shí)間長(zhǎng)、重度子癇前期及休克晚期原因或病因?qū)?yīng)的高危因素子宮收縮乏力全身因素產(chǎn)婦體質(zhì)虛弱、合43Prevention—

ManagementoflaborprocessProlongedlaborRapidlaborEpitomyOxytocinusagePrevention—

Managementofla44Prevention

—

IntenseobservationafterbirthUterinemassageMonitorvitalsign、uteruscontraction、bloodlosswithin2hoursrightafterbabydeliveryBreastfeedingUrinatePrevention—

Intenseobservat45SUMMARYPPHisemergentandcriticalRiskfactorPresageofPPHBloodlossmeasurementTreatpromptlytoimproveconsequenceCooperation!SUMMARYPPHisemergentandcri46THANKSTHANKS47POSTPARTUMHEMORRHAGEPPH產(chǎn)后出血POSTPARTUMHEMORRHAGEPPH482005

MaternalMortality（1/100000）World

400USA

11UK8Sweden

3Ireland

1Japan6Korea

14China

45SierraLeone21002005MaternalMortality（1/100049INCIDENCETheleadingcauseofmaternalmortalitynearly14,000,000cases/year127,000deathsannuallyworldwide99%indevelopingcountry50%～55%casesshouldavoidINCIDENCETheleadingcauseof50DEFINITION

ExcessivebloodLoss（>500ml)duringthefirst24hoursafterdelivery(earlyPPH)Bloodlossbetween24hoursand6weeksafterdelivery(latePPH－mostlyduetoinfectionandretainedplacentatissue)BloodlossthatneedtransfusionDEFINITION51ETIOLOGY–4“T”Tone：Uterineatony

-70％Tissue：Retainedplacenta-20%Trauma：Lacerations-10%Thrombin：Coagulopathy-1%ETIOLOGY–4“T”Tone：Uterin521.UterineAtonyGeneralconditionDrugLaborprocessObstetricalcomplicationsUterinedisorder1.UterineAtonyGeneralconditi53DualBloodSupplyDualBloodSupply54Myometriumhasnotcontractedtocutofftheuterinespiralarteriesthataresupplyingtheplacentalbed.PATHOLOGYMyometriumhasnotcontracted55DiagnosisSoftuterus(i.e,likedough)thatispalpableabovetheumblicusBoggyuterusDiagnosisSoftuterus(i.e,lik562.RetainedPlacentalTISSUEPlacentaretainedPlacentaaccetePlacentaincretaMembraneadherenceSuccenturiateplacenta2.RetainedPlacentalTISSUEPla57DiagnosisDelayedspontaneousseparetionofplacentaInspectionofplacentaUltrasoundMRIDiagnosisDelayedspontaneouss58PlacentaincretaPlacentaAccreta:PlacentaadherenttomyometriumPlacentaIncreta:myometrialinvasionPlacentaPercreta:penetrationofmyometriumtoorbeyondserosa.PlacentaincretaPlacentaAccre593.LacerationofGenitalTractPerineum/vaginal/cervicallacerationHematomaUterinesectionlacerationUterinerupture3.LacerationofGenitalTractP60PathologyInstrumenteddelivery(forceps)Manipulativedelivery(breechextraction,precipitouslabor,macrosomia)SofttissuedisorderPathologyInstrumenteddelivery61DiagnosisBleedingwithafirmcontracteduterus.Thebloodisbrightred.Thevaginalsidewallsandcervixshouldbeespeciallycarefullyinspected.DiagnosisBleedingwithafirm62Vulvalaceration

ⅠⅡ

Ⅲ

ⅣVulvalacerationⅠ63VaginalhematomacervicallacerationVaginalhematomacervicallacer644.CoagulationdefectsAcquiredabnormalityinbloodclottingabruptionplacentaamnioticfluidembolismseverepre－eclampsiaCongenitalabnormalityinbloodclottingthrombocytopeniaseverehepaticdiseasesleukemia4.CoagulationdefectsAcquired65DiagnosisContinuousgeneralizedoozingfromtheskin,subcutaneousandfascialtissuesSuchevidencealsomaybegainedbyobservingcontinuousoozingfromepisiotomyincisionsorperineallacerations.ExcessivebleedingatsitesofmodesttraumacharacterizesdefectivehemostasisNobloodclot.DiagnosisContinuousgeneralize66PROGNOPSISAnemiaSubsequentpuerperalinfectionTransfusiontherapy(hepatitis,HIV,transfusionreaction)Postpartumpanhypopituitarism

