美国ACOG产后大出血治疗策略 PostPartumHemorrhage课件

PostPartumHemorrhageDistrictIACOGMedicalStudentTeachingModule2010铭谋住骄厘鹤召蔚专埂斥摆杠渭琶假抡退潭围挤羹伪分枷芋昭搽睁致亥违美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePostPartumHemorrhageDistric1PostPartumHemorrhage-DefinitionCommonlydefinedas….SVD>500ccbloodlossC/S>1000ccbloodloss*PPHgenerallyreferstoGA>20wks

肋疵揖溺奖损茫窑虏抓律竖涅碾呵泻炉签岔塔桩盆汛祸缠缨插驱庄银箱明美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePostPartumHemorrhage-Defin2OtherDefinitionsHematocritChange–definedaschange>10%butnotusefulinacutesettingNeedforTransfusion–variablepracticeHemodynamicstabilityTiming–earlyorlateSymptomatic厩苛妈洲摸部遇醇哨屠溺稿曝初砧腹售廊喧录址僻使穿敝槐桩蕾皋务狮体美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageOtherDefinitions厩苛妈洲摸部遇醇哨屠溺稿曝3RelevanceOneoftopfivecausesofmaternalmortalityanywhere#1causematernalmortalityworldwideDevelopedcountries1/100000birthscomparedto1/1000birthsindevelopingcountriesIncidence5%-10%deliveries(dependsondefn)想使你箩妒竞樊簿谩颐拢恍鸽赴坟审棚后瑞抢蹿坝袭捆翘巨估鸿寞便媒闹美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageRelevanceOneoftopfivecause4PhysiologicAdaptationsofPregnancyplasmavolume40-50%RBC20-30%*inseverePIH-hemoconcentration形土也剔姥厚扮艇景其裹食菩舅象异词碳括非武逛睬烷傈娇碗金延温压矣美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePhysiologicAdaptationsofPre5NormalMechanismofHemostasis‘Livingligatures’–Baskett2000IntrinsicvasospasmLocaldecidualhemostaticfactorsincludingtissuefactor&type1plasminogenactivatorinhibitorclottingfactors(exceptIandXI)侍椭吧始织盅往弹呜憋乓簿丑买碱窍意操时威互咀扬呆磊嵌梗碍朗庐朱篆美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageNormalMechanismofHemostasis6铺嗓右米窑畔肺煤沃骡孤吼锁付藤跋泊懊法棒储砍眯主执酒净缘胳禁己痈美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhage铺嗓右米窑畔肺煤沃骡孤吼锁付藤跋泊懊法棒储砍眯主执酒净缘胳禁7ZymogensofSerineProteasesActivitiesFactorXIIbindstoexposedcollagenatsiteofvesselwallinjury,activatedbyhigh-MWkininogenandkallikreinFactorXIactivatedbyfactorXIIaFactorIXactivatedbyfactorXIainpresenceofCa2+FactorVIIactivatedbythrombininpresenceofCa2+FactorXactivatedonsurfaceofactivatedplateletsbytenasecomplexandbyfactorVIIainpresenceoftissuefactorandCa2+FactorIIactivatedonsurfaceofactivatedplateletsbyprothrombinasecomplexCofactorsActivitiesFactorVIIIactivatedbythrombin;factorVIIIaisacofactorintheactivationoffactorXbyfactorIXaFactorVactivatedbythrombin;factorVaisacofactorintheactivationofprothrombinbyfactorXaFactorIII(tissuefactor)asubendothelialcell-surfaceglycoproteinthatactsasacofactorforfactorVIIFibrinogenActivityFactorIcleavedbythrombintoformfibrinclotTransglutaminaseActivityFactorXIIIactivatedbythrombininpresenceofCa2+;stabilizesfibrinclotbycovalentcross-linkingRegulatoryandotherproteinsActivitiesvonWillebrandfactorassociatedwithsubendothelialconnectivetissue;servesasabrigdebetweenplateletglycoproteinGPIb/IXandcollagenProteinCactivatedtoproteinCabythrombinboundtothrombomodulin;thendegradesfactorsVIIIaandVaProteinSactsasacofactorofproteinC;bothproteinscontainglaresiduesThrombomodulinproteinonthesurfaceofendothelialcells;bindsthrombin,whichthenactivatesproteinCAntithrombinIIImostimportantcoagulationinhibitor,controlsactivitiesofthrombin,andfactorsIXa,Xa,XIaandXIIa挨聋芦斥浦堑支境只合港店浑赌庭起淡匪昌琉瘁嘘题涵颅驻芭迸赞梳帚找美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageZymogensofSerineProteasesAc8BloodLossEstimationAllstudiesshowgrossunderestimationofbloodlossatdeliveryVisualestimationespeciallyunreliableforsmallandlargeamountsofbloodlossPrasertcheroensuketal(2000)-228womenin3rdstage->500cc:visual(5.7%)actual(27.63%)->1000cc:visual(.44%)actual(3.51%)***Incidenceunderestimated90%版仇遇待讶驹忻迟牛遮惨宴挫湃艰尤徒嘻惹涸剥坟拔怯僻跌卫挛永通锯狮美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageBloodLossEstimationAllstudi9Primary,EarlyorAcutePPHDelivery-<24hPP90%PPHcasesAssociatedwithmorebleeding您行谦赚闻千焦挖浮腋赛善鸭不时房浆钵栓仗尝杜纹弟痊伊亚略磺式扁仑美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePrimary,EarlyorAcutePPHDel10SecondaryorLatePPH24h–12weekspostpartumAffects1-3%ofalldeliveriesCommoncausesinclude:

-infection-RPOC-Abnormaluterineinvolution泛痛忿窄才顿泄缮凳视硷明恃魏垒琅浦肺戍龙锋凰柜亭畏顿摈幻享凄余倘美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageSecondaryorLatePPH24h–1211Etiology4T’s-Tone-Tissue-Trauma-Thrombin株备舶纬奏局泞遂襄谋骂拒活笋块逞榜锰邢仲蔓染其虚电赢队织狼址脉卸美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageEtiology4T’s株备舶纬奏局泞遂襄谋骂拒活笋块逞12UterineAtony75-90%PPHMostlyassociatedwith10PPH6%afterc/sRiskfactorsafterc/sinclmultiples,Hispanicethnicity,induced/augmentedlabor,macrosomia,andchorioamnionitis娠裴诺缀熙绦弗仓镑蛙银轿岳睬腻嫡的叔董棍乌亢阉彰狡乖凡俱莽洗吨危美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageUterineAtony75-90%PPH娠裴诺缀熙绦弗13TissueRetainedplacenta10%PPHcases10%placenta’shavefundalimplantationPlacentaaccreta0.005%ofalldeliveries90%ofaccreta’shavePPHand50%ofthesehavehyst委撅坷矿隧夜脓侍酷铂淖钧胞躬荆未衙泥唱住奥夷姜度谰型妮牟吓腥臣呸美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageTissueRetainedplacenta10%PP14Trauma10causePPHin20%casesInjurytogenitaltractduringdelvOR1.765%uterineinversionshavePPH48%uterineinversionshavebldtransfusion厕辣讫炯苔疮烃肾享摔富舜丫逾赫糟写监塔疑昭嗡拿玛西然认灵殖礁赤爱美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageTrauma10causePPHin20%case15Thrombin1%casesofPPHKnownassociationwithcoagulationfailure-abruption-PIH-sepsis-IUFD-incompatibleblood-abortion登叫塌胳指斥姆送勋章哲晨卧绦寿交蜜极丙挫添悸梨轰鸟例瓦感件铜广堵美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageThrombin1%casesofPPH登叫塌胳指斥姆16RiskFactorsinPPHEtiologyProcessClinicalRiskFactorsToneOverdistendedUterusPolyhydramnios,MultipleGestationMacrosomiaUterineMuscleFatigueRapidLabor,ProlongedLaborHighParityIntraAmnioticInfectionFever,ProlongedROMFunctional/AnatomicDistortionoftheUterusFibroidUterusPlacentaPreviaUterineAnomaliesTissueRetainedProductsAbnormalPlacentaIncompletePlacentaatDeliveryPreviousUterineScarHighParityRetainedBloodClotsAtonicUterusTraumaLacerationsPrecipitousorOperativeDeliveryExtensionsatC/SMalposition,DeepEngagementUterineRupturePreviousUterineSurgeryUterineInversionHighParity,FundalPlacentaThrombinPre-existingCoagulopaties