妇产科学 产后出血
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• • • • 催产素 （Oxytocin ） 麦角新碱（Methergine） 欣母沛（Hemabate） 米索前列醇（Misoprostol ）
Uterotonics Pitocin
Dose/ Route 10U im 20U in 500ml NS ivgtt Mast dose 80U 0.2mg im Q2-4 hours
病因
Congenital
Von Willebrand's disease
Acquired
DIC,
Obstetric disorders
HELLP syndrome DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism)
Uterines Internal iliac artery
Step V Post Hysterectomy Bleeding
Abdominal Packing Angiographic Embolization
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
Laceration, hematoma, 20% inversion, rupture Retained placenta, invasive placenta Coagulopathies 10% 1%
TISSUE 胎盘因素 THROMBIN 凝血功能
Am Fam Physician 2007; 75:875.
产后出血止血原理
出血
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
止血
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
病因
The 4 T’s of PPH
CAUSE TONE 子宫收缩乏力 TRAUMA 软产道裂伤 Atony INCIDENCE (APPROX) 70%
Uterus Placenta
Internal hand along plane of cleavage Anaesthesia Antibiotics IV line Oxytocics Check placenta is complete Check the uterus is empty Check for trauma of GT
Head down tilt
Transfuse oxygen saturation
Observe clots
Coagulation screen Group and crossmatch
Correct inversion
Correct coagulopathy
Step II Continuing PPH
Gauze 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(2 of 4)
Gabbe, Ch 18
手术介入(3 of 4)
手术介入(4 of 4)
出血的评估
• • • • • • • 肉眼观察: 容器: 量杯 表面积: blood stained 10cmx10cm = 10ml 称重: 1.05g = 1ml Hct<=30%, Hb50-70g/L, blood loss >1000ml 每小时尿量<25ml, blood loss >2500ml 休克指数= 脉搏/收缩压
Collapse Air hunger Anuria
治疗原则
• 2 方面
– 复苏 – 止血 • 识别和治疗4Ts
• 治疗：及时，系统
Step I Initial Assessment and treatment
Resuscitation
Assess Etiology
Management
手术介入(1 of 4)
Gabbe, Ch 18
COMPRESSION SUTURES
Cornu Fallopian tube Fallopian tube Ovary Ovary
Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology. 2002
病因
Planned
•Cesarean section 剖宫产 •Episiotomy 外阴侧切
Unplanned
•Vaginal/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
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, SengstakenBlakemore Tube
Jacobs AJ, Up to Date 2009
Anti coagulant therapy
Heparin
病因
PPH 最常见病因(70%)
Systemic factors
Spirit, Chronic diseases
Obstetric factors
Prolonged labor, PIH
Uterine factors
High parity, Multiple gestation, macrosomia, Leiomyomas
Massage Oxytocin
Blood loss > 500 ml PPH
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）
Large bore IV(s) Oxygen by mask Monitor BP,P,R
Explore uterus (tone,tissue) Massage /compress Explore LGT (trauma) Review history (thrombin)
Remove placenta Repair trauma
Compensation
Blood Loss 500-1000 ml 10-15%
Leabharlann Baidu
Mild
1000-1500 ml 15-25% Slight fall
(80-100 mmHg)
Moderate
1500-2000 ml 25-35%
Severe
2000-3000 ml 35-45%
B.P.Change None (SBP)
– 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！
Blood Product Utilization
Product Whole Blood PRBCs Platelets Contents Volume 500ml RBCs, WBCs, few 300ml plasma proteins Pooled concentrate 1 unit = 6 pack Fibrinogen, ATIII, clotting factors, plasma 50ml Effect ↑ Hct 3% ↑ Hct 3%, less fever ↑ PLT 5-10K
Palpitation Dizziness Tachycardia
Marked fall
(70-80 mmHg)
Profound fall
(50-70 mmHg)
Symptoms & Signs
Weakness Sweating Tachycardia
Restlessness Pallor Oliguria
– – – – 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
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
胎盘植入
前置胎盘
胎盘残留
胎盘滞留、 嵌顿
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
ContraIndications
Methergine
Hypertension Scleroderma, Raynaud’s Asthma
Hemabate
0.25 mg im Q15min to max dose 2mg
Cytotec
200 – 1000mcg Oral / Vaginal / Rectal Q 6 hours
Get Help
Local Control
BP and coagulation
Obstetrician / surgeon Anesthesiologist Lab and ICU
Manual compression +/- pack uterus +/- vasopressin +/-embolization
Crystalloid Blood products
Step III Surgery
Repair Lacerations
Local control
Ligate Vessels
Hysterectomy
Undersutering the placental bed Square suture B-Lynch suture
– 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 placenta
External hand steadies the uterine fundus
FFP
250ml
↑ fibrinogen 510mg/dl
Cryoprecipitate
Fibrinogen, Factor VIII, XIII, vWF
40ml
↑ fibrinogen 510mg/dl
Active management of the third stage of labor Brisk bleeding Blood pressure falling Pulse rising
产后出血
Postpartum Hemorrhage PPH
Zhangye Xu M.D. Department of Obstetrics and Gynecology 1st Affiliated Hospital, Wenzhou Medical Colleg
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
Drug factors
tocolytic agents
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
Uterotonics Pitocin
Dose/ Route 10U im 20U in 500ml NS ivgtt Mast dose 80U 0.2mg im Q2-4 hours
病因
Congenital
Von Willebrand's disease
Acquired
DIC,
Obstetric disorders
HELLP syndrome DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism)
Uterines Internal iliac artery
Step V Post Hysterectomy Bleeding
Abdominal Packing Angiographic Embolization
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
Laceration, hematoma, 20% inversion, rupture Retained placenta, invasive placenta Coagulopathies 10% 1%
TISSUE 胎盘因素 THROMBIN 凝血功能
Am Fam Physician 2007; 75:875.
产后出血止血原理
出血
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
止血
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
病因
The 4 T’s of PPH
CAUSE TONE 子宫收缩乏力 TRAUMA 软产道裂伤 Atony INCIDENCE (APPROX) 70%
Uterus Placenta
Internal hand along plane of cleavage Anaesthesia Antibiotics IV line Oxytocics Check placenta is complete Check the uterus is empty Check for trauma of GT
Head down tilt
Transfuse oxygen saturation
Observe clots
Coagulation screen Group and crossmatch
Correct inversion
Correct coagulopathy
Step II Continuing PPH
Gauze 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(2 of 4)
Gabbe, Ch 18
手术介入(3 of 4)
手术介入(4 of 4)
出血的评估
• • • • • • • 肉眼观察: 容器: 量杯 表面积: blood stained 10cmx10cm = 10ml 称重: 1.05g = 1ml Hct<=30%, Hb50-70g/L, blood loss >1000ml 每小时尿量<25ml, blood loss >2500ml 休克指数= 脉搏/收缩压
Collapse Air hunger Anuria
治疗原则
• 2 方面
– 复苏 – 止血 • 识别和治疗4Ts
• 治疗：及时，系统
Step I Initial Assessment and treatment
Resuscitation
Assess Etiology
Management
手术介入(1 of 4)
Gabbe, Ch 18
COMPRESSION SUTURES
Cornu Fallopian tube Fallopian tube Ovary Ovary
Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology. 2002
病因
Planned
•Cesarean section 剖宫产 •Episiotomy 外阴侧切
Unplanned
•Vaginal/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
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, SengstakenBlakemore Tube
Jacobs AJ, Up to Date 2009
Anti coagulant therapy
Heparin
病因
PPH 最常见病因(70%)
Systemic factors
Spirit, Chronic diseases
Obstetric factors
Prolonged labor, PIH
Uterine factors
High parity, Multiple gestation, macrosomia, Leiomyomas
Massage Oxytocin
Blood loss > 500 ml PPH
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）
Large bore IV(s) Oxygen by mask Monitor BP,P,R
Explore uterus (tone,tissue) Massage /compress Explore LGT (trauma) Review history (thrombin)
Remove placenta Repair trauma
Compensation
Blood Loss 500-1000 ml 10-15%
Leabharlann Baidu
Mild
1000-1500 ml 15-25% Slight fall
(80-100 mmHg)
Moderate
1500-2000 ml 25-35%
Severe
2000-3000 ml 35-45%
B.P.Change None (SBP)
– 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！
Blood Product Utilization
Product Whole Blood PRBCs Platelets Contents Volume 500ml RBCs, WBCs, few 300ml plasma proteins Pooled concentrate 1 unit = 6 pack Fibrinogen, ATIII, clotting factors, plasma 50ml Effect ↑ Hct 3% ↑ Hct 3%, less fever ↑ PLT 5-10K
Palpitation Dizziness Tachycardia
Marked fall
(70-80 mmHg)
Profound fall
(50-70 mmHg)
Symptoms & Signs
Weakness Sweating Tachycardia
Restlessness Pallor Oliguria
– – – – 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
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
胎盘植入
前置胎盘
胎盘残留
胎盘滞留、 嵌顿
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
ContraIndications
Methergine
Hypertension Scleroderma, Raynaud’s Asthma
Hemabate
0.25 mg im Q15min to max dose 2mg
Cytotec
200 – 1000mcg Oral / Vaginal / Rectal Q 6 hours
Get Help
Local Control
BP and coagulation
Obstetrician / surgeon Anesthesiologist Lab and ICU
Manual compression +/- pack uterus +/- vasopressin +/-embolization
Crystalloid Blood products
Step III Surgery
Repair Lacerations
Local control
Ligate Vessels
Hysterectomy
Undersutering the placental bed Square suture B-Lynch suture
– 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 placenta
External hand steadies the uterine fundus
FFP
250ml
↑ fibrinogen 510mg/dl
Cryoprecipitate
Fibrinogen, Factor VIII, XIII, vWF
40ml
↑ fibrinogen 510mg/dl
Active management of the third stage of labor Brisk bleeding Blood pressure falling Pulse rising
产后出血
Postpartum Hemorrhage PPH
Zhangye Xu M.D. Department of Obstetrics and Gynecology 1st Affiliated Hospital, Wenzhou Medical Colleg
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
Drug factors
tocolytic agents
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