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1、產(chǎn)后出血產(chǎn)后出血 Postpartum Hemorrhage PPH 1 學(xué)習(xí)目標(biāo)學(xué)習(xí)目標(biāo) 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(yù)防 2 3 簡介簡介 最普遍的嚴(yán)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(yù)測 災(zāi)難性的 出血的評估比較主觀 4 定義定義 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） 5 產(chǎn)后出血止血原理產(chǎn)后出血止血原理 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
2、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 6 病因病因 The 4 Ts of PPH CAUSE INCIDENCE (APPROX) TONE 子宮收縮乏力 Atony 70% TRAUMA 軟產(chǎn)道裂傷 Laceration, hematoma, inversion, rupture 20% TISSUE 胎盤因素 Retained placenta, invasive placenta 10% THROMBIN 凝血功能 Coagulopathies 1% Am Fam Physician 2007; 7
3、5:875. 7 病因病因 Planned Cesarean section 剖宮產(chǎn)剖宮產(chǎn) Episiotomy 外陰側(cè)切外陰側(cè)切 Unplanned Vaginal/cervical tear 陰道宮頸裂傷陰道宮頸裂傷 Surgical trauma 手術(shù)創(chuàng)傷手術(shù)創(chuàng)傷 Uterine rupture 子宮破裂子宮破裂 8 軟產(chǎn)道裂傷診斷軟產(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 9 軟產(chǎn)道裂傷治療軟產(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(yù)防感染 輸血 10 Cervical la
4、ceration repair 11 陰道裂傷陰道裂傷 I裂傷 皮膚黏膜 II裂傷肌層 III裂傷肛門括約肌 IV裂傷直腸 12 13 病因病因 前置胎盤前置胎盤 胎盤殘留胎盤殘留 胎盤滯留、胎盤滯留、嵌頓嵌頓 胎盤植入胎盤植入 14 胎盤因素出血診斷胎盤因素出血診斷 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(shù) 過度牽拉臍帶導(dǎo)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 15 胎盤因素治療胎盤因素治療 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
5、，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(shù)治療 抗炎治療 16 Manual removal of placenta External hand steadies the uterine fundus Internal hand along plane of cleavage Check placenta is complete Check the uterus is empty Check for trauma of GT Anaesthesia Antibiotics IV line Oxytocics Uterus Placenta 17 病因病因 Congenita
6、l Von Willebrands disease Acquired DIC, Obstetric disorders HELLP syndrome DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism) Anti coagulant therapy Heparin 18 病因病因 Systemic factors Spirit, Chronic diseases Obstetric factors Prolonged labor, PIH Uteri
7、ne factors High parity, Multiple gestation, macrosomia, Leiomyomas Drug factors tocolytic agents PPH 最常見病因(70%) 19 宮縮乏力的診斷宮縮乏力的診斷 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 20 宮縮乏力的預(yù)防宮縮乏力的預(yù)防 21 宮縮乏力治療宮縮乏力治療 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 22 宮縮乏力的治療宮縮乏力的治療 宮縮劑宮縮劑 催產(chǎn)素 （Oxytocin ） 麥角新堿（Methe
8、rgine） 欣母沛（Hemabate） 米索前列醇（Misoprostol ） 23 Uterotonics Dose/ Route Contra-Indications Pitocin 10U im 20U in 500ml NS ivgtt Mast dose 80U Methergine 0.2mg im Q2-4 hours Hypertension Scleroderma, Raynauds Hemabate 0.25 mg im Q15min to max dose 2mg Asthma Cytotec 200 1000mcg Oral / Vaginal / Rectal Q
9、6 hours 24 宮縮劑療效不佳宮縮劑療效不佳 尋找其他原因! 開放靜脈通路 血交叉，備血，輸血 留置導(dǎo)尿，24hr出入量 監(jiān)測生命體征 凝血功能監(jiān)測 25 子宮填塞子宮填塞 Bakri Balloon Foley, BT-Cath, Sengstaken-Blakemore Tube Jacobs AJ, Up to Date 2009 26 Gauze Packing 27 子宮動脈栓塞子宮動脈栓塞 Requires available facilities/ personnel Hemodynamically Stable Patient Temporizing measure en