,LiverDiseaseAcquiredinPregnancyITP,DICTherapeuticAnti-coagHistoryofclots造铬兆馏碍森兼寓弧诅仿棚离悉更啤竖临怕哮烈渍哀纷冲逊搪对好铆吓胜美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageRiskFactorsinPPHEtiologyPr17FactorsAssociatedWithPPHRetainedPlacenta(OR3.5)FailuretoProgress2ndStage(OR3.4)PlacentaAccreta(OR3.3)Lacerations(OR2.4)InstrumentalDelivery(OR2.3)LargeForGANewborn(OR1.9)HypertensiveDisorders(OR1.7)InductionofLabor(OR1.4)AugmentationofLaborWithOxytocin(OR1.4)戚旅痪鸣抚具窥辛鹊窒悼唤硝奖虞丹淫懊阮昏辊拜滋毒怒胖涟苑景婆准沧美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageFactorsAssociatedWithPPHRet18FactorsAssociatedWithPPHDM–30-35%comparedto5-10%Inheritedcoagulopathies

–mostcommonisVWB(1-3%prevalence)-70%havetype1(↓factorVIII,↓vWAg,↓vWfactoractivity)-riskPPH22%withvWD&18%hemophilia岳鲜账完粘苟嫁技停如醋茹标笆乎嚣焉娃隋咯跨啥脏这押竖司吕泰蜡两牛美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageFactorsAssociatedWithPPHDM19AdditionalRiskFactorsAge>35yAsianorHispanicethnicityObesityPostdates>42wksPreviousPPHPlacentaPrevia澜眶赃取室韭漳下丫屈癸河制遮嫉狮岗汹互媳诉化斋苛互棘陶献瘪砸威松美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageAdditionalRiskFactorsAge>320KeyManagementIssuesPreventionEarlyRecognitionImmediateAppropriateIntervention蛹道票察徘恢奴邱白己砸具卸巧锤玲醉恨爪犀中墙憾摈骇暖巳牧仗睦禽思美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageKeyManagementIssuesPreventio21BloodLossSigns&SymptomsBloodLoss(%)BloodPressureSigns&Symptoms500-1000ml(10-15)normalPalpitations,dizziness,tachycardia1000-1500ml(15-25)SlightlylowWeakness,sweating,tachycardia1500-2000ml(25-35)70-80Restlessness,pallor,oliguria2000-3000ml(35-45)50-70Collapse,airhunger,anuria>2500ccbloodloss–50%mortalityifnotmanagedurgently&appropriately众轻养御胁磺咋镭愤鼎探罢谨绦攀爬薪捷陕忱纷轿但莉谗而蜜七龋谨该棵美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageBloodLossSigns&SymptomsBlo22InitialManagementABC’sCallforhelpMobilizeteam(staff,anesthesia,bloodbanketc)IVaccessFluidresuscitationExaminepatientincludingfundalmassage,dxtrauma/inversion/otheretiologies,andfundalmassageFoleycatheterBloodwork(CBC,coagprofile,crossmatch)Reversecoagulationabnormality墅擒烷诸秋耶盅炼鸟论毁殉瓦壁隘搭伏寻年岛挚睫紊泰谦缆蚤肠雌驭土猩美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageInitialManagementABC’s墅擒烷诸秋耶盅23UterotonicMedicationsOxytocinErgotHemabateMisoprostolVasopressin踏铸撕体滩墅撼两柱磅丸郧予铂莹袍啮珍洛靠酷慑船绪仲挫仅塌翟厨肛逸美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageUterotonicMedicationsOxytocin24DrugTherapyForPPHDrugDoseSideEffectsContraindicationsOxytocin10IUIM/IMM5IUivbolus10-40IU/L-Usuallynone-ctx-N&V-waterintoxication-hypersensitivityErgot0.25mgIM0.125mgIVQ5minsX5doses-peripheralvasospasm-HTN-N&V-HTN-peripheraldisease-Raynauld’s-hypersensitivityHemabate(PGF2α)0.25mgIM/IMMQ15minsX8doses-flushing-diarrhea/N&V-O2desats-bronchospasm-restlessness-hypersensitivity-asthma-activecardiac,pulmonary,renal,orhepaticdiseaseMisoprostol(PGE1)400-1000mcgPR/PV/POX1dose-pyrexia/flushing-N&V/diarrhea-abdpain-HA-hypersensitivity-pregnancyVasopressin20U/100mlsalineInject1mlatbleedingsite-acuteHTN-bronchospasm-N&V/cramps-HA,vertigo-angina-deathifiv-coronaryarterydisease-hypersensitivity胜侣轰训裴摩床奸汁逗皱毁羹趋赏挫瑶钵仕识昔恨儡样咕吱磷索务岛钓千美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageDrugTherapyForPPHDrugDoseSi25SurgicalManagementCurettageEmbolizationTamponade(Balloon,packingetc…)CompressionsuturesVesselligationHysterectomy沏宫炊葱螟抹萝纷掇士模扛集检寂答疾斥库孝杆认操卢试次构朴烬宣越珐美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageSurgicalManagementCurettage沏宫26TamponadeBakriBalloon

-Siliconeballoon-500cccapacityFoleycatheterwith30ccballoonSengstaken-BlakemoreBalloonVaginalpackingSalinefilledglove堰渭莆诽堰触馏蜂顺佃慧去扔厩域出貉是寻撇据首兑此些哄渡写插刷搓汽美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageTamponadeBakriBalloon堰渭莆诽堰触馏27B-LynchSuture拼削搁佑生垒郑萤柳软敲惋趟精迷沧册苞统工稿车悲耿炎遣风境满搁篱报美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageB-LynchSuture拼削搁佑生垒郑萤柳软敲惋趟精迷沧28VesselLigation禹坪苞径酥闰灰性咐祸煮谰柬藐咨壬恕酱屈绑姑泌迪赠掇屁卯怠栏执伦狗美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageVesselLigation禹坪苞径酥闰灰性咐祸煮谰柬藐咨29VesselLigationUterine-O’LearyStitch-Chromic0passedthroughlateralaspectoflowersegmentasclosetocervixaspossibleandthenthroughbroadligamentlateraltovesselsOvarian-distaltocornuabypassingsuturethroughmyometriummedialtovessels詹泛坟侄狡素侩凤釉衫佑沼泳欣半擂蹈竖驾驼死桐乱融超槛瞩酒恨矿宪赣美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageVesselLigationUterine詹泛坟侄狡素侩凤30RecombinantActivatedFactorVIIaTxofbleedingdisordersDoseupto120mcg/kgq2huntilhemostasisPromisingbutneedsmorestudies$10,000/mgRiskthromboembolism祝庐档鸥笑稍巷猜瞬乎孟硕庸梯候桅创词参民铅呆红热扦焚烤参椒柜聂佐美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageRecombinantActivatedFactorV31Step1–InitialAssessmentResuscitationLargeboreiv’sO2Vitals±foleycatheterDxEtiology-exploreuterus(tone/tissue)-exploregenitaltract(trauma)-reviewhistory(thrombin)-observeclotsLabs-CBC-coagprofile-crossmatchStep2–DirectedTherapyTone-massage-compress-drugsTissue-manualremoval-curettageTrauma-correctinversion-repairlaceration-identifyruptureThrombin-reverseanticoagulation-replacefactorsStep3–IntractablePPHGetHelp-OB/Surgery-Anesthesia-Lab/BloodBank-ICULocalControl-manualcompression-±packuterus-±vasopressin-±embolizationBPandCoagulation-crystalloids-bloodproductsStep4-SurgeryRepairLacerationsLigateVessels-uterines-ovarian-internaliliacHysterectomyStep5–PostHysterectomyBleedingAbdominalPackingEmbolization回霖誊坏似忌眷砖驶捕税熟钝搭管姐膊寝荆他望札佰匆函付谚含咱联耐拽美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageStep1–InitialAssessmentRes32SecondaryPPHGenerallylessbleedingMostlyrelatedtoinfectionorRPOCNoRCT’sAbx/uterotonicsasappropriateEvacuation操境缚誊仟娩横嫌呢屁阔泳酝顽秦梁纂杖瑚践林涉河叶阳区怎渗胎哄屈炳美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageSecondaryPPHGenerallylessbl33PostPartumHemorrhageDistrictIACOGMedicalStudentTeachingModule2010铭谋住骄厘鹤召蔚专埂斥摆杠渭琶假抡退潭围挤羹伪分枷芋昭搽睁致亥违美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePostPartumHemorrhageDistric34PostPartumHemorrhage-DefinitionCommonlydefinedas….SVD>500ccbloodlossC/S>1000ccbloodloss*PPHgenerallyreferstoGA>20wks

