1、POSTPARTUM HEMORRHAGE2005 Maternal Mortality（1/100000）World 400USA 11UK 8Sweden 3Ireland 1Japan 6Korea 14China 45Sierra Leone 2100INCIDENCE The leading cause of maternal mortality nearly 14,000,000 cases/year 127,000 deaths annually worldwide 99%in developing country 50%55%cases should avoidDEFINITI
2、ON Excessive blood Loss（500ml)during the first 24 hours after delivery(early PPH)Blood loss between 24hours and 6weeks after delivery(late PPH mostly due to infection and retained placenta tissue)Blood loss that need transfusionETIOLOGY 4“T”Tone：Uterine atony -70-70 Tissue：Retained placenta -20%-20%
3、Trauma：Lacerations -10%-10%Thrombin：Coagulopathy -1%-1%1.Uterine Atony General condition Drug Labor process Obstetrical complications Uterine disorderDual Blood SupplyMyometrium has not contracted to cut off the uterine spiral arteriesthat are supplying the placental bed.PATHOLOGYDiagnosis Soft uter
4、us(i.e,like dough)that is palpable above the umblicus Boggy uterus2.Retained Placental TISSUE Placenta retained Placenta accete Placenta increta Membrane adherence Succenturiate placentaDiagnosis Delayed spontaneous separetion of placenta Inspection of placenta Ultrasound MRIPlacenta increta Placent
5、a Accreta:Placenta adherent to myometrium Placenta Increta:myometrial invasion Placenta Percreta:penetration of myometrium to or beyond serosa.3.Laceration of Genital Tract Perineum/vaginal/cervical laceration Hematoma Uterine section laceration Uterine rupturePathology Instrumented delivery(forceps
6、)Manipulative delivery(breech extraction,precipitous labor,macrosomia)Soft tissue disorderDiagnosis Bleeding with a firm contracted uterus.The blood is bright red.The vaginal side walls and cervix should be especially carefully inspected.Vulva laceration Vaginal hematomacervical laceration4.Coagulat
7、ion defectsAcquired abnormality in blood clotting abruption placenta amniotic fluid embolism severe preeclampsiaCongenital abnormality in blood clotting thrombocytopenia severe hepatic diseases leukemiaDiagnosis Continuous generalized oozing from the skin,subcutaneous and fascial tissues Such eviden
8、ce also may be gained by observing continuous oozing from episiotomy incisions or perineal lacerations.Excessive bleeding at sites of modest trauma characterizes defective hemostasis No blood clot.PROGNOPSIS Anemia Subsequent puerperal infection Transfusion therapy(hepatitis,HIV,transfusion reaction
9、)Postpartum panhypopituitarism （Sheehans syndrome）Acute renal failure Sterility Maternal mortality Key-point to diagnosis:Estimate of Blood LossThe velocity of blood loss Blood loss 150ml/min Blood loss within 3H 50%general amount Blood loss within 24H general amountDiscretion of the PPH cause Right
10、 after fetal delivery-TRAUMA Fewer min after fetal delivery-TISSUE Bleeding after placenta delivery TONE/TISSUE Contineously/no clotting-THROMBINEvaluation of Blood Loss WeightWeight VolumeVolume DimensionDimension：Gauze blood area Shock index=PShock index=Pulse/Systolic pressure HemoglobinHemoglobi
11、n：10g/L 400-500ml blood loss。Vital sign Vital sign、urine amount urine amountTREATMENT PROCESSwarningmanagementcrisisPrimarySecondaryTertiary产后出血预防与处理指南（2014）中华医学会Primary(Blood loss400ml）Help Vessel Oxygen supply Vital sign monitor Lab Examination(CBC+Coagulation)Prepare for transfusion Investigate 4
12、“T”Secondary（5001500ml）Etiological treatment Anti-Shock treatmentTONEn按摩子宫n使用宫缩剂n宫腔填塞nB-lynchn血管结扎TRAUMAn缝合裂伤n清除血肿n恢复解剖TISSUEn人工剥离n清宫THROMBINn补充凝血因子：新鲜冰冻血浆、血小板、凝血酶原复合物Uterine Atony-MassageTone-Uterotonic agents Oxytocin：im.iv.gtt Hemobate（欣母沛）：im.Misoprostol:rectal or oral Carbetocin（巧特欣）:im.Tone Ut
13、erine packingGauzeTemponadeTone B-lynch suture正面观背面观正面观Trauma-RepairVaginal lacerationCervical lacerationTissue Manual removeTissue dilation&curettageTissue Placenta Accreta（胎盘植入胎盘植入）Conservative treatment Hysterectomy产前应作充分评估向孕妇和家属交待有子宫切除和输血的可能准备血制品和凝血物质充分的人员安排和器械准备Thrombin Transfusion Correct the
14、coagulation defect Resuscitation Infusion of crystalloid and colloid Blood transfusion Infusion of platelets coagulation factorsCoagulation factors 补充相应凝血因子补充相应凝血因子 Platelet：2050109/L Fresh frozen plasma：凝血因子、血浆蛋白、纤维蛋白原 Fibrogin：1克=血中25mg/dl 冷沉淀：凝血因子、vWF、纤维蛋白原、因子 冻干人凝血酶原复合物：因子、Tertiary Management Ox
15、ygen Maintain circulation DIC treatment Protect vital organs Intensive care unit Intensive maneuverArtery ligation盆腔血管结扎术结扎子宫动脉Arterial Embolization 子宫次全切子宫全切Hysterectomy休克抢救流程REACT Resuscitation Evaluation Arrest hemorrhage Consult Treat complication2013 WHO recommendationsUniversal prevention of P
16、PHFirst choice:Oxytocin 10IU IV/IMIdentification of PPHUterine massage IV oxytocinIV ergometrineOxytocin-ergometrine fixed doseSublingual misoprostolIntrauterine balloon tamponadeUterine artery embolizationSurgical intervantions(Laparotomy)Oxytocin unavailable/persistent PPHPersistent PPHPersistent
17、PPHPersistent PPHPrevention Prenatal Evaluation Risk factor Medical&Obstetrical Complications Referral system ICU center原因或病因对应的高危因素子宫收缩乏力全身因素产妇体质虚弱、合并慢性全身性疾病或精神因素药物过多使用麻醉剂、镇静剂或宫缩抑制剂等产程因素急产、产程延长或滞产、试产失败等产科并发症子痫前期等羊膜腔内感染胎膜破裂时间长、发热等子宫过度膨胀羊水过多、多胎妊娠、巨大儿等子宫肌壁损伤多产、剖宫产史、子宫肌瘤剔除术后等子宫发育异常双子宫、双角子宫、残角子宫等产道损伤子宫颈
18、、阴道或会阴裂伤急产、手术产、软产道弹性差、水肿或瘢痕形成等胎位不正、胎头位置过低等剖宫产子宫切口延伸或裂伤子宫破裂子宫手术史子宫体内翻多产、子宫底部胎盘、第三产程处理不当胎盘因素胎盘异常多次人工流产或分娩史、子宫手术史、前置胎盘胎盘、胎膜残留胎盘早剥、胎盘植入、多产、既往有胎盘粘连史凝血功能障碍血液系统疾病遗传性凝血功能疾病、血小板减少症肝脏疾病重症肝炎、妊娠期急性脂肪肝产科DIC羊水栓塞、度胎盘早剥、死胎滞留时间长、重度子痫前期及休克晚期Prevention Management of labor process Prolonged labor Rapid labor Epitomy Ox
19、ytocin usagePrevention Intense observation after birth Uterine massage Monitor vital sign、uterus contraction、blood loss within 2 hours right after baby delivery Breast feeding UrinateSUMMARY PPH is emergent and critical Risk factor Presage of PPH Blood loss measurement Treat promptly to improve consequence Cooperation!
