产后出血2010(北医三院八年制临床医学课件)

“ObstetricsisBloodyBusiness”*PostpartumHemorrhage:*Cunningham,et.al:WilliamsObstetrics,21sted.,2001PPHistheleadingcauseofdeathrelatedtopregnancyworldwide…1“ObstetricsisBloodyBusinessMajorcausesofdeathforpregnancywomen

（maternalmortality)

Postpartumhemorrhage（28%)heartdiseasespregnancy-inducedhypertension(orAmnioticfluidembolism)infection2MajorcausesofdeathforpregDefinitionofPPHTheearlyPPHisdefinedasabloodlossexceeding500mlafterdeliveryoftheinfant<24hThelatePPH:occursafter24hourofdeliveryto6weeks3DefinitionofPPHTheearlyPPHMajorcausesUterineatony(90%)Lacerationsofthegenitaltract(6%)Retainedplacenta(3%-4%)Coagulationdefects(blooddyscrasia)

(4T:tone,tissue,trauma,thrombin)Etiology/prediction/prevention/management4MajorcausesUterineatony(901.UterineatonyLocalfactors:OverdistentionoftheuterineConditionthatinterferewithcontraction(leiomyoma)Complications(PIH,anemia,placentaprevia)Systemicfactors:NervousDrugsAbnormallaborHistoryofpreviousPPHPreeclampsia,abnormalplacentationEtiology/prediction/prevention/management51.UterineatonyLocalfactors:PathologyContractionconstrictingthespiralarteriesPreventingtheexcessivebleedingfromtheplacentaimplantationsiteUterineatonygiverisetoPPHwhennocontractionoccurEtiology/prediction/prevention/management6PathologyContractionconstrictMaincomplainHaveheartpalpitationsFeelfaintLightheadedBreathless…Etiology/prediction/prevention/management7MaincomplainHaveheartpalpit2.LacerationsofthegenitaltractCauses:Instrumenteddelivery(forceps)manipulativedelivery(breechextraction,precipitouslabor,macrosomia)Types:perineumlacerationvaginallacerationcervicallacerationEtiology/prediction/prevention/management82.Lacerationsofthegenital3.RetainedplacentaSeparationandexplosionofplacentaiscausedbystronguterinecontractionPlacentatissueremainingintheuteruspreventadequatecontractionandpredisposetoexcessivebleedingEtiology/prediction/prevention/management93.RetainedplacentaSeparation4.CoagulationdefectsAcquiredabnormalityinbloodclotting:abruptionplacenta,amnioticfluidembolismseverepreeclampsiaCongenitalabnormalityinbloodclotting:thrombocytopeniaseverehepaticdiseasesleukemiaEtiology/prediction/prevention/management104.CoagulationdefectsAcquireddisseminatedintravascularcoagulopathy(DIC)ifbleedingpersistsinspiteofallothertreatmentdescribed,DICshouldbesuspectedthebloodpassingfromthegenitaltractisnotclottingshock:reductionofeffectivecirculationinadequateperfusionofalltissuesoxygendepletiondepressionoffunctions11disseminatedintravascularcoaD.D.withPPHColor,order,amountRiskreasonsClot“Bloody”Etiology/prediction/prevention/management12D.D.withPPHColor,order,amoConsequencesofPPHHypovolemicshockBloodtransfusionanditsattendantcomplicationsSurgicalinjury,fever,renalandhepaticfailureAcuterespiratorydistresssyndromeDisseminatedintravascularcoagulopathyLossoffertility,andSheehan'ssyndrome13ConsequencesofPPHHypovolemicCASE36ysPrimiparity,acceptedC-sectionbecauseofmarginalplacentaandfibroidsAfterbirth,PPHhappenedimmediatelycausedbyuterineatony,Oxytocinwasusedwhilestitching,buthemorrhagewascontinue…14CASE36ysPrimiparity,acceptedRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

15RiskfactorsforPPHAdvancedmRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

16RiskfactorsforPPHAdvancedmPreventionandtreatmentTheplacentashouldbeexaminedcarefullymanualremovalofplacentahysterectomyisrequiredforplacentauterinecontractiondrugsEtiology/prediction/prevention/management17PreventionandtreatmentTheplPreventionuterineatonyAdministrationofmedicine:promotescontractionoftheuterinecorpusdecreasesthelikelihoodofuterineatonyOxytocinagentsProstaglandinEtiology/prediction/prevention/management18PreventionuterineatonyAdminimanagementVaginalexaminationsoonafterdelivery