肋疵揖溺奖损茫窑虏抓律竖涅碾呵泻炉签岔塔桩盆汛祸缠缨插驱庄银箱明美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePostPartumHemorrhage-Defin35OtherDefinitionsHematocritChange–definedaschange>10%butnotusefulinacutesettingNeedforTransfusion–variablepracticeHemodynamicstabilityTiming–earlyorlateSymptomatic厩苛妈洲摸部遇醇哨屠溺稿曝初砧腹售廊喧录址僻使穿敝槐桩蕾皋务狮体美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageOtherDefinitions厩苛妈洲摸部遇醇哨屠溺稿曝36RelevanceOneoftopfivecausesofmaternalmortalityanywhere#1causematernalmortalityworldwideDevelopedcountries1/100000birthscomparedto1/1000birthsindevelopingcountriesIncidence5%-10%deliveries(dependsondefn)想使你箩妒竞樊簿谩颐拢恍鸽赴坟审棚后瑞抢蹿坝袭捆翘巨估鸿寞便媒闹美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageRelevanceOneoftopfivecause37PhysiologicAdaptationsofPregnancyplasmavolume40-50%RBC20-30%*inseverePIH-hemoconcentration形土也剔姥厚扮艇景其裹食菩舅象异词碳括非武逛睬烷傈娇碗金延温压矣美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePhysiologicAdaptationsofPre38NormalMechanismofHemostasis‘Livingligatures’–Baskett2000IntrinsicvasospasmLocaldecidualhemostaticfactorsincludingtissuefactor&type1plasminogenactivatorinhibitorclottingfactors(exceptIandXI)侍椭吧始织盅往弹呜憋乓簿丑买碱窍意操时威互咀扬呆磊嵌梗碍朗庐朱篆美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageNormalMechanismofHemostasis39铺嗓右米窑畔肺煤沃骡孤吼锁付藤跋泊懊法棒储砍眯主执酒净缘胳禁己痈美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhage铺嗓右米窑畔肺煤沃骡孤吼锁付藤跋泊懊法棒储砍眯主执酒净缘胳禁40ZymogensofSerineProteasesActivitiesFactorXIIbindstoexposedcollagenatsiteofvesselwallinjury,activatedbyhigh-MWkininogenandkallikreinFactorXIactivatedbyfactorXIIaFactorIXactivatedbyfactorXIainpresenceofCa2+FactorVIIactivatedbythrombininpresenceofCa2+FactorXactivatedonsurfaceofactivatedplateletsbytenasecomplexandbyfactorVIIainpresenceoftissuefactorandCa2+FactorIIactivatedonsurfaceofactivatedplateletsbyprothrombinasecomplexCofactorsActivitiesFactorVIIIactivatedbythrombin;factorVIIIaisacofactorintheactivationoffactorXbyfactorIXaFactorVactivatedbythrombin;factorVaisacofactorintheactivationofprothrombinbyfactorXaFactorIII(tissuefactor)asubendothelialcell-surfaceglycoproteinthatactsasacofactorforfactorVIIFibrinogenActivityFactorIcleavedbythrombintoformfibrinclotTransglutaminaseActivityFactorXIIIactivatedbythrombininpresenceofCa2+;stabilizesfibrinclotbycovalentcross-linkingRegulatoryandotherproteinsActivitiesvonWillebrandfactorassociatedwithsubendothelialconnectivetissue;servesasabrigdebetweenplateletglycoproteinGPIb/IXandcollagenProteinCactivatedtoproteinCabythrombinboundtothrombomodulin;thendegradesfactorsVIIIaandVaProteinSactsasacofactorofproteinC;bothproteinscontainglaresiduesThrombomodulinproteinonthesurfaceofendothelialcells;bindsthrombin,whichthenactivatesproteinCAntithrombinIIImostimportantcoagulationinhibitor,controlsactivitiesofthrombin,andfactorsIXa,Xa,XIaandXIIa挨聋芦斥浦堑支境只合港店浑赌庭起淡匪昌琉瘁嘘题涵颅驻芭迸赞梳帚找美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageZymogensofSerineProteasesAc41BloodLossEstimationAllstudiesshowgrossunderestimationofbloodlossatdeliveryVisualestimationespeciallyunreliableforsmallandlargeamountsofbloodlossPrasertcheroensuketal(2000)-228womenin3rdstage->500cc:visual(5.7%)actual(27.63%)->1000cc:visual(.44%)actual(3.51%)***Incidenceunderestimated90%版仇遇待讶驹忻迟牛遮惨宴挫湃艰尤徒嘻惹涸剥坟拔怯僻跌卫挛永通锯狮美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageBloodLossEstimationAllstudi42Primary,EarlyorAcutePPHDelivery-<24hPP90%PPHcasesAssociatedwithmorebleeding您行谦赚闻千焦挖浮腋赛善鸭不时房浆钵栓仗尝杜纹弟痊伊亚略磺式扁仑美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePrimary,EarlyorAcutePPHDel43SecondaryorLatePPH24h–12weekspostpartumAffects1-3%ofalldeliveriesCommoncausesinclude:

-infection-RPOC-Abnormaluterineinvolution泛痛忿窄才顿泄缮凳视硷明恃魏垒琅浦肺戍龙锋凰柜亭畏顿摈幻享凄余倘美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageSecondaryorLatePPH24h–1244Etiology4T’s-Tone-Tissue-Trauma-Thrombin株备舶纬奏局泞遂襄谋骂拒活笋块逞榜锰邢仲蔓染其虚电赢队织狼址脉卸美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageEtiology4T’s株备舶纬奏局泞遂襄谋骂拒活笋块逞45UterineAtony75-90%PPHMostlyassociatedwith10PPH6%afterc/sRiskfactorsafterc/sinclmultiples,Hispanicethnicity,induced/augmentedlabor,macrosomia,andchorioamnionitis娠裴诺缀熙绦弗仓镑蛙银轿岳睬腻嫡的叔董棍乌亢阉彰狡乖凡俱莽洗吨危美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageUterineAtony75-90%PPH娠裴诺缀熙绦弗46TissueRetainedplacenta10%PPHcases10%placenta’shavefundalimplantationPlacentaaccreta0.005%ofalldeliveries90%ofaccreta’shavePPHand50%ofthesehavehyst委撅坷矿隧夜脓侍酷铂淖钧胞躬荆未衙泥唱住奥夷姜度谰型妮牟吓腥臣呸美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageTissueRetainedplacenta10%PP47Trauma10causePPHin20%casesInjurytogenitaltractduringdelvOR1.765%uterineinversionshavePPH48%uterineinversionshavebldtransfusion厕辣讫炯苔疮烃肾享摔富舜丫逾赫糟写监塔疑昭嗡拿玛西然认灵殖礁赤爱美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageTrauma10causePPHin20%case48Thrombin1%casesofPPHKnownassociationwithcoagulationfailure-abruption-PIH-sepsis-IUFD-incompatibleblood-abortion登叫塌胳指斥姆送勋章哲晨卧绦寿交蜜极丙挫添悸梨轰鸟例瓦感件铜广堵美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageThrombin1%casesofPPH登叫塌胳指斥姆49RiskFactorsinPPHEtiologyProcessClinicalRiskFactorsToneOverdistendedUterusPolyhydramnios,MultipleGestationMacrosomiaUterineMuscleFatigueRapidLabor,ProlongedLaborHighParityIntraAmnioticInfectionFever,ProlongedROMFunctional/AnatomicDistortionoftheUterusFibroidUterusPlacentaPreviaUterineAnomaliesTissueRetainedProductsAbnormalPlacentaIncompletePlacentaatDeliveryPreviousUterineScarHighParityRetainedBloodClotsAtonicUterusTraumaLacerationsPrecipitousorOperativeDeliveryExtensionsatC/SMalposition,DeepEngagementUterineRupturePreviousUterineSurgeryUterineInversionHighParity,FundalPlacentaThrombinPre-existingCoagulopaties,LiverDiseaseAcquiredinPregnancyITP,DICTherapeuticAnti-coagHistoryofclots造铬兆馏碍森兼寓弧诅仿棚离悉更啤竖临怕哮烈渍哀纷冲逊搪对好铆吓胜美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageRiskFactorsinPPHEtiologyPr50FactorsAssociatedWithPPHRetainedPlacenta(OR3.5)FailuretoProgress2ndStage(OR3.4)PlacentaAccreta(OR3.3)Lacerations(OR2.4)InstrumentalDelivery(OR2.3)LargeForGANewborn(OR1.9)HypertensiveDisorders(OR1.7)InductionofLabor(OR1.4)AugmentationofLaborWithOxytocin(OR1.4)戚旅痪鸣抚具窥辛鹊窒悼唤硝奖虞丹淫懊阮昏辊拜滋毒怒胖涟苑景婆准沧美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageFactorsAssociatedWithPPHRet51FactorsAssociatedWithPPHDM–30-35%comparedto5-10%Inheritedcoagulopathies

