产后出血2010(北医三院八年制临床医学课件)优质PPT.ppt

1、Williams Obstetrics,21st ed.,2001PPH is the leading cause of death related to pregnancy worldwide 1 1Major causes of death for pregnancy women（maternal mortality）l lPostpartum hemorrhage（28%）l lheart diseasesl lpregnancy-induced hypertensionl l（or Amniotic fluid embolism）l linfection2 2Definition of

2、 PPHl lThe early PPH is defined as a blood loss exceeding 500ml after delivery of the infant2cm in length and be actively bleedingl llaceration of vaginal and perineumEtiology/prediction/prevention/management1919Record:l lPulseshock indexl lblood pressurel lmaternal heart ratel lcentral venous press

3、urel lurine outputEtiology/prediction/prevention/management2020Lab tests:l lHb,l lBT（bleeding time）,CT（clotting time）,l lplatelets countl lfibrinogenl lprothrombin time and patial thromboplastin timel lFDPl lwomens blood group and cross-matchingEtiology/prediction/prevention/management2121Treatment:

4、l lthe key is correcting the coagulation defectl lresuscitation must be started as soon as possiblel linfusion of crystalloid（saline）and Dextran is started firstly while arranging the blood transfusionl lblood transfusion is essentiall linfusion of red cells,platelets,fresh frozen plasma,FDP,clottin

5、g factors,Etiology/prediction/prevention/management2222Perineum vaginal and cervical lacerationl lonly skin and a minor part of the perineal bodyl lperineal body and vaginal lanal sphincter and anal canalEtiology/prediction/prevention/management2323Stimulation of uterine contractionl lMassage of ute

6、rus through the abdomen and bimanual compression l lintrauterine packingEtiology/prediction/prevention/management2424Surgical therapyl lcausing uterine contraction or compressionl ltamponade the uterine cavity l ldecrease blood supply to the uterusl l remove the uterusl l.Etiology/prediction/prevent

7、ion/management2525Surgical methodsIf massage and agents are unsuccessful:l lLigation or embolization of the uterine arteriesl lHysterectomy Etiology/prediction/prevention/management2626adherence of placenta（accreta increta pericreta）Etiology/prediction/prevention/management2727Potential complication

8、s of PPHl lPostpartum infectionl lAnemial lTransfusion hepatitis,l lSheehans syndromel lAshermans syndromeThe best management of PPH is prevention Etiology/prediction/prevention/management2828Resuscitation for PPHl lcall an assistantl lresuscitate the patient vigorously What is the state of her peri

9、pheral circulation?How much blood has she lost?Is it clotting normally in the receiver used to collect it?What has been done so far?Monitor the volume of blood she continues to loseher peripheries,pulse and blood pressure,and her urine output.2929Summary:remember 4 Tsl l“TONE”“TONE”l lRule out Uteri

10、ne Rule out Uterine AtonyAtonyl lPalpate fundus.Palpate fundus.l lMassage uterus.Massage uterus.l lOxytocin 20U/500cc.Oxytocin 20U/500cc.l lProstaglandinProstaglandinl l HemabateHemabate IM q 15min IM q 15min3030Summary:remember 4 Tsl l“Tissue”“Tissue”l lR/O retained placentaR/O retained placental l

11、Inspect placenta for Inspect placenta for missing cotyledons.missing cotyledons.l lExplore uterus.Explore uterus.l lTreat abnormal Treat abnormal implantation.implantation.3131Summary:remember 4 Tsl l“TRAUMA”“TRAUMA”l lR/o cervical or vaginal R/o cervical or vaginal lacerations.lacerations.l lObtain

12、 good Obtain good exposure.exposure.l lInspect cervix and Inspect cervix and vagina.vagina.l lWorry about slow Worry about slow bleeders.bleeders.l lTreat hematomas.Treat hematomas.3232Summary:remember 4 Tsl l“THROMBIN”“THROMBIN”l lCheck labs if Check labs if suspicious.suspicious.3333Case-2 l l37ys

13、,37ys,multiparitymultiparity,was admitted in her 40,was admitted in her 40+2+2wks for wks for irregular contraction without any abnormal sign.irregular contraction without any abnormal sign.l lTwo hrs later,the contraction became stronger and Two hrs later,the contraction became stronger and membran

14、es ruptured when h with membranes ruptured when h with meconiummeconium-stained-stained amniotic fluid Iamniotic fluid I degree.degree.l l7:33 7:33 cyanochroiacyanochroia happened with breathless and loss happened with breathless and loss of consciousness in a second.of consciousness in a second.343

15、4What is the diagnosisl l8:20pm still-birth weight 3.2kg.l lPPH emerged as soon as placenta delivered without any clot.l lThe patient was in the state of unconsciousness and became pale3535Hysterectomyl lHysterectomy was done soon after resuscitation.l lThe amount was about 4000ml.l lRed cell was tr

16、ansfused 1600ml,fresh plasma 400ml,platelet 20u,cryoprecipitate 10u.l lTransfusion was continued after OP 1800ml.3636l l，Hb38g/L,APTT43.4秒，PT45.0（正常11-14sec）,PT比例3.52（正常0.85-1.15），Fbg 0.976g（正常2-4g/L）,APTT不凝，TT44.Tsec（正常14-21sec）。FDP（+），D-2聚集体（+），3P试验（+）。尿常规Pro 2+,比重1.000,RBC 10-15/HP,可见颗粒管型。3737l l术术后后4141小小时时拔拔除除气气管管插插管管，并并停停用用多多巴巴胺胺，生生命命体体征征平平稳稳。术术后后4040小小时时发发现现左左上上肢肢皮皮肤肤感感觉觉减减退退，运运动动受受限限。头头部部MRIMRI：左左侧侧小小脑脑半半球球、双双侧侧枕枕、顶顶