10、 route to OR (Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992) 28 29 手術(shù)介入手術(shù)介入(1 of 4) Gabbe, Ch 18 30 COMPRESSION SUTURES Cornu Fallopian tube Ovary Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology. 2002 Ovary Fallopian tube 31 手術(shù)介入手術(shù)介入(2 of 4) Gabbe, Ch 18 32 手術(shù)介入手
11、術(shù)介入(3 of 4) 33 手術(shù)介入手術(shù)介入(4 of 4) 34 出血的評估出血的評估 肉眼觀察: 容器: 量杯 表面積: blood stained 10cmx10cm = 10ml 稱重: 1.05g = 1ml Hct1000ml 每小時尿量2500ml 休克指數(shù)= 脈搏/收縮壓 35 Compensation Mild Moderate Severe Blood Loss 500-1000 ml 10-15% 1000-1500 ml 15-25% 1500-2000 ml 25-35% 2000-3000 ml 35-45% B.P.Change (SBP) None Sligh
12、t fall (80-100 mmHg) Marked fall (70-80 mmHg) Profound fall (50-70 mmHg) Symptoms & Signs Palpitation Dizziness Tachycardia Weakness Sweating Tachycardia Restlessness Pallor Oliguria Collapse Air hunger Anuria 36 治療原則治療原則 2 方面方面 復(fù)蘇 止血 識別和治療4Ts 治療：及時，系統(tǒng) 37 Step I Initial Assessment and treatment Resu
13、scitation Assess Etiology Management Large bore IV(s) Oxygen by mask Monitor BP,P,R Head down tilt Transfuse oxygen saturation Explore uterus (tone,tissue) Explore LGT (trauma) Review history (thrombin) Observe clots Coagulation screen Group and crossmatch Massage /compress Remove placenta Repair tr
14、auma Correct inversion Correct coagulopathy 38 Step II Continuing PPH Get HelpGet Help Local ControlLocal Control BP and coagulationBP and coagulation Obstetrician / surgeon Anesthesiologist Lab and ICU Manual compression +/- pack uterus +/- vasopressin +/-embolization Crystalloid Blood products 39
15、Step III Surgery RepairRepair LacerationsLacerations Local controlLocal control Ligate VesselsLigate Vessels Hysterectomy Hysterectomy Undersutering the placental bed Square suture B-Lynch suture Uterines Internal iliac artery Step V Post Hysterectomy Bleeding Abdominal Packing Abdominal Packing Ang
16、iographic EmbolizationAngiographic Embolization 40 預(yù)防預(yù)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(yù)防應(yīng)用 縮宮素第三產(chǎn)程常規(guī)使用可以預(yù)防60%PPH 仔細(xì)檢查軟產(chǎn)道，胎盤 41 血制品的應(yīng)用血制品的應(yīng)用 不用等待實驗室結(jié)果! 大量出血沒有輸入凝血因子將導(dǎo)致凝血功能異常！ 42 Product Contents Volume Effect Whole Blood 500ml Hct 3% PRBCs RBCs, WBCs, few plasma proteins 300ml Hct 3%, less f
17、ever Platelets Pooled concentrate 1 unit = 6 pack 50ml PLT 5-10K FFP Fibrinogen, ATIII, clotting factors, plasma 250ml fibrinogen 5-10mg/dl Cryoprecipitate Fibrinogen, Factor VIII, XIII, vWF 40ml fibrinogen 5-10mg/dl Blood Product Utilization 43 44 Active management of the third stage of labor Blood
18、 loss 1000 to 1500ml massive PPH Brisk bleeding Blood pressure falling Pulse rising Massage Oxytocin Explore genital tract Inspect placenta Observe clotting Coagulation screen The Four T s Soft, boggy uterus Tone Resuscitation Genital tract tear Trauma Placenta retained Tissue Blood not clotting Thr
19、ombin Hemabate Methergine cytotec Suture Manual remove Blood product, Surgical Intervention Blood loss 500 ml PPH Replace factor 45 Conclusions ！ Be prepared Practice prevention Assess the loss Assess the maternal status Resuscitate vigorously and appropriately Diagnose the cause Summary: Remember 4
20、 Ts Understanding its etiology is fundamental to effectively managing Treat the cause Active management of the third stage of labor is also a key component in its prevention. 46 軟軟 胎盤胎膜異常胎盤胎膜異常 軟產(chǎn)道裂傷軟產(chǎn)道裂傷 暗紅暗紅 鮮紅鮮紅 陣發(fā)性陣發(fā)性 持續(xù)性持續(xù)性 胎盤剝離后胎盤剝離后 胎盤娩出前胎盤娩出前 胎兒娩出后胎兒娩出后 宮縮乏力宮縮乏力 胎盤因素胎盤因素 產(chǎn)道裂傷產(chǎn)道裂傷 凝血功能障礙：出血晚，
21、血液不凝凝血功能障礙：出血晚，血液不凝 不同病因陰道出血特點不同病因陰道出血特點 依據(jù)出血時間、出血量、出血性質(zhì)判斷出血原因依據(jù)出血時間、出血量、出血性質(zhì)判斷出血原因 產(chǎn)后出血原因互為因果產(chǎn)后出血原因互為因果 出血時間出血時間 出血性質(zhì)出血性質(zhì) 出血顏色出血顏色 檢查檢查 47 Case Presentation Case Presentation Personal HistoryPersonal History 23 year old lady Married for 3 years G 2nd Para 1; no living Past Obstetric HistoryPast Obs
22、tetric History In 2002 Gestational Diabetes + Preeclampsia（PE） Delivered at 38 weeks Vaginal delivery on 5/2002 Dead male baby 4.5 kg Current PregnancyCurrent Pregnancy LMP 10/10/2003 Twin pregnancy Regular prenatal care in a private clinic No document of screening for GDM in this pregnancy On admis
23、sion: History of unsatisfactory fetal movements for the last 3 days Labor pains for 3 hours AdmissionAdmission 21:00, May 321:00, May 3rdrd 20042004 liquor above average, uterine contractions 2/10 min, each 20 sec. PV: 4 cm dilated, 1 cm long, central, soft U.S. scan U.S. scan Twin pregnancy Monoamn
24、iotic monochorionic 1st cephalic, F. Life +ve, 24+2 wk 2nd transverse, F. Life ve, 22 wk Placenta fundal anterior grade II Liquor: clear, AFI 27 cm ProgressProgress Patient spontaneously miscarried at 03:00 1 L male 500 gm (died later) 1 SB male 1 kg Vaginal bleeding associated with retained placent
25、a. 3 am3 am3 amTransferred to theatre 3 am3 am3 am3 am3 am3 am3 amEmptying the bladder IV crystalloids Manual separation of the placenta Excessive vaginal bleeding Uterine massage and bimanual compression Uterus stayed atonic (F.Level 18 wk) Received 3 units of whole blood in last 20 minutes Uteroto
26、nics: 1000 ug Misoprostol rectal (5 tabs) 60 units oxytocin (IVI) 500ug Hemabate Temporarily effective Re-accumulation of blood clots in the uterus Bleeding Controlled Uterine artery embolization Postoperative RecoveryPostoperative Recovery F.U.: vital data stable U.O.P adequate Drain 150 ml Uterine
27、 massage 1 pm Case 1 Healthy, age: 32, G2P1. Augmented vaginal delivery, no tears. Nurse calls you one hour after delivery because of heavy bleeding. What do you do? What do you order? 57 Case 2 26 years G4 now P4. You leave the room to answer a page while waiting for placenta to deliver, but are called back overhead. Huge blood clot seen in vagina. What is this, and what do you do next? 58 59
（優(yōu)質(zhì)課件）婦產(chǎn)科學(xué)產(chǎn)后出血