（Sheehan’ssyndrome）AcuterenalfailureSterilityMaternalmortality↑PROGNOPSISAnemia67Key-pointtodiagnosis:

EstimateofBloodLossThevelocityofbloodlossBloodloss＞150ml/minBloodlosswithin3H>50%generalamountBloodlosswithin24H>generalamountDiscretionofthePPHcauseRightafterfetaldelivery-TRAUMAFewerminafterfetaldelivery-TISSUEBleedingafterplacentadelivery–TONE/TISSUEContineously/noclotting-THROMBINKey-pointtodiagnosis:

Estim68EvaluationofBloodLossWeightVolumeDimension：GauzebloodareaShockindex=Pulse/SystolicpressureHemoglobin：↓10g/L≈400-500mlbloodloss。Vitalsign、urineamountEvaluationofBloodLossWeight69TREATMENTPROCESSwarning＞400mlmanagement500~1500mlcrisis＞1500mlPrimarySecondaryTertiary產(chǎn)后出血預(yù)防與處理指南（2014）－中華醫(yī)學(xué)會(huì)TREATMENTPROCESSwarning＞400ml70Primary(Bloodloss＞400ml）HelpVesselOxygensupplyVitalsignmonitorLabExamination(CBC+Coagulation)PreparefortransfusionInvestigate4“T”Primary(Bloodloss＞400ml）Help71Secondary（500~1500ml）EtiologicaltreatmentAnti-ShocktreatmentTONE按摩子宮使用宮縮劑宮腔填塞B-lynch血管結(jié)扎TRAUMA縫合裂傷清除血腫恢復(fù)解剖TISSUE人工剝離清宮THROMBIN補(bǔ)充凝血因子：新鮮冰凍血漿、血小板、凝血酶原復(fù)合物Secondary（500~1500ml）Etiologic72UterineAtony--MassageUterineAtony--Massage73Tone--UterotonicagentsOxytocin：im.／iv.gttHemobate（欣母沛）：im.Misoprostol:rectalororalCarbetocin（巧特欣）:im.Tone--UterotonicagentsOxyto74Tone–UterinepackingGauzeTemponadeTone–UterinepackingGauzeTem75Tone–B-lynchsuture正面觀背面觀正面觀Tone–B-lynchsuture正面觀背面觀正面觀76Trauma--RepairVaginallacerationCervicallacerationTrauma--RepairVaginallacera77Tissue–ManualremoveTissue–Manualremove78Tissue–dilation&curettageTissue–dilation&curettage79Tissue–PlacentaAccreta（胎盤植入）ConservativetreatmentHysterectomy產(chǎn)前應(yīng)作充分評(píng)估向孕婦和家屬交待有子宮切除和輸血的可能準(zhǔn)備血制品和凝血物質(zhì)充分的人員安排和器械準(zhǔn)備Tissue–PlacentaAccreta（胎盤植入80Thrombin－TransfusionCorrectthecoagulationdefectResuscitationInfusionofcrystalloidandcolloidBloodtransfusionInfusionofplatelets＋coagulationfactorsThrombin－TransfusionCorrectt81Coagulationfactors補(bǔ)充相應(yīng)凝血因子Platelet：＜20~50×109/LFreshfrozenplasma：凝血因子、血漿蛋白、纖維蛋白原Fibrogin：1克=血中25mg/dl冷沉淀：凝血因子Ⅷ、vWF、纖維蛋白原、因子ⅩⅢ凍干人凝血酶原復(fù)合物：因子Ⅱ、Ⅶ、Ⅸ、Ⅹ

Coagulationfactors補(bǔ)充相應(yīng)凝血因子82

TertiaryManagementOxygenMaintaincirculationDICtreatmentProtectvitalorgansIntensivecareunitIntensivemaneuverTertiaryManagementOxy83Arteryligation盆腔血管結(jié)扎術(shù)結(jié)扎子宮動(dòng)脈Arteryligation盆腔血管結(jié)扎術(shù)結(jié)扎子宮動(dòng)脈84ArterialEmbolizationArterialEmbolization85子宮次全切子宮全切Hysterectomy子宮次全切子宮全切Hysterectomy86休克搶救流程－REACTResuscitationEvaluationArresthemorrhageConsultTreatcomplication休克搶救流程－REACTResuscitation872013WHOrecom