（培训课件）产科-产后出血PPT幻灯片.pptx

1、,Postpartum Hemorrhage,1,In 1990, a technical working group of the World Health Organization (WHO) defined PPH as blood loss of 500 ml or more from the genital tract after vaginal delivery.,Primary PPH is loss of blood estimated to be 500 ml, from the genital tract, within 24 hours of delivery (the

2、most common obstetric hemorrhage)1:,Minor PPH is estimated blood loss of up to 1000 mls. Major PPH is any estimated blood loss over 1000 mls.,Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until six weeks postpartum.,1.Prevention and management of

3、postpartum haemorrhage; Royal College of Obstetricians and Gynaecologists (May 2009 with revisions April 2011),2,Tone,Tissue,Trauma,Thrombin,Abnormality Of Uterine Contraction UTERINE ATONY,Retained Products Of Conception,Of Genital Tract,Abnormality Of Coagulation,The “Four Ts” of Causes of Postpar

4、tum Hemorrhage,3,The “Four Ts” Mnemonic Device Causes of Postpartum Hemorrhage,JANICE M. ANDERSON, M.D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician 2007;75:875-82.,4,Antenatal risk factors:,Antepartum haemorrhage in this pregnancy. Placenta praevia (Risk ). Suspected or prov

5、en placental abruption. Multiple pregnancy (Risk ). Also other causes of uterine over-distention such as polyhydramnios or macrosomia. Pre-eclampsia or pregnancy-induced hypertension (Risk ). Grand multiparity (four or more pregnancies). Previous PPH (Risk ) or previous history of retained placenta.

6、 Asian ethnic origin (Risk ). Maternal obesity. Body mass index 35 kg/m2 (Risk ). Existing uterine abnormalities. Maternal age (40 years or older). Maternal anaemia. Hb 9g/dL (Risk).,5,Factors relating to delivery:,Emergency caesarean section (Risk ). Elective caesarean section (Risk ) - especially

7、if 3 repeat procedures. Retained placenta (Risk ). Mediolateral episiotomy (Risk ). Induction of labour (Risk ). Operative vaginal delivery (Risk ). Labour of 12 hours (Risk ). 4 kg baby (Risk ). Maternal pyrexia in labour (Risk ).,6,Pre-existing maternal hemorrhagic conditions:,Factor 8 deficiency

8、- haemophilia A carrier. Factor 9 deficiency - haemophilia B carrier. Von Willebrands Disease.,Note:Von Willebrand disease (VWD) is a genetic disorder caused by missing or defective von Willebrand factor (VWF), a clotting protein. VWF binds factor VIII, a key clotting protein, and platelets in blood

9、 vessel walls, which help form a platelet plug during the clotting process. The condition is named after Finnish physician Erik von Willebrand, a who first described it in the 1920s.,7,The usual presentation of PPH is one of heavy vaginal bleeding that can quickly lead to signs and symptoms of hypov

10、olemic shock.,American College of Obstetricians and Gynecologists. ACOG educational bulletin. Hemorrhagic shock. Number 235, April 1997 (replaces no. 82, December 1984). American College of Obstetricians and Gynecologists.Int J Gynaecol Obstet. 1997 May. 57(2):219-26.,8,Active management of the thir

11、d stage of labor Oxytocin (Pitocin) administered with or following delivery Controlled cord traction Uterine massage after delivery of placenta.,Blood loss 500 mL Postpartum hemorrhage,Brisk bleeding Blood pressure falling Pulse rising,Bimanual uterine massage Oxytocin 20 IU/L of normal saline Infus

12、e up to 500 mL over 10 minutes,Explore lower genital tract Consider exploring uterus,Inspect placenta,Observe clotting Consider CBC, type and cross, coagulation screen,9,Resuscitation 2 large-bore IV needles Oxygen by mask Monitor blood pressure, pulse, urine output Team approach*,The Four T s,Soft,

13、 “boggy” uterus TONE,Genital tract tear Inversion of uterus TRAUMA,Placenta retained TISSUE,Blood not clotting THROMBIN,Carboprost (Hemabate) 0.25 mg IM Misoprostol (Cytotec) 1,000 mcg rectally Methylergonovine (Methergine) 0.2 mg IM,Suture lacerations Drain hematomas 3 cm Replace inverted uterus,Ma

14、nual removal Curettage Methotrexate,Replace factors Fresh frozen plasma Recombinant factor VIIa Platelet transfusion,Blood loss 1,000 to 1,500 mL Massive hemorrhage,Transfuse RBCs, platelets, and clotting factors；Support blood pressure with vasopressors ICU for anesthesia, hematology, surgery；Uterin

