妇产科学产后出血

产后出血PostpartumHemorrhagePPHZhangyeXuM.D.DepartmentofObstetricsandGynecology1stAffiliatedHospital,WenzhouMedicalCollege学习目标•掌握产后出血的重要原因•熟悉产后出血临床表现及初步处理方法•了解产后出血预防简介•最普遍的严重的产科并发症–产妇死亡的主要原因–急性血液丢失–经常不可预测–灾难性的–出血的评估比较主观定义•问题–PPH诊断的问题性–出血评估的主观性和不精确性•传统–阴道出血500ml•早期出血：产后24hr内•晚期出血：产后24hr后（感染、胎盘）产后出血止血原理止血1.断裂血管壁肌层环形收缩2.凝血系统3.最有效的止血方法：子宫收缩PPH:通常在胎盘剥离后发生胎盘剥离时，胎盘附着处的母体血管的终末端发生断裂，直接向子宫腔开放，正常分娩时出血量约为200-400ml出血病因The4T’sofPPHCAUSEINCIDENCE(APPROX)TONE子宫收缩乏力Atony70%TRAUMA软产道裂伤Laceration,hematoma,inversion,rupture20%TISSUE胎盘因素Retainedplacenta,invasiveplacenta10%THROMBIN凝血功能Coagulopathies1%AmFamPhysician2007;75:875.病因Planned•Cesareansection剖宫产•Episiotomy外阴侧切Unplanned•Vaginal/cervicaltear阴道宫颈裂伤•Surgicaltrauma手术创伤•Uterinerupture子宫破裂软产道裂伤诊断•如果宫缩好，软产道裂伤出血首先考虑–出血是明显而迅速的，在胎儿娩出后–持续出血，宫缩好–缝扎可以止血–确定方法：软产道检查软产道裂伤治疗•可吸收肠线•全层连续或间断缝合•抗炎治疗：预防感染•输血Cervicallacerationrepair阴道裂伤I裂伤–皮肤黏膜II裂伤–肌层III裂伤–肛门括约肌IV裂伤–直肠病因前置胎盘胎盘残留胎盘滞留、嵌顿胎盘植入胎盘因素出血诊断•胎盘娩出30分•危险增加：剖宫产，子宫感染，多次妊娠分娩人流刮宫术•过度牵拉脐带导致脐带断裂，子宫内翻•通常的治疗方法是人工取出胎盘•出血往往发生在人工剥离胎盘之时胎盘因素治疗•催产素10U+NS20ml脐静脉iv•如果失败–开放静脉通路–备血–人工剥离胎盘•麻醉或药物止痛•手在宫壁与胎盘之间，轻轻剥离，胎盘完整全部取出•如果人工剥离胎盘失败–刮宫–手术治疗–抗炎治疗ManualremovalofplacentaExternalhandsteadiestheuterinefundusInternalhandalongplaneofcleavageCheckplacentaiscompleteChecktheuterusisemptyCheckfortraumaofGTAnaesthesiaAntibioticsIVlineOxytocicsUterusPlacenta病因CongenitalVonWillebrand'sdiseaseAcquiredDIC,ObstetricdisordersHELLPsyndromeDIC(eclampsia,intrauterinefoetaldeath,septicaemia,placentaabruptio,amnioticfluidembolism)AnticoagulanttherapyHeparin病因SystemicfactorsSpirit,ChronicdiseasesObstetricfactorsProlongedlabor,PIHUterinefactorsHighparity,Multiplegestation,macrosomia,LeiomyomasDrugfactorstocolyticagentsPPH最常见病因(70%)宫缩乏力的诊断•腹部检查：子宫软，无张力•阴道出血在胎盘娩出之后•阵发性出血宫缩乏力的预防宫缩乏力治疗•人工按摩–双手按摩：–按摩子宫是有效的简单的刺激子宫收缩的方法AndersonJM,AFP2007宫缩乏力的治疗宫缩剂•催产素（Oxytocin）•麦角新碱（Methergine）•欣母沛（Hemabate）•米索前列醇（Misoprostol）UterotonicsDose/RouteContra-IndicationsPitocin10Uim20Uin500mlNSivgttMastdose80UMethergine0.2mgimQ2-4hoursHypertensionScleroderma,Raynaud’sHemabate0.25mgimQ15mintomaxdose2mgAsthmaCytotec200–1000mcgOral/Vaginal/RectalQ6hours宫缩剂疗效不佳•寻找其他原因!•开放静脉通路•血交叉，备血，输血•留置导尿，24hr出入量•监测生命体征•凝血功能监测子宫填塞•BakriBalloon•Foley,BT-Cath,Sengstaken-BlakemoreTubeJacobsAJ,UptoDate2009GauzePacking子宫动脉栓塞•Requiresavailablefacilities/personnel•HemodynamicallyStablePatient•TemporizingmeasureenroutetoOR(ObstetGynecolSurvey2007;62(8):540,ObstetGynecol2009MAY;113(5):992)手术介入(1of4)Gabbe,Ch18COMPRESSIONSUTURESCornuFallopiantubeOvaryHaymanR,ArulkumaranS,SteerPObstetrics&Gynecology.2002OvaryFallopiantube手术介入(2of4)Gabbe,Ch18手术介入(3of4)手术介入(4of4)出血的评估•肉眼观察:•容器:量杯•表面积:bloodstained10cmx10cm=10ml•称重:1.05g=1ml•Hct=30%,Hb50-70g/L,bloodloss1000ml•每小时尿量25ml,bloodloss2500ml•休克指数=脉搏/收缩压CompensationMildModerateSevereBloodLoss500-1000ml10-15%1000-1500ml15-25%1500-2000ml25-35%2000-3000ml35-45%B.P.Change(SBP)NoneSlightfall(80-100mmHg)Markedfall(70-80mmHg)Profoundfall(50-70mmHg)Symptoms&SignsPalpitationDizzinessTachycardiaWeaknessSweatingTachycardiaRestlessnessPallorOliguriaCollapseAirhungerAnuria治疗原则•2方面–复苏–止血•识别和治疗4Ts•治疗：及时，系统StepIInitialAssessmentandtreatmentResuscitationAssessEtiologyManagementLargeboreIV(s)OxygenbymaskMonitorBP,P,RHeaddowntiltTransfuseoxygensaturationExploreuterus(tone,tissue)ExploreLGT(trauma)Reviewhistory(thrombin)ObserveclotsCoagulationscreenGroupandcrossmatchMassage/compressRemoveplacentaRepairtraumaCorrectinversionCorrectcoagulopathyStepIIContinuingPPHGetHelpLocalControlBPandcoagulationObstetrician/surgeonAnesthesiologistLabandICUManualcompression+/-packuterus+/-vasopressin+/-embolizationCrystalloidBloodproductsStepIIISurgeryRepairLacerationsLocalcontrolLigateVesselsHysterectomyUndersuteringtheplacentalbedSquaresutureB-LynchsutureUterinesInternaliliacarteryStepVPostHysterectomyBleedingAbdominalPackingAngiographicEmbolization预防•产前评估•停止治疗性的肝素，阿司匹林•积极管理第三产程•温和牵拉脐带•宫缩剂的预防应用–缩宫素第三产程常规使用可以预防60%PPH•仔细检查软产道，胎盘血制品的应用•不用等待实验室结果!•大量出血没有输入凝血因子将导致凝血功能异常！ProductContentsVolumeEffectWholeBlood500ml↑Hct3%PRBCsRBCs,WBCs,fewplasmaproteins300ml↑Hct3%,lessfeverPlateletsPooledconcentrate1unit=6pack50ml↑PLT5-10KFFPFibrinogen,ATIII,clottingfactors,plasma250ml↑fibrinogen5-10mg/dlCryoprecipitateFibrinogen,FactorVIII,XIII,vWF40ml↑fibrinogen5-10mg/dlBloodProductUtilizationActivemanagementofthethirdstageoflaborBloodloss1000to1500mlmassivePPHBriskbleedingBloodpressurefallingPulserisingMassageOxytocinExploregenitaltractInspectplacentaObserveclottingCoagulationscreenTheFourTsSoft,boggyuterusToneResuscitationGenitaltracttearTraumaPlacentaretainedTissueBloodnotclottingThrombinHemabateMetherginecytotecSutureManualremoveBloodproduct,SurgicalInterventionBloodloss500mlPPHReplacefactorConclusions！•Beprepared•Practiceprevention•Assesstheloss•Assessthematernalstatus•Resuscitatevigorouslyandappropriately•Diagnosethecause–Summary:Remember4Ts–Understandingitsetiologyisfundamentaltoeffectivelymanaging•Treatthecause•Activemanagementofthethirdstageoflaborisalsoakeycomponentinitsprevention.软胎盘胎膜异常软产道裂伤暗红鲜红阵发性持续性胎盘剥离后