产后出血-熊钰

JinyingYangObstetric&GynecologyDepartmentPostpartumHemorrhageDefinition:Bloodlossinexcessofvaginalbirth≥500mlcesareanbirth≥1000mlwithinthefirst24hoursofdeliverySeriousandcommonintrapartumcomplicationThemostsignificantcauseofmaternaldeathworldwidemortality（worldwide）:140000peryear(1maternaldeathevery4minutes)mortality（China）:8.0/100000,thefirstreason(27.1%)ofmaternaldeathIncidence:4–6%ofpregnanciesActualincidence:morehigherbecauseofinaccurate,significantunderreportingPrimaryPPHOccurringwithinthefirst24hoursofdelivery4–6%ofpregnanciesCausedbyuterineatonyin80%ormoreofcasesSecondaryPPHOccurringbetween24hoursand6–12weekspostpartum1%ofpregnancies4“T”Tone:uterineatonyTissue:retainedplacentaTrauma:vaginal,cervical,oruterineinjuryThrombin:coagulopathy(pre-existingoracquired)——SOGCguideline(number235,October2009):ActiveManagementoftheThirdStageofLabor:PreventionandTreatmentofPostpartumHemorrhage.ThemostcommonandimportantcauseofPPHTheprimaryprotectivemechanismforimmediatehemostasisafterdelivery:Myometrialcontractioncausingocclusionofuterinebloodvessels——livingligaturesoftheuterusBloodflowfromthevascularspacetotheuterinecavityviathemyometriumisimpededEtiologiccategoryandprocessHighriskfactorsOverdistensionofuterusPolyhydramnios,Multiplegestation,MacrosomiaUterinemuscleexhaustionRapidlabor,Prolongedlabor,Highparity,OxytocinuseIntra-amnioticinfectionFever,ProlongedruptureofmembranesFunctional/anatomicdistortionofuterusFibroids,Adenomyosis,Placentaprevia,UterineanomaliesUterine-relaxingmedicationsHalogenatedanesthetics,NitroglycerinBladderdistensionPlacentaabruption胎儿子宫内膜胎盘脐带宫颈出血PlacentapreviaTwinpregnancy胎儿胎儿胎盘宫颈脐带脐带阴道fibroid肌壁间肌瘤浆膜下肌瘤内膜下肌瘤带蒂浆膜下肌瘤带蒂内膜下肌瘤UterineanomaliesCaseApatientwaspregnancywithtwinsandhadplacentaprevia.At36w,shewakedupwithastarttofindherselflyinginpoolofblood.EmergenctCSwasdone.Inoperation,uterineatonyoccurredandwasn’tcorrectedbyutrotonicdrugs.Finallythebleedingwasceasedbyusinguterinetampon.Thenextday,thepatientbledagainwhentamponwasextracting.Soextractionwasstoppedandshewasundergoneembolism.Thetamponwasextractedtotally24hourslater,andthepatientnomorebled.EtiologiccategoryandprocessClinicalriskfactorsAvulsedlobule,SuccenturiatelobeIncompleteplacentaatdeliveryAbnormallyadhered:Accreta,Increta,PercretaPlacentapreviawithorwithoutpreviousuterinesurgery,Priormyomectomy,Priorcesareandelivery,Asherman’ssyndrome,Submucousleiomyomata,Maternalageolderthan35yearsSuccenturiatelobePlacentavilliattachPlacentavilliinvadePlacentavillipenetratetothemyometriumintothemyometriumthroughthemyometriumAccretaIncretaPercretaEtiologiccategoryandprocessClinicalriskfactorsLacerationsofthecervix,vaginal,orperineumPrecipitousdeliveryOperativedeliveryPuerperalHematomasNulliparity,episiotomy,andforcepsdeliveryLacerationofcervixIIIIIILacerationsofperineumSkinandmucosamuscleExternalanussphincterEtioiogiccategoryandprocessClinicalriskfactorsPre-existingstatesPrimarythrombocytopeniaAplasticanemiaAcquiredinpregnancyHELLPsyndromeAbruptionplacentaProlongedintrauterinefetaldemiseSepsisAmnioticfluidembolismSignificanthemorrhageElevatedbloodpressureAntepartumhemorrhageFetaldemiseFeverSuddencollapseVaginalbleedingBleedingwithcharacteristicsoft,poorlycontracted(“boggy”)uterusonbimanualpelvicexamination——uterineatonyBleedingwhiletheuterusisfirmlycontracted——retainedplacenta——genitaltractlacerationBleedingwithoutclot——coagulopathyPelvicorrectalpressureandpain——genitaltracthematomasHypovolemicshockIrritablepallorandclamminessofskintachycardianarrowpulsepressureWeightmethod：Bloodloss(ml)＝（dressingwetweightafterbirth－dressingdryweightbeforebirth）/1.05(specificgravityofblood)Volumemethod:CollectbloodusingacontainerAreamethod：10cm*10cmgausesoakblood=10mlbloodShockindex=heartrate/systolicpressure（mmHg）（normal0.5）shockindexestimatelossofblood（ml）lossofbloodvolume0.6~0.9500~75020%=1.01000~150020~30%=1.51500~250030~50%≥2.02500~3500≥50~70%TheinitialgoalIdentifyingandtreatingthecauseofbloodlossInstitutingresuscitativemeasurestomaintainhemodynamicstabilityandoxygenperfusionofthetissuesCallforhelpResuscitationAssessthe“ABC”MonitorBP,P,REmptybladder,monitorurineoutputIVlineCrystalloid,isotonicfluidreplacementOxygenbymaskLaboratorytestsCompletebloodcountCoagulationscreenBloodgroupingandcross——SOGC2009UterinemassageDiminishbleeding,expelbloodandclots,andallowtimeforothermeasurestobeimplementedUterotonicdrugsOngoingbloodlossinthesettingofdecreaseduterinetonerequirestheadministrationofadditionaluterotonicsasthefirst-linetreatmentforhemorrhageDrugDose/RouteFrequencyCommentOxytocinIV:10–40unitsin1liternormalsalineorlactatedRinger’ssolutionIM:10unitsContinuousAvoidundilutedrapidIVinfusion,whichcauseshypotensionCarbetocinIV/IM：100μgErgometrineIM:0.2mgEvery2–4hAvoidifpatientishypertensiveDrugDose/RouteFrequencyComment15-methylPGF2α(Hemabate)IM:0.25mgEvery15–90min,8dosesmaximumAvoidinasthmaticpatientsDiarrhea,fever,tachycardiacanoccurDinoprostone(PGE2)Suppository:vaginalorrectal20mgEvery2hAvoidifpa