15、e packing / tamponade procedure Vessel embolization, ligation, and compression sutures；Hysterectomy,10,3.1. COMMUNICATION,3.1.1. Alert all relevant professionals 3.1.2. For major PPH, activate. RED ALERT:,3.1.3. Communicate with patient and the partner with clear information of what happening,Call e

16、xperienced Midwife Call Specialist Alert Consultant Call Anaesthetist (specialist) Alert Consultant clinical Haemotologist on call Alert blood bank Call PPK for delivery of specimens / blood Record the events, fluid, drugs and vital sign,11,3.2. RESUSCITATION,3.2.1. The measurement for resuscitation

17、 depend on condition and degree of shock 3.2.2. Assess Airway and Breathing Give oxygen 10-15 L/min via face mask regardless the maternal O2 If airway is compromised due to impaired conscious level, need to intubate with anaesthetic assistance,12,3.2. RESUSCITATION,3.2.3. Evaluate Circulation 2 larg

18、e-bore branula (14-16 gauge) (Take blood for FBC, coagulation profile, BUSE/Cr/LFT, Fibrinogen, GXM 4 units) Position flat, lateral tilt Keep patient warm Give crystalloid infusion (Hartmann) 3.2.4. In Major PPH, add Tranfuse blood asap,Until blood is available, total volume of 3.5 litres crystalloi

19、d infuse up to 2 L of warmed crystalloid Hartmann solution and/or colloid (1-2 L) as rapidly as required if blood still not available. May require DIVC regime,13,3.2. RESUSCITATION,3.2.5. Aim to restore the both blood volume and oxygen-carrying capacity 3.2.6. Volume replacement must be undertaken o

20、n the basis that blood loss is often grossly underestimated,3.2.7. The therapeutic goals of management of massive blood loss is to maintain 3.2.8. Role of recombinant factor VIIa therapy (rFVIIa) 3.2.9. Role of anti fibrinolytic drugs there is role of management of obstetric hemorrhage.,14,3.3. MONI

21、TORING Royal College of Obstetricians and Gynaecologists (May 2009 with revisions April 2011),18,. Pharmacology,Repeat IM Syntocinon or Syntometrine IV Pitocin 40 units in 500 ml Hartmanns solution, run at 125ml/hr IM Carboprost (Haemabate) 0.25mg, may repeated at interval not less than 15 mi

22、n to a maximum 8 doses (contraindicated in Asthma),Intramyometrial of Carboprost 0.25-0.5mg Misoprostol 1000 mcg rectally or cervagem per rectally,19,. Surgery,If fail pharmacological Depends on the clinical circumstances and available expertise First line is Balloon Tamponade Various types o

23、f hydrostatic balloon catheter Foley catheter, Bakri balloon, Sengstaken- Blakemore oesophageal catheter and a condom catheter,20,. Surgery,Prevention and management of postpartum haemorrhage; Royal College of Obstetricians and Gynaecologists (May 2009 with revisions April 2011),21,. S

24、urgery,No evidence of how long the balloon tamponade should be left in place Most cases, 4-6 hours of tamponade is adequate to achieve haemostasis Should be remove during daytime hours with presence of appropriate senior staff as further intervention may be necessary,The tamponade test A positive te

25、st A negative test,22,3.4.3. Case of RETAINED PLACENTA empty bladder, attempt CCT If fail, proceed with Manual Removal of Placenta (MRP) either under sedation or GA Take consent If under sedation, give IV Pethidine 25-50mg stat, IV Midazolam 2.5-5.0 mg stat Continous SPO2 monitoring, Litothomy posit

26、ion,23,IV Ampicillin 1g stat, IV Flagyl 500 mg stat Fully gown, mask, long-sleeve glove - Introduce one hand into vagina along the cord,JANICE M. ANDERSON, M.D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician 2007;75:875-82.,24,JANICE M. ANDERSON, M.D. Prevention and Management

27、of Postpartum Hemorrhage. Am Fam Physician 2007;75:875-82.,Other hand grasp the fundal of uterus and the hand just now move through the cervix to the intrauterine cavity Detaching the placenta by sideways slicing movement of the fingers,25,Once able to detach the placenta part from the intrauterine

28、wall, grasp the placenta and bring out in piece Then recheck again inside the uterus for any remnant part of placenta,26,1. Prevention and management of postpartum haemorrhage; Royal College of Obstetricians and Gynaecologists (May 2009 with revisions April 2011) 2. FIGO Guidelines: Prevention and treatment of p