妇产科课件产后出血2015八年制

PostpartumHemorrhage

PPHZhuJieping朱洁萍ShanghaiJiaotongUniversityAffiliatedSixthPeople'sHospitalDeptofObs&Gyn

Maternalmortality2014年上海市总分娩量24万孕产妇死亡6.7/10万CausesofMaternalMortalityDefinitionofPPHAbloodlossof500ml(1000mlforCS)ormorewithin24hoursafterbirthDeliveryofplacenta2hoursafterdeliverySeverePPH:1000mlormoreLeadingcauseofmaternalmortality,affectsapproximately2%ofallmaternaldeathsPredisposingfactorsandcausesUterineatonyPlacentaabnormityTraumatothegenitaltractCoagulationdefects子宫肌纤维结构？胎盘附着面结构？孕期凝血功能变化？1.UterineAtony(宫缩乏力)ObstetricfactorProlongedlabor滞产Precipitatedelivery急产Pregnantcomplicationsplacentapreviaplacentalabruptionchorioamnionitis(绒毛膜羊膜炎)Oxytocin-inducedlabor引产orAugmentedlabor催产?正常产程SystemicfactorPsychologicalfactorsTocolyticagent宫缩抑制剂Conductionanalgesia(镇痛分娩)UterusfactorOverdistendeduterus:macrosomia巨大儿,twins,hydramniosUterusmyoma,historyofCS,myomectomyHighparityIncidenceIncidence

ofPPHPPHofUterineAtony2014年本市危重孕产妇中PPH占34%（>2000ml）2.PlacentalfactorsRetainedplacentaltissuePlacenta(3rdstageoflabor?)Succentuiatelobe(副叶胎盘)Embryolemma(fetalmembrane)AbnormallyadherentAccreta,increta,percreta(粘连，植入，穿透)InducedabortionScarrduterusMultipara3.TraumatothegenitaltractLacerationofperineum,vagina,cervixUterineRuptureHaematomasCausesPrecipitatedelivery（急产）LargefetusShoulderdystocia(肩难产)pletehemostasisIimproper

protection

of

perineum4.CoagulationdefectsPregnantcomplicationsAmnioticfluidembolism(AFI,羊水栓塞)HypertensivedisordersPlacentalabruptionStillbirthHaematologicaldiseasesIdiopathicthrombocytopenic(特发性血小板减少性紫癜)Aplasticanemia(再生障碍性贫血)HepaticdiseasesClinicalmanifestationVaginalbleeding出血发生时间有无凝血块血肿？隐性出血SymptomsofshockSevereanemiaDiagnosisEstimatingbloodlossVisualestimationObjectivemeasurement称重法面积法10cm*10cm=10mlShockindex=HR/SBP0.5normal<500ml1.0bloodloss20~30%1000ml1.5bloodloss30~50%1500ml2.0bloodloss≥50%≥2500mlDiagnosisCauseanalysisUterineatony:asoft,boggyuterus

正常胎儿娩出后宫底位置？Riskfactors?Placentalfactors

正常胎盘娩出时间？如何检查？

PPHisadescription,notadiagnosis.DiagnosisCauseanalysisTraumaPerineallacerationVaginallaceration,hematomaCervicaltraumaCoagulationdisordersHistoryLabtestManagementOrganizationofthemultidisciplinaryteam组织抢救400ml、500~1500ml、>1500mlRestorationofbloodvolume补充血容量Correctionofdefectivecoagulationwithbloodproductsandfactors纠正凝血功能Evaluationofresponsetotreatmentbyhaemodynamicandlaboratoryassessment评估Remedyingoftheunderlyingcause治疗原发病ManagementEtiologicaltreatmentHomostasis(止血)Anti-shock:bloodtransfusionAntibioticprophylaxisUterineAtonyEmptyingofthebladderStimulatinguterinemuscletonebimanualcompression,uterinemassageUterotonicagentsOxytocinProstaglandinsTamponade填塞BakriballoontamponadeUterineAtonyUterinecompressionsutures：B-lynchAngiographicarterialembolization动脉栓塞ArterialligationHysterectomy子宫切除B-lynchPlacentalfactorsManualremovalCuretage:Ringcuret刮宫术Placentaincreta/percreta:hysterectomyTraumaLacerationsSurgicalrepair:upperangleHematomasSmall:expectantly,incisionandsutureEnlarged:promptincision,drainageCoagulationdefectsTransfusiontherapyRBCsPlateletsFresh-frozenplasmaCoagulationfactorsCryoprecipitate(冷沉淀物，凝血第Ⅷ因子)Precautions?Pregnancyhealth