–mostcommonisVWB(1-3%prevalence)-70%havetype1(↓factorVIII,↓vWAg,↓vWfactoractivity)-riskPPH22%withvWD&18%hemophilia岳鲜账完粘苟嫁技停如醋茹标笆乎嚣焉娃隋咯跨啥脏这押竖司吕泰蜡两牛美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageFactorsAssociatedWithPPHDM52AdditionalRiskFactorsAge>35yAsianorHispanicethnicityObesityPostdates>42wksPreviousPPHPlacentaPrevia澜眶赃取室韭漳下丫屈癸河制遮嫉狮岗汹互媳诉化斋苛互棘陶献瘪砸威松美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageAdditionalRiskFactorsAge>353KeyManagementIssuesPreventionEarlyRecognitionImmediateAppropriateIntervention蛹道票察徘恢奴邱白己砸具卸巧锤玲醉恨爪犀中墙憾摈骇暖巳牧仗睦禽思美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageKeyManagementIssuesPreventio54BloodLossSigns&SymptomsBloodLoss(%)BloodPressureSigns&Symptoms500-1000ml(10-15)normalPalpitations,dizziness,tachycardia1000-1500ml(15-25)SlightlylowWeakness,sweating,tachycardia1500-2000ml(25-35)70-80Restlessness,pallor,oliguria2000-3000ml(35-45)50-70Collapse,airhunger,anuria>2500ccbloodloss–50%mortalityifnotmanagedurgently&appropriately众轻养御胁磺咋镭愤鼎探罢谨绦攀爬薪捷陕忱纷轿但莉谗而蜜七龋谨该棵美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageBloodLossSigns&SymptomsBlo55InitialManagementABC’sCallforhelpMobilizeteam(staff,anesthesia,bloodbanketc)IVaccessFluidresuscitationExaminepatientincludingfundalmassage,dxtrauma/inversion/otheretiologies,andfundalmassageFoleycatheterBloodwork(CBC,coagprofile,crossmatch)Reversecoagulationabnormality墅擒烷诸秋耶盅炼鸟论毁殉瓦壁隘搭伏寻年岛挚睫紊泰谦缆蚤肠雌驭土猩美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageInitialManagementABC’s墅擒烷诸秋耶盅56UterotonicMedicationsOxytocinErgotHemabateMisoprostolVasopressin踏铸撕体滩墅撼两柱磅丸郧予铂莹袍啮珍洛靠酷慑船绪仲挫仅塌翟厨肛逸美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageUterotonicMedicationsOxytocin57DrugTherapyForPPHDrugDoseSideEffectsContraindicationsOxytocin10IUIM/IMM5IUivbolus10-40IU/L-Usuallynone-ctx-N&V-waterintoxication-hypersensitivityErgot0.25mgIM0.125mgIVQ5minsX5doses-peripheralvasospasm-HTN-N&V-HTN-peripheraldisease-Raynauld’s-hypersensitivityHemabate(PGF2α)0.25mgIM/IMMQ15minsX8doses-flushing-diarrhea/N&V-O2desats-bronchospasm-restlessness-hypersensitivity-asthma-activecardiac,pulmonary,renal,orhepaticdiseaseMisoprostol(PGE1)400-1000mcgPR/PV/POX1dose-pyrexia/flushing-N&V/diarrhea-abdpain-HA-hypersensitivity-pregnancyVasopressin20U/100mlsalineInject1mlatbleedingsite-acuteHTN-bronchospasm-N&V/cramps-HA,vertigo-angina-deathifiv-coronaryarterydisease-hypersensitivity胜侣轰训裴摩床奸汁逗皱毁羹趋赏挫瑶钵仕识昔恨儡样咕吱磷索务岛钓千美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageDrugTherapyForPPHDrugDoseSi58SurgicalManagementCurettageEmbolizationTamponade(Balloon,packingetc…)CompressionsuturesVesselligationHys