repair:cervicallaceration>2cminlengthandbeactivelybleedinglacerationofvaginalandperineumEtiology/prediction/prevention/management19managementVaginalexaminationRecord:Pulse—shockindexbloodpressurematernalheartratecentralvenouspressureurineoutputEtiology/prediction/prevention/management20Record:Etiology/prediction/preLabtests:Hb,BT(bleedingtime),CT(clottingtime),plateletscountfibrinogenprothrombintimeandpatialthromboplastintimeFDPwomen’sbloodgroupandcross-matchingEtiology/prediction/prevention/management21Labtests:Etiology/prediction/Treatment:thekeyiscorrectingthecoagulationdefectresuscitationmustbestartedassoonaspossibleinfusionofcrystalloid(saline)andDextranisstartedfirstlywhilearrangingthebloodtransfusionbloodtransfusionisessentialinfusionofredcells,platelets,freshfrozenplasma,FDP,clottingfactors,Etiology/prediction/prevention/management22Treatment:Etiology/prediction/Perineumvaginalandcervicallaceration

onlyskinandaminorpartoftheperinealbodyperinealbodyandvaginaanalsphincterandanalcanalEtiology/prediction/prevention/management23PerineumvaginalandcervicalStimulationofuterinecontractionMassage

ofuterusthroughtheabdomenandbimanualcompressionintrauterinepackingEtiology/prediction/prevention/management24StimulationofuterinecontracSurgicaltherapycausinguterinecontractionorcompressiontamponadetheuterinecavitydecreasebloodsupplytotheuterusremovetheuterus.Etiology/prediction/prevention/management25SurgicaltherapycausinguterinSurgicalmethodsIfmassageandagentsareunsuccessful:LigationorembolizationoftheuterinearteriesHysterectomy

Etiology/prediction/prevention/management26SurgicalmethodsIfmassageandadherenceofplacenta(accretaincretapericreta)Etiology/prediction/prevention/management27adherenceofplacenta(accretaPotentialcomplicationsofPPHPostpartuminfectionAnemiaTransfusionhepatitis,Sheehan’ssyndromeAsherman’ssyndromeThebestmanagementofPPHisprevention

Etiology/prediction/prevention/management28PotentialcomplicationsofPPHResuscitationforPPH

callanassistantresuscitatethepatientvigorouslyWhatisthestateofherperipheralcirculation?Howmuchbloodhasshelost?Isitclottingnormallyinthereceiverusedtocollectit?Whathasbeendonesofar?Monitorthevolumeofbloodshecontinuestoloseherperipheries,pulseandbloodpressure,andherurineoutput.29ResuscitationforPPH

callanSummary:remember4Ts“TONE”RuleoutUterineAtonyPalpatefundus.Massageuterus.Oxytocin20U/500cc.ProstaglandinHemabateIMq15min30Summary:remember4Ts“TONE”PaSummary:remember4Ts“Tissue”R/OretainedplacentaInspectplacentaformissingcotyledons.Exploreuterus.Treatabnormalimplantation.31Summary:remember4Ts“Tissue”Summary:remember4Ts“TRAUMA”R/ocervicalorvaginallacerations.Obtaingoodexposure.Inspectcervixandvagina.Worryaboutslowbleeders.Treathematomas.32Summary:remember4Ts“TRAUMA”Summary:remember4Ts“THROMBIN”Checklabsifsuspicious.33Summary:remember4Ts“THROMBICase-237ys,multiparity,wasadmittedinher40+2wksforirregularcontractionwithoutanyabnormalsign.Twohrslater,thecontractionbecamestrongerandmembranesrupturedwhenhwithmeconium-stainedamnioticfluidI

degree.7:33cyanochroiahappenedwithbreathlessandlossofconsciousnessinasecond.34Case-237ys,multiparity,wasWhatisthediagnosis8:20pmstill-birthweight3.2kg.PPHemergedassoonasplacentadeliveredwithoutanyclot.Thepatientwasinthestateofunconsciousnessandbecamepale…35Whatisthediagnosis8:20pmstHysterectomyHysterectomywasdonesoonafterresuscitation.Theamountwasabout4000ml.Redcellwastransfused1600ml,freshplasma400ml,platelet20u,cryoprecipitate10u.TransfusionwascontinuedafterOP1800ml.36HysterectomyHysterectomywasd，Hb38g/L,APTT43.4秒，PT45.0(正常11-14sec),PT比例3.52(正常0.85-1.15)，Fbg0.976g(正常2-4g/L),APTT不凝，TT44.Tsec(正常14-21sec)。FDP（+），D-2聚集体（+），3P试验（+）。尿常规Pro2+,比重1.000,RBC10-15/HP,可见颗粒管型。37，Hb38g/L,APTT43.4秒，PT45.0(正常1术后41小时拔除气管插管，并停用多巴胺，生命体征平稳。术后40小时发现左上肢皮肤感觉减退，运动受限。头部MRI：左侧小脑半球、双侧枕、顶叶及右侧丘脑多发脑梗塞，胸部CT：两肺纹理明显增多，两下肺见散在斑点状致密影，心影增大，两则胸腔积液，两侧胸腔积液。术后18天复查血、尿常规、凝血功能除Hb102g/L外，均正常。胸部CT：正常。头部MRI：梗塞灶明显缩小。左上肢皮肤感觉功能恢复，但肌力仍低下。术后5个月恢复正常。38术后41小时拔除气管插管，并停用多巴胺，生命体征平稳。术后4UterinepathologyCervicalbloodcampexpansion,congestionandthesmallfocal-likebleedinginthesmallvesselsseenintheamnioticfluidcomposition.Subclavianveinbloodsmearinspection,microscopicexaminationshowslikematerialandalittlemeconiumkeratosis-likematerial.39UterinepathologyCervicalb术后15天复查头部MRT表现右顶叶及丘脑病灶范围缩小。原双侧枕叶，左顶叶及左小脑半球病灶已吸收消散，胸部CT提示原病灶及胸腔积液均已消失。40术后15天复查头部MRT表现右顶叶及丘脑病灶范围缩小。原双侧AmnioticfluidembolismClinicalcharacter

