Obstetrics is a bloody business 产科出血是我国孕产妇死亡的第一位原因

Obstetrical Hemorrhage 产科出 血 Ref: 1, 妇产科学 ( 八年制 3ed) 2,Willams obstetrics(24 ed) 3,Current Obstetric & Gynecologic Diagnosis & Treatment (11th)

Obstetrics is a bloody business 产科出血是我国孕产妇死亡的第一位原因

Obstetrical Hemorrhage n 产前出血 ( 胎儿娩出前出血 ) Ø 前置胎盘 Ø 胎盘早剥 Ø 子宫破裂 n 产后出血 ( 胎儿娩出后出血 ) Ø 病因 :4T Ø 临床表现及诊断 Ø 处理

Placental bed bleeding( 最常见原因 ) Placenta previa( 前置胎盘 ) 产前出 血 ( 原因 ) Placental abruption( 胎盘早剥 ) Uterine bleeding( 子宫破裂 ) Lower segment scar rupture ( 既往剖宫产瘢痕 子宫再次妊娠分娩 ) rupture of other scars ( 子宫肌瘤挖出术后瘢痕 子宫妊娠分娩 ) Cervical lesion(<5%) Cervical erosion, cervicitis( 子宫颈炎 ) cervical carcinoma (rare,but must be excluded) Fetoplacental: 脐带帆状附着 血管前置 (very rare)

前置胎盘 : 胎盘位于胎 儿先露之前, 达到或覆盖 子宫颈胎盘早剥 : 正常位置的胎盘, 在胎 儿娩出前从 子宫壁剥离

Placenta previa( 前置胎盘 ) The placenta is located over or near the internal os(>28w) Classification 中央性 ( 完全性 ) 前置胎盘部分性前置胎盘边缘性前置胎盘低置胎盘胎盘前置状态 凶险性前置胎盘

中央性前置胎盘子宫切除标本

Placenta previa( 前置胎盘 ) Etiology 子宫内膜损伤或病变 胎盘异常 受精卵滋养层发育迟缓 辅助 生殖技术 High risk factors: increased maternal age, prior CS, multiparity( 经产妇 ), and smoking

Placenta previa( 前置胎盘 ) Clinical feature Sudden, Painless vaginal bleeding during late pregnancy (degree depend on the type) The uterus is soft, nontender, the size of uteri is corresponded to its gestational age. but may have uterine contraction. Life-threatening hemorrhage associated with hypovolemic shock An unstable fetal lie, fetal distress in severe cases

Placenta previa( 前置胎盘 ) High risk factors Diagnosis Sudden painless vaginal bleeding during the latter half of pregnancy, soften uterine Solography: simplest, most accuracy (>95%), safest. Definitive diagnosis before delivery 阴道检查 : 慎用 肛查 : 禁用 产后查胎盘胎膜

中央性前置胎盘的超声影像

中央性前置胎盘的 MRI 影像

Placenta previa ( 前置胎盘 ) Maternal-fetal complications Risk of postpartum hemorrage, shock, death Placenta accreta( 粘连 ), increta( 植 入 ), percreta( 穿透 ) Anemia, infection Perinatal ( 围产 )morbidity and mortality increased (prematurity hemorrhage)

Placenta accrete syndromes 正常位置胎盘 :0.004% 前置胎盘 : 9.3% 合并瘢痕 子宫的前置胎盘 :67%

Management of antepartum hemorrage n maternal situation? (amount of hemorrage) n fetal maturity? fetal compromise? ( 有 无窒息 )

Placenta previa ( Management ) Expectant therapy No active bleeding with a premature live fetus (<34w) Rest in bed, hospitalisation? Always prepared to transport to hospital immediately! Tocolysis ( 宫缩抑制剂 ): main way for hemostasis Anemia therapy, Prevention of infection & FGR. The administration of steroid( 糖 皮质激素 ) to promote fetal lung maturity : 24(28) ~34W Fetal monitoring

Placenta previa ( Management ) Delivery:The hemorrhage is severe / life-threatening, or the fetus is reasonably mature(>36w) CS( 剖宫产 ): Cesareen delivery is necessary in practically all cases of placenta previa. ( 抢救休克及 子宫切除的准备 ) Vaginal delivery( 阴道分娩 ): 边缘性或低置胎盘 and cephalic presentation( 头先露 ), fewer bleeding, can be deliveried in short time. Ready for CS!

Placental abruption( 胎盘早剥 ) Premature separation (total or partial) of the normally implanted placenta (>20w) 分类 : 显性 隐性 混合性

Placental abruption ( 胎盘早剥 ) Etiology Vascular deficiency: Hypertension, renal disease, diabetes External trauma ( 创伤 ) Sudden decreased uterine volume: during labor Increased uterine venous presure High risk factors: advancing maternal age, multiparity, smoking, cocaine abuse.

Placental abruption ( 胎盘早剥 ) Pathology: decidual hematoma

Placental abruption( 胎盘早剥 ) Clinical feature: can vary considerably ( 临床上分为 I II III 度 ) Ø Abdominal (uterine) pain or back pain Ø irritable, tender, and often hypertonic( 高张 ) uterus Ø Vaginal bleeding: the symptoms could be out of proportion to the amount of hemorrhage Ø Fetal distress( 胎 儿窘迫 ), demise ( 死胎 ) Ø Hypovolemic shock DIC

Placental abruption( 胎盘早剥 ) Diagnosis Risk factors, abdominal pain/uterine tenderness, viginal bleeding Ultrasound(25%): negative findings can not exclude placental abruption Lab: anemia, coagulopathy

胎盘早剥超声影像

Placental abruption ( 胎盘早剥 ) Complication DIC Uteroplacental apoplexy Hemorrhage & shock Amniotic fluid embolism Renal failure Fetal mortality (50~80 %) 子宫胎盘卒中

Placental abruption ( 胎盘早剥 ) Management Delivery: decided once diagnosis for an expanding abruption or an a major abruption or fetal maturity CS:Severe condition, fetal distress Vaginal delivery:limited separation with close observation, can be deliveried in short time.

Placental abruption ( 胎盘早剥 ) Expectant therapy? Maternal-fetal safety and immature fetus: <34w, I 度胎盘早剥 Tocolytic agents The administration of steroids to promote fetal lung maturity Fetal