妇产科学--产后出血

1、产后出血Postpartum HemorrhagePPH,Zhangye Xu M.D. Department of Obstetrics and Gynecology 1st Affiliated Hospital, Wenzhou Medical College,学习目标,掌握产后出血的重要原因 熟悉产后出血临床表现及初步处理方法 了解产后出血预防,简介,最普遍的严重的产科并发症 产妇死亡的主要原因 急性血液丢失 经常不可预测 灾难性的 出血的评估比较主观,定义,问题 PPH 诊断的问题性 出血评估的主观性和不精确性 传统 阴道出血 500ml 早期出血：产后24hr内 晚期出血：产后24

2、hr后（感染、胎盘,产后出血止血原理,止血,1. 断裂血管壁肌层环形收缩,2. 凝血系统,3. 最有效的止血方法：子宫收缩,PPH: 通常在胎盘剥离后发生,胎盘剥离时，胎盘附着处的母体血管的终末端发生断裂，直接向子宫腔开放，正常分娩时出血量约为200-400ml,出血,病因The 4 Ts of PPH,Am Fam Physician 2007; 75:875,病因,Planned Cesarean section 剖宫产 Episiotomy 外阴侧切,Unplanned Vaginal/cervical tear 阴道宫颈裂伤 Surgical trauma 手术创伤 Uterine r

3、upture 子宫破裂,软产道裂伤诊断,如果宫缩好，软产道裂伤出血首先考虑 出血是明显而迅速的，在胎儿娩出后 持续出血，宫缩好 缝扎可以止血 确定方法：软产道检查,软产道裂伤治疗,可吸收肠线 全层连续或间断缝合 抗炎治疗：预防感染 输血,Cervical laceration repair,阴道裂伤 I裂伤 皮肤黏膜 II裂伤肌层 III裂伤肛门括约肌 IV裂伤直肠,病因,前置胎盘,胎盘残留,胎盘滞留、嵌顿,胎盘植入,胎盘因素出血诊断,胎盘娩出 30 分 危险增加：剖宫产，子宫感染，多次妊娠分娩人流刮宫术 过度牵拉脐带导致脐带断裂，子宫内翻 通常的治疗方法是人工取出胎盘 出血往往发生在人工剥离

4、胎盘之时,胎盘因素治疗,催产素 10U + NS 20ml 脐静脉 iv 如果失败 开放静脉通路 备血 人工剥离胎盘 麻醉或药物止痛 手在宫壁与胎盘之间，轻轻剥离，胎盘完整全部取出 如果人工剥离胎盘失败 刮宫 手术治疗 抗炎治疗,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,An

5、aesthesia Antibiotics IV line Oxytocics,Uterus,Placenta,病因,Congenital Von Willebrands disease,Acquired DIC, Obstetric disorders HELLP syndrome DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism) Anti coagulant therapy Heparin,病因,Systemic factors Spirit

6、, Chronic diseases Obstetric factors Prolonged labor, PIH Uterine factors High parity, Multiple gestation, macrosomia, Leiomyomas Drug factors tocolytic agents,PPH 最常见病因(70,宫缩乏力的诊断,腹部检查：子宫软，无张力 阴道出血在胎盘娩出之后 阵发性出血,宫缩乏力的预防,宫缩乏力治疗,人工按摩 双手按摩： 按摩子宫是有效的简单的刺激子宫收缩的方法,Anderson JM, AFP 2007,宫缩乏力的治疗宫缩剂,催产素 （Oxy

7、tocin ） 麦角新碱（Methergine） 欣母沛（Hemabate） 米索前列醇（Misoprostol,宫缩剂疗效不佳,寻找其他原因! 开放静脉通路 血交叉，备血，输血 留置导尿，24hr出入量 监测生命体征 凝血功能监测,子宫填塞,Bakri Balloon Foley, BT-Cath, Sengstaken-Blakemore Tube,Jacobs AJ, Up to Date 2009,Gauze Packing,子宫动脉栓塞,Requires available facilities/ personnel Hemodynamically Stable Patient Te

8、mporizing measure en route to OR (Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992,手术介入(1 of 4,Gabbe, Ch 18,COMPRESSION SUTURES,Cornu,Fallopian tube,Ovary,Hayman R, Arulkumaran S, Steer P Obstetrics no living,Past Obstetric History,In 2002 Gestational Diabetes + Preeclampsia

9、（PE） Delivered at 38 weeks Vaginal delivery on 5/2002 Dead male baby 4.5 kg,Current Pregnancy,LMP 10/10/2003 Twin pregnancy Regular prenatal care in a private clinic No document of screening for GDM in this pregnancy On admission: History of unsatisfactory fetal movements for the last 3 days Labor p

10、ains for 3 hours,Admission21:00, May 3rd 2004,liquor above average, uterine contractions 2/10 min, each 20 sec. PV: 4 cm dilated, 1 cm long, central, soft,U.S. scan,Twin pregnancy Monoamniotic monochorionic 1st cephalic, F. Life +ve, 24+2 wk 2nd transverse, F. Life ve, 22 wk Placenta fundal anterior

11、 grade II Liquor: clear, AFI 27 cm,Progress,Patient spontaneously miscarried at 03:00 1 L male 500 gm (died later) 1 SB male 1 kg Vaginal bleeding associated with retained placenta,Transferred to theatre,Emptying the bladder IV crystalloids,Manual separation of the placenta,Excessive vaginal bleedin

12、g Uterine massage and bimanual compression,Uterus stayed atonic (F.Level 18 wk,Received 3 units of whole blood in last 20 minutes,Uterotonics: 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 Recovery,F.U.: vital data stable U.O.P adequate Drain 150 ml Uterine massage,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 ord