HeartandlungfailureBleedinginducedbyDICAcuterenalfailureDiagnosis“amnioticfluidcomposition”incirculationortissue41AmnioticfluidembolismClinicaKeywordsUterineatonythedefinitionofPPHAmnioticfluidembolismPROM42Keywords42QuestionsafterclassWhenyoumeetapatientwithPPH,whatyoucandoasanintern?HowcanyoufindthetruereasonsforPPHinthelaborroom?43QuestionsafterclassWhenyou

谢谢44

“ObstetricsisBloodyBusiness”*PostpartumHemorrhage:*Cunningham,et.al:WilliamsObstetrics,21sted.,2001PPHistheleadingcauseofdeathrelatedtopregnancyworldwide…45“ObstetricsisBloodyBusinessMajorcausesofdeathforpregnancywomen

（maternalmortality)

Postpartumhemorrhage（28%)heartdiseasespregnancy-inducedhypertension(orAmnioticfluidembolism)infection46MajorcausesofdeathforpregDefinitionofPPHTheearlyPPHisdefinedasabloodlossexceeding500mlafterdeliveryoftheinfant<24hThelatePPH:occursafter24hourofdeliveryto6weeks47DefinitionofPPHTheearlyPPHMajorcausesUterineatony(90%)Lacerationsofthegenitaltract(6%)Retainedplacenta(3%-4%)Coagulationdefects(blooddyscrasia)

(4T:tone,tissue,trauma,thrombin)Etiology/prediction/prevention/management48MajorcausesUterineatony(901.UterineatonyLocalfactors:OverdistentionoftheuterineConditionthatinterferewithcontraction(leiomyoma)Complications(PIH,anemia,placentaprevia)Systemicfactors:NervousDrugsAbnormallaborHistoryofpreviousPPHPreeclampsia,abnormalplacentationEtiology/prediction/prevention/management491.UterineatonyLocalfactors:PathologyContractionconstrictingthespiralarteriesPreventingtheexcessivebleedingfromtheplacentaimplantationsiteUterineatonygiverisetoPPHwhennocontractionoccurEtiology/prediction/prevention/management50PathologyContractionconstrictMaincomplainHaveheartpalpitationsFeelfaintLightheadedBreathless…Etiology/prediction/prevention/management51MaincomplainHaveheartpalpit2.LacerationsofthegenitaltractCauses:Instrumenteddelivery(forceps)manipulativedelivery(breechextraction,precipitouslabor,macrosomia)Types:perineumlacerationvaginallacerationcervicallacerationEtiology/prediction/prevention/management522.Lacerationsofthegenital3.RetainedplacentaSeparationandexplosionofplacentaiscausedbystronguterinecontractionPlacentatissueremainingintheuteruspreventadequatecontractionandpredisposetoexcessivebleedingEtiology/prediction/prevention/management533.RetainedplacentaSeparation4.CoagulationdefectsAcquiredabnormalityinbloodclotting:abruptionplacenta,amnioticfluidembolismseverepreeclampsiaCongenitalabnormalityinbloodclotting:thrombocytopeniaseverehepaticdiseasesleukemiaEtiology/prediction/prevention/management544.CoagulationdefectsAcquireddisseminatedintravascularcoagulopathy(DIC)ifbleedingpersistsinspiteofallothertreatmentdescribed,DICshouldbesuspectedthebloodpassingfromthegenitaltractisnotclottingshock:reductionofeffectivecirculationinadequateperfusionofalltissuesoxygendepletiondepressionoffunctions55disseminatedintravascularcoaD.D.withPPHColor,order,amountRiskreasonsClot“Bloody”Etiology/prediction/prevention/management56D.D.withPPHColor,order,amoConsequencesofPPHHypovolemicshockBloodtransfusionanditsattendantcomplicationsSurgicalinjury,fever,renalandhepaticfailureAcuterespiratorydistresssyndromeDisseminatedintravascularcoagulopathyLossoffertility,andSheehan'ssyndrome57ConsequencesofPPHHypovolemicCASE36ysPrimiparity,acceptedC-sectionbecauseofmarginalplacentaandfibroidsAfterbirth,PPHhappenedimmediatelycausedbyuterineatony,Oxytocinwasusedwhilestitching,buthemorrhagewascontinue…58CASE36ysPrimiparity,acceptedRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

59RiskfactorsforPPHAdvancedmRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

60RiskfactorsforPPHAdvancedmPreventionandtreatmentTheplacentashouldbeexaminedcarefullymanualremovalofplacentahysterectomyisrequiredforplacentauterinecontractiondrugsEtiology/prediction/prevention/management61PreventionandtreatmentTheplPreventionuterineatonyAdministrationofmedicine:promotescontractionoftheuterinecorpusdecreasesthelikelihoodofuterineatonyOxytocinagentsProstaglandinEtiology/prediction/prevention/management62PreventionuterineatonyAdminimanagementVaginalexaminationsoonafterdelivery

repair:cervicallaceration>2cminlengthandbeactivelybleedinglacerationofvaginalandperineumEtiology/prediction/prevention/management63managementVaginalexaminationRecord:Pulse—shockindexbloodpressurematernalheartratecentralvenouspressureurineoutputEtiology/prediction/prevention/management64Record:Etiology/prediction/preLabtests:Hb,BT(bleedingtime),CT(clottingtime),plateletscountfibrinogenprothrombintimeandpatialthromboplastintimeFDPwomen’sbloodgroupandcross-matchingEtiology/prediction/prevention/management65Labtests:Etiology/prediction/Treatment:thekeyiscorrectingthecoagulationdefectresuscitationmustbestartedassoonaspossibleinfusionofcrystalloid(saline)andDextranisstartedfirstlywhilearrangingthebloodtransfusionbloodtransfusionisessentialinfusionofredcells,platelets,freshfrozenplasma,FDP,clottingfactors,Etiology/prediction/prevention/management66Treatment:Etiology/prediction/Perineumvaginalandcervicallaceration

onlyskinandaminorpartoftheperinealbodyperinealbodyandvaginaanalsphincterandanalcanalEtiology/prediction/prevention/management67PerineumvaginalandcervicalStimulationofuterinecontractionMassage

ofuterusthroughtheabdomenandbimanualcompressionintrauterinepackingEtiology/prediction/prevention/management68StimulationofuterinecontracSurgicaltherapycausinguterinecontractionorcompressiontamponadetheuterinecavitydecreasebloodsupplytotheuterusremovetheuterus.Etiology/prediction/prevention/management69SurgicaltherapycausinguterinSurgicalmethodsIfmassageandagentsareunsuccessful:LigationorembolizationoftheuterinearteriesHysterectomy

Etiology/prediction/prevention/management70SurgicalmethodsIfmassageandadherenceofplacenta(accretaincretapericreta)Etiology/prediction/prevention/management71adherenceofplacenta(accretaPotentialcomplicationsofPPHPostpartuminfectionAnemiaTransfusionhepatitis,Sheehan’ssyndromeAsherman’ssyndromeThebestmanagementofPPHisprevention

Etiology/prediction/prevention/management72PotentialcomplicationsofPPHResuscitationforPPH

callanassistantresuscitatethepatientvigorouslyWhatisthestateofherperipheralcirculation?Howmuchbloodhasshelost?Isitclottingnormallyinthereceiverusedtocollectit?Whathasbeendonesofar?Monitorthevolumeofbloodshecontinuestoloseherperipheries,pulseandbloodpressure,andherurineoutput.73ResuscitationforPPH

callanSummary:remember4Ts“TONE”RuleoutUterineAtonyPalpatefundus.Massageuterus.Oxytocin20U/500cc.ProstaglandinHemabateIMq15min74Summary:remember4Ts“TONE”PaSummary:remember4Ts“Tissue”R/OretainedplacentaInspectplacentaformissingcotyledons.Exploreuterus.Treatabnormalimplantation.75Summary:remember4Ts“Tissue”Summary:remember4Ts“TRAUMA”R/ocervicalorvaginallacerations.Obtaingoodexposure.Inspectcervixandvagina.Worryaboutslowbleeders.Treathematomas.76Summary:remember4Ts“TRAUMA”Summary:remember4Ts“THROMBIN”Checklabsifsuspicious.77Summary:remember4Ts“THROMBICase-237ys,multiparity,wasadmittedinher40+2wksforirregularcontractionwithoutanyabnormalsign.Twohrslater,thecontractionbecamestrongerandmembranesrupturedwhenhwithmeconium-stainedamnioticfluidI

degree.7:33cyanochroiahappened