产后出血 Postpartum Hemorrhage,PPH 马润玫昆明医学院第一附属医院妇产科 Department of Obstetrics & Gynecology, 1st Affiliated Hospital of Kunming Medical University
Background( 背景 ) ä Maternal death( 孕产妇死亡 ): - Death occurring within 1 year of delivery ä Major health issue & great challenge worldwide ä Estimated by WHO in 1990:annual maternal death >585,000,25% of which died of OB haemorrhage ä 98% occurring in the developing world!
Maternal mortality rate (MMR, 孕产妇死亡率 ) The number of maternal deaths per 100,000( 多少个 / 十万 )deliveries in 1 year
为什么会发生孕产妇死亡呢?
Major causes for maternal death ä Obstetric hemorrhage( 产科出血 ) (the 1 st leading cause of maternal death in the developing world) ä Hypertensive diseases of pregnancy( ( 妊娠期高血压疾病 ) ä Medical complications( ( 内科并发症 ) ä Infection( ( 感染 )
Obstetric hemorrhage_the first leading cause in China 西亚 非洲 中国第一位
Postpartum Hemorrhage (PPH)
Contents( 内容 ) ä Definition( 定义 )&& incidence( 发生 率 ) ä High risk factors & causes( 高危因素 和原因 ) ä Clinical features and management( 临 床特征和处理 ) ä Case discussion ( 病案讨论 )
Definition & incidence PPH defined as blood loss from the vagina after delivery 500ml Can occur before, during, or after delivery of placenta ( 胎盘 ) More frequently within the first 24 hours of birth (primary PPH, 原发性产后出血 ) ä ä ä 24h 以后 -6W( 产褥期 ):secondary PPH( 继发性产后出血 ) Vaginal delivery( ( 阴道分娩 ):) : 2-3% 2 C/S( ( 剖宫产 ):) : 6%
妊娠后子宫动脉的血流变化 Pregnancy 妊娠 full term 足月 non-pregnancy 非妊娠 Bleeding from the gravid uterus can be fatal
Understanding the physiological changes in uterus( 子宫生理变化 ) ä ä Three layers in myometrial fibers that surround the blood vessels supplying the placental implantation site 三层肌纤维交织分布, 血管位于其内 contraction
正常产后生理性止血机制 Placental expulsion in the 3rd Stage Effective uterine contraction Expulsion into the lower uterine Separation of the placenta segment and upper vagina from uterine wall Complete expulsion of the placenta from the genital tract
正常产后生理性止血机制 子宫呈圆球形 ( 安全球 ) 宫底平脐或脐下一指 质硬 推宫底无活动性阴道出血
Contents( 内容 ) ä Definition( 定义 )&& incidence( 发生 率 ) ä High risk factors & causes( 高危因素 和原因 ) ä Clinical features and management( 临 床特征和处理 ) ä Case discussion ( 病案讨论 )
Etiology of PPH(4 病因 ) 考点 äuterine Uterine atony( ( 宫缩乏力 ) äretained Retained placental tissues( ( 胎盘残留 ) älacerations( ( 产道裂伤 Coagulation defects ( 凝血功能障碍 )
Etiology- 宫缩乏力 ( 首位原因 ) uterine atony >50% 考点 general factors 全身 local factors 局部 uterine overdistension general (twin/polyhydramnios Anesthesia 全麻 /macrosomia 子宫过度膨胀 ) stress 焦虑 systematic iseases 全身疾病 prolonged labour, dystocia 难产 extravasation of blood into myometrium 子宫肌渗血 uterine myomas distortion 子宫肌瘤, 畸形
Etiology 胎盘残留 (Retained placenta 5-10%) Abnormal Placentation(invasion) invasion) 正常蜕膜 植入 : 深肌层 肌层侵犯程度 粘连 : 表层 / 浅肌层 穿透 : 肌层抵达浆膜层或突破
Etiology - 软产道裂伤 Genital tract lacerations 20% Hyperstimulation 宫缩过强急产 Macrosomia 巨大儿 inappropriate delivery skills 助产不佳 vulva 外阴 vagina 阴道 cervix 宫颈 lower segment of uterus 子宫下段 retroperitoneal hematoma 腹膜后血肿
Etiology- 凝血功能障碍 Coagulation defects rare Acquired coagulation defects Pregnancy complications 妊娠并发症 leukemia hepatitis autoimmune thrombocytopenia acute fatty liver in pregnancy pre-eclampsia HELLP 子痫前期 missed abortion 稽留流产 placental Abruption 胎盘早剥 amniotic flui embolismaf
Clinical features of PPH 临床特征 ä 失血性休克 (haemorrhagic shock) ä 死亡 (death) ä 贫血 (anaemia) ä 感染 (infection)
低血容量的诊断 基本素质 ä 满足下列一条或以上标准 : - SBP<100mmHg( 排除麻醉因素所致 ) - P 100 bpm - tilt test (+): P 20bpm or SBP 20mmHg or 体位性症状 ( 眩晕, 虚脱, 恶心, 呕 吐 ) - 尿量 <30ml/h - 失血后 Hct<20% or 正在失血中 Hct=20-30% Alexander JM et al:obstet Gynecol 2009;113(6):1320-1326 1326
Sheehan s syndrome 席汉氏综合征 Prolonged postpartum hemorrhagic shock partial or total necrosis( 坏死 ) of the anterior pituitary gland 垂体前叶坏死 Sheehan s s syndrome
Clinical features of PPH 因病因不同而异 多种因素并存 Ker factors: 病因?
不同病因 PPH 的临床表现及诊断 - 子宫收缩乏力 ä 宫缩差时, 子宫松软如袋状, 轮廓不清或摸不到宫底, 推压宫底大量血液或血块从阴道涌出 ä 宫缩改善时, 子宫轮廓清楚, 较硬, 推宫底阴道出血少 ä 胎盘娩出前 / 后间歇性阴道流血, 血色多呈暗红色
不同病因 PPH 的临床表现及诊断 - 胎盘因素 ä 胎盘娩出前阴道流血多 ä 胎盘部分粘连 剥离不全或剥离后滞留宫腔 胎盘完全剥离但嵌顿于子宫下段 妨碍子宫收缩 宫缩乏力胎盘因素 互为因果
Etiology 胎盘残留 (Retained placenta 5-10%) Abnormal Placentation(invasion) invasion) 正常蜕膜 植入 : 深肌层 肌层侵犯程度 粘连 : 表层 / 浅肌层 穿透 : 肌层抵达浆膜层或突破
胎盘穿透 Placental percreta 2010-07 07-26
Retained placenta and uterine atony co-exists
不同病因 PPH 的临床表现及诊 ä 胎儿娩出后, 立即出 现 : - 持续阴道流血 - 鲜红色 - 子宫收缩良好 ( 安全 球存在 ) - 仔细检查软产道可明 确裂伤和出血部位 断 - 软产道裂伤
不同病因 PPH 的临床表现及诊断 - 软产道裂伤 ä 子宫下段 ä 宫颈 :3,9 点处 ( 两侧 ) ä 阴道裂伤 : 侧壁, 后壁, 常与会阴裂伤并存 ä 会阴裂伤
不同病因 PPH 的临床表现及诊断 - 凝血功能障碍 ä 病史 - 妊娠并发症 - 妊娠合并出血性疾病 ä 产后多表现为子宫大量出血 - 持续不断出血 - 血液不凝 - 病史 + 凝血功能的实验室检查
Management options for PPH ä PPH may be sudden and profound and may rapidly lead to cardiovascular collapse or even maternal death. Immediate management is life-saving. ä A call for help( 呼救 ) from obstetrics, midwifery, anesthetics and hematology is important. In general, two steps must be followed( 二步骤 ): ä 1 st : controlling the bleeding, including - estimate the amount of blood loss( 评估失血量 ) - whether the placenta is still in uterus or it has been expelled( 胎盘娩出否 )
Management options for PPH 重点 ä If the placenta has been expelled, the uterus is soft and bleeding is periodic poor uterine contraction (uterine atony 宫缩乏力 ) : - Massage( 按摩 ) of the uterus to stimulate a contraction and expel any retained clot - Inject oxytocin( 缩宫素 ) or ergometrine - Check that the placenta and membranes are complete, if not, then manual exploration( 指搔 ) of the uterine cavity is indicated( 指征 ) - 前列腺素 ( 欣母沛, 卡孕栓 ) - 长效缩宫素 ( 卡贝缩宫素 ):60min
Management options for PPH 重点 ä If the placenta is retained 胎盘残留 : - apply cord traction( 旋转脐带 ) to help deliver the placenta - if this fails, manual removal of the placenta may be needed. ä If the bleeding continues despite the presence of a well- contracted uterus, the vagina and cervix should be examined the any laceration 裂伤 sutured to ensure haemostasis( 止血 ) - As for supportive management, replacement of blood loss and resuscitation( 抗休克 - 复苏 )
Surgical intervention for PPH ä Pelvic packing( 宫腔或盆腔填塞 ) ä B-lynch suture( ( 缝合 ) ä Artery ligation (internal iliac & uterine 动脉结扎 ) ä Arterial embolization( ( 动脉栓塞 ) ä Hysterectomy( 子宫切除术 )
B-lynch suture( 缝合 )
Bakri balloon 产后止血球囊 54cm,24Fr. ACOG FIGO ICM 包括中国的围产医学指南中推荐使用
子宫动脉结扎术
子宫动脉结扎术 - uterine artery ligation
髂内动脉结扎术 - internal iliac artery ligation
子宫切除术 -hysterectomy
Key points ä Rapidly convert a happy,normal event to a potential tragedy ä Commonest causes _ uterine atony, retained products, obstetrical lacerations should be constantly born in mind ä Risk assessment must be an integral part of the management of each pregnancy and preventive measures should in place
Case Discussion(1) ä A 37-year year-old woman, para 5, was noted to have heavy bleeding following a twins( 双胎 ) delivery ä The uterus was palpable( 触及 ) abdominally ( 腹部 )above the umbilicus ( 脐部 ) and was noted to be poorly contracted( 收缩 ).
Case Discussion(1) ä On vaginal( 阴道 ) examination, 600ml of blood was removed from the cervix( 宫 颈 )and vagina ä Uterine activity stimulated by rubbing the uterus and starting a Syntocinon ( 缩宫 素 )infusion, after which the bleeding settled.
Questions ä Can the patient be diagnosed as PPH, why? ä What is the type of PPH in this patient? ä What high-risk factors associated with PPH does the patient have?
Case Discussion(2) ä A 21-year year-old woman delivered by mid-low level forceps( 中低位产钳 ) was found to have steady, heavy vaginal bleeding following repair of her episiotomy( 会阴侧切 ).. The uterus was felt to be well contracted and the bleeding did not respond to intravenous( 静脉 ) Syntocinon. Further bleeding required transfusion( 输血 ),, and the patient was taken to the operation theatre( 手术室 ) for examination under anaesthesia( 镇痛 ),, when a laceration at the left vaginal fornix( 穹窿 ) was repaired.
Questions 1. Can the patient be diagnosed as massive PPH? Why? 2. What are the causes for PPH?
Reference for further reading
ä 永 不言弃
Obstetrics is a bloody business Are you ready? Thank you!