医学教学资料：OBSTETRICAL HEMORRHAGE

1、1 OBSTETRICAL HEMORRHAGE 2 Rationale (why we care) 4-5% of pregnancies complicated by 3rd trimester bleeding Immediate evaluation needed Significant threat to mother & fetus (consider physiologic increase in uterine blood flow) Consider causes of maternal & fetal death Priorities in management (tria

2、ge!) 3 OBSTETRICAL HEMORRHAGE lOBSTETRICS - “bloody business” Delivery should be considered in any woman at term with unexplained vaginal bleeding - hemorrhage is leading cause of maternal mortality and ICU care in obstetrics hospital 4 Vaginal Bleeding: Differential diagnosis Common: Abruption, pre

3、via, preterm labor, labor Less common: Uterine rupture, lacerations/lesions, vasa previa, fetal vessel rupture cervicitis, polyps, cervical cancer, foreign body, bleeding disorders Unknown NOT vaginal bleeding! (happens more than you think!) 5 normal hemorrhage lBloody show: - antepartum in active l

4、abor the consequence of effacement & dilatation of cervix tearing of small veins 6 Definition conditions lThe definition of obstetrical hemorrhage cannot be determined precisely lBleeding500ml lNeed transfusion lHct drop of 10 vol% 7 Predisposing conditions lPredisposing conditions cannot be determi

5、ned precisely l3.9% in vaginal delivery l68% in cesarean delivery lthe high risk factors 8 9 Causes of hemorrhage causes of hemorrhage number(%) Placental abruption 141(19) Laceration/uterine rupture 125(16) Uterine atony 115(15) Coagulopathies 108(14) Placental previa 50(7) Uterine bleeding 47(6) P

6、lacenta accreta/increta/percreta 44(6) Retained placenta 32(4) 10 OBSTETRICAL HEMORRHAGE lAntepartum lplacental previa lplacetal abruption lvasa previa lPostpatrum luterine atony lnormal placentation lgenital tract laceration lcoagulation defects 11 lDefinition - the placenta is located over or very

7、 near the internal os of cervix total partial marginal low-lying 12 Etiology - multiparity - multifetal gestations - prior cesarean delivery : 1.9 % (2 times c/sec) 4.1% (3 times c/sec) prior uterine incision with a previa increases the incidence of cesarean hysterectomy - smoking : CO hypoxemia com

8、pensatory placetal hypertrophy 13 Diagnosis lThe time of uterine bleeding lduring the later half of pregnancy digital examination : torrential hemorrhage! lsonography - placental location can almost be obtained - transabdominal - transvaginal - transperineal - MRI 14 15 Management l may be considere

9、d as follows: 1. fetus is preterm 2. indication for delivery or in labor Have indication: partial, less bleeding vaginal delivery 3. fetus is reasonably mature 4. hemorrhage is so severe as to mandate delivery despite fetal immaturity 16 Management : other considerations Must consider these diagnose

10、s if previa present Placenta accreta, increta, percreta Cesarean delivery may be necessary History of uterine surgery increases risk Could require further evaluation, imaging (MRI considered now) 17 Delivery lcesarean delivery lincision (transverse or vertical) lif incision extends through the place

11、nta, maternal or fetal outcome: risk increase ladequate transfusion and cesarean delivery : marked reduction in maternal mortality fail. Hysterectomy ! 18 lDefinition - the separation of the placenta from its site of implantation before delivery Frequency Incidence 0.5-1.5% of all pregnancies - tota

12、l vs. partial external vs. concealed : concealed - much greater maternal and fetal hazard - diagnosis typically is made later 19 20 Perinatal mortality Risk factors for intrauterine fetal death (1988-2009). placental abruption (OR 2.9, 95% CI 2.4-3.5, p 500mL after completion of the third stage of l

13、abor - late postpartum hemorrhage : hemorrhage after the first 24 hours POSTPARTUM HEMORRHAGE 40 PPH Clinical characteristics - the effect of hemorrhage depend to : nonpregnant blood volume : magnitude of pregnancy induced hypervolemia : degree of anemia at the time of delivery : hypovolemic ex) nor

14、motensive hypertensive at initially hypertensive normotensive although remarkably hypovolemic 41 PPH Clinical characteristics - with severe preeclampsia : not normally expanded blood volume : very sensitive and intolerant to blood loss : so, when excessive hemorrhage is suspected, prompt vigorous cr

15、ystalloid and blood replacement 42 Estimated blood loss lexcept intrauterine & intravaginal accumulation of blood or intraperitoneal bleeding (uterine rupture) lweight method lmeasure volume larea-method locular estimate lHb lSymptoms and physical findings 43 EBL lShock index blood loseShock index b

16、lood lose（mlml） rate of blood rate of blood volume volume l 0.60.60.9 5000.9 500750 20%750 20% l =1.0 1000 =1.0 10001500 201500 2030%30% l =1.5 1500 =1.5 15002500 302500 3050%50% l2.0 25002.0 25003500 503500 5070%70% 44 Uterine atony same overall mgmt regardless of delivery type Recognition Uterine

17、exploration lblood may not escape vaginally - adherent pieces of placenta or large blood clots prevent effective contraction and retraction Uterine massage 45 Bleeding unresponsive to medicines l1. bimanual uterine compression 2. help ! 3. 2nd IV line : crystalloid with medicines 4. blood transfusio

18、n 5. explore uterine cavity manually : placental remnant or laceration 6. inspect the cervix and vagina 7. foley keep : urine output check (renal perfusion) 46 47 Uterine atony Medical mgmt: Pitocin (20-80 u in 1 L NS) Long-acting Pitocin (100 iv) Methergine (ergonovine maleate 0.2 mg IM) Not advise

19、d for use if hypertension Hemabate (prostaglandin F2) 48 Uterine atony B-lynch suture (to compress uterus) Uterine packing Uterine artery ligation Internal iliac artery ligation Uterine artery embolization Hysterectomy (last resort) Anesthesia involved Whether in L&D room or the OR! 49 50 宫腔填塞 51 In

20、ternal iliac artery ligation l- reduce the hemorrhage technically difficult, successful in less than half - nonabsorbable material suture - mechanism : 85% reduction in pulse pressure in those arteries distal to the ligation : more amenable to hemostasis via simple clot formation - bilateral : dose

21、not interfere subsequent reproduction 52 53 Under what circumstances is arterial embolization indicated? lA patient with stable vital signs and persistent bleeding, especially if the rate of loss is not excessive, may be a candidate for arterial embolization. lRadiographic identification of bleeding

22、 vessels allows embolization with Gelfoam, coils, or glue. lBalloon occlusion is also a technique used in such circumstances. lEmbolization can be used for bleeding that continues after hysterectomy or can be used as an alternative to hysterectomy to preserve fertility. 54 Proposed Performance Measu

23、re If hysterectomy is performed for uterine atony there should be documentation of other therapy attempts. 55 Lacerations: Recognition Perineal, vaginal, cervical, Uterine All can be rather bloody! Assistance Lighting Appropriate repair Control of bleeding Identify apex for initial stitch placement

24、56 57 Uterine inversion: Management Call for help Manual replacement of uterus Uterotonics and Appropriate anesthesia to necessary to relax uterus & allow thorough manual exploration of uterine cavity Concern for shock to be discussed (and managed by the help youve called into the room!) Exploratory

25、 laparotomy may be necessary 58 What are the clinical considerations for suspected placenta accreta? lIf the diagnosis or a strong suspicion is formed before delivery, a number of measures should be taken: - The patient should be counseled about the likelihood of hysterectomy and blood transfusion. - Blood products and clotting factors should be ava