产后出血Postpartum Hemorrhage PPH Zhangye Xu M.D. Department of Obstetrics and Gynecology1st Affiliated Hospital, Wenzhou Medical College学习习目标标 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 The 4 Ts of PPHCAUSEINCIDENCE (APPROX)TONE 子宫收缩乏力Atony70%TRAUMA 软产道裂伤 Laceration, hematoma, inversion, rupture20%TISSUE 胎盘因素Retained placenta, invasive placenta10%THROMBIN 凝血功能Coagulopathies1%Am Fam Physician 2007; 75:875.病因PlannedCesarean section 剖宫产 Episiotomy 外阴侧切UnplannedVaginal/cervical tear 阴道宫颈裂伤Surgical trauma 手术创伤Uterine rupture 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Cervical laceration repair阴道裂伤lI裂伤 皮肤黏膜lII裂伤肌层lIII裂伤肛门括约肌lIV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 + NS 20ml 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Manual removal of placentaExternal hand steadies the uterine fundusInternal hand along plane of cleavageCheck placenta is complete Check the uterus is empty Check for trauma of GTAnaesthesia Antibiotics IV line OxytocicsUterusPlacenta病因CongenitalVon Willebrands diseaseAcquiredDIC, Obstetric disorders HELLP syndrome DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism)Anti coagulant therapy Heparin病因 Systemic factorsSpirit, Chronic diseases Obstetric factorsProlonged labor, PIH Uterine factorsHigh parity, Multiple gestation, macrosomia, Leiomyomas Drug factorstocolytic agentsPPH 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Anderson JM, AFP 2007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- Indications Pitocin10U im 20U in 500ml NS ivgtt Mast dose 80U Methergine0.2mg im Q2-4 hoursHypertension Scleroderma, Raynauds Hemabate0.25 mg im Q15min to max dose 2mgAsthmaCytotec200 1000mcg Oral / Vaginal / Rectal Q 6 hours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 Bakri Balloon Foley, BT-Cath, Sengstaken- Blakemore TubeJacobs AJ, Up to Date 2009Gauze Packing子宫动脉栓塞 Requires available facilities/ personnel Hemodynamically Stable Patient Temporizing measure en route to OR(Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992)手术介入(1 of 4)Gabbe, Ch 18COMPRESSION SUTURESCornuFallopian tubeOvaryHayman R, Arulkumaran S, Steer P Obstetrics no livingPara 1; no livingPast Obstetric HistoryIn 2002In 2002Gestational Diabetes + PreeclampsiaGestational Diabetes + Preeclampsia（PEPE）Delivered at 38 weeksDelivered at 38 weeksVaginal delivery on 5/2002Vaginal delivery on 5/2002Dead male baby 4.5 kgDead male baby 4.5 kgCurrent PregnancyLMP 10/10/2003 LMP 10/10/2003 Twin pregnancyTwin pregnancyRegular prenatal Regular prenatal care care in a private clinicin a private clinicNo document of screening for GDM in this No document of screening for GDM in this pregnancypregnancyOn admission:On admission: History of unsatisfactory fetal movements for History of unsatisfactory fetal movements for the last 3 daysthe last 3 days Labor pains for 3 hoursLabor pains for 3 hoursAdmissionAdmission 21:00, May 321:00, May 3rdrd 20042004liquor above average, uterine liquor above average, uterine contractions 2/10 min, each 20 sec.contractions 2/10 min, each 20 sec.PV: 4 cm dilated, 1 cm long, PV: 4 cm dilated, 1 cm long, central, softcentral, softU.S. scan Twin pregnancyTwin pregnancy Monoamniotic monochorionicMonoamniotic monochorionic 1 1st stcephalic, cephalic, F. Life +veF. Life +ve, 24, 24+2+2 wkwk 2 2ndnd transverse, transverse, F. Life veF. Life ve, 22 wk, 22 wk Placenta fundal anterior grade IIPlacenta fundal anterior grade II Liquor: clear, AFI 27 cmLiquor: clear, AFI 27 cmProgressProgressPatient spontaneously miscarried at Patient spontaneously miscarried at 03:0003:00 1 L male 500 gm (died later)1 L male 500 gm (died later) 1 SB male 1 kg1 SB male 1 kgVaginal bleeding associated with retained Vaginal bleeding associated with retained placenta.placenta.Transferred to theatreTransferred to theatreEmptying the bladderEmptying the bladderIV crystalloidsIV crystalloidsManual separation of the placentaManual separation of the placentaExcessive vaginal bleeding Excessive vaginal bleeding Uterine massage and bimanual compressionUterine massage and bimanual compressionUterus stayed atonic (F.Level 18 wk)Uterus stayed atonic (F.Level 18 wk)Received 3 units of