产后出血临床医学课件).ppt

1、*Cunningham, et. al: Williams Obstetrics, 21st ed., 2001PPH is the leading cause of death related to pregnancy worldwide Major causes of death for pregnancy women（maternal mortality)lPostpartum hemorrhage（28%)lheart diseaseslpregnancy-induced hypertensionl(or Amniotic fluid embolism )linfectionDefin

2、ition of PPHlThe early PPH is defined as a blood loss exceeding 500ml after delivery of the infant2cm in length and be actively bleedingllaceration of vaginal and perineumEtiology/prediction/prevention/managementlPulseshock indexlblood pressurelmaternal heart ratelcentral venous pressurelurine outpu

3、tEtiology/prediction/prevention/managementlHb,lBT(bleeding time), CT( clotting time),lplatelets countlfibrinogenlprothrombin time and patial thromboplastin timelFDPlwomens blood group and cross-matchingEtiology/prediction/prevention/managementlthe key is correcting the coagulation defectlresuscitati

4、on must be started as soon as possiblelinfusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusionlblood transfusion is essentiallinfusion of red cells, platelets, fresh frozen plasma, FDP , clotting factors,Etiology/prediction/prevention/managementPerineum v

5、aginal and cervical lacerationlonly skin and a minor part of the perineal bodylperineal body and vaginalanal sphincter and anal canalEtiology/prediction/prevention/managementStimulation of uterine contractionof uterus through the abdomen and bimanual compression lintrauterine packingEtiology/predict

6、ion/prevention/managementSurgical therapylcausing uterine contraction or compressionltamponade the uterine cavity ldecrease blood supply to the uterusl remove the uterusl. Etiology/prediction/prevention/managementSurgical methodsIf massage and agents are unsuccessful:lLigation or embolization of the

7、 uterine arterieslHysterectomy Etiology/prediction/prevention/managementadherence of placenta (accreta increta pericreta)Etiology/prediction/prevention/managementPotential complications of PPHlPostpartum infectionlAnemialTransfusion hepatitis,lSheehans syndromelAshermans syndromeEtiology/prediction/

8、prevention/managementlcall an assistantlresuscitate the patient vigorously What is the state of her peripheral 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 periphe

9、ries, pulse and blood pressure, and her urine output.Summary: remember 4 Tsl“TONE”lRule out Uterine AtonylPalpate fundus.lMassage uterus.lOxytocin 20U/500cc.lProstaglandinl Hemabate IM q 15minSummary: remember 4 Tsl“Tissue”lR/O retained placentalInspect placenta for missing cotyledons.lExplore uteru

10、s.lTreat abnormal implantation.Summary: remember 4 Tsl“TRAUMA”lR/o cervical or vaginal lacerations.lObtain good exposure.lInspect cervix and vagina.lWorry about slow bleeders.lTreat hematomas.Summary: remember 4 Tsl“THROMBIN”lCheck labs if suspicious.Case-2 l37ys, multiparity, was admitted in her 40

11、+2wks for irregular contraction without any abnormal sign.lTwo hrs later, the contraction became stronger and membranes ruptured when h with meconium-stained amniotic fluid I degree.l7:33 cyanochroia happened with breathless and loss of consciousness in a second. What is the diagnosisl8:20pm still-b

12、irth weight 3.2kg.lPPH emerged as soon as placenta delivered without any clot.lThe patient was in the state of unconsciousness and became paleHysterectomylHysterectomy was done soon after resuscitation.lThe amount was about 4000ml.lRed cell was transfused 1600ml, fresh plasma 400ml, platelet 20u, cr

13、yoprecipitate 10u. lTransfusion was continued after OP 1800ml.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。 l术后41小时拔除气管插管，并停用多巴胺，生命体征平稳。术后40小时发现左上肢皮肤感觉减退，运动受限。头部MRI：

14、左侧小脑半球、双侧枕、顶叶及右侧丘脑多发脑梗塞，胸部CT：两肺纹理明显增多，两下肺见散在斑点状致密影，心影增大，两则胸腔积液，两侧胸腔积液。术后18天复查血、尿常规、凝血功能除Hb 102g/L外，均正常。胸部CT：正常。头部MRI：梗塞灶明显缩小。左上肢皮肤感觉功能恢复，但肌力仍低下。术后5个月恢复正常。Uterine pathology Cervical blood camp expansion, congestion and the small focal-like bleeding in the small vessels seen in the amniotic fluid comp

15、osition. Subclavian vein blood smear inspection, microscopic examination shows like material and a little meconium keratosis-like material.l术后15天复查头部MRT表现右顶叶及丘脑病灶范围缩小。原双侧枕叶，左顶叶及左小脑半球病灶已吸收消散，胸部CT提示原病灶及胸腔积液均已消失。Amniotic fluid embolismlClinical character Heart and lung failure Bleeding induced by DIC A

16、cute renal failure lDiagnosis “amniotic fluid composition” in circulation or tissueKey wordslUterine atonylthe definition of PPHlAmniotic fluid embolism lPROMQuestions after classlWhen you meet a patient with PPH, what you can do as an intern?lHow can you find the true reasons for PPH in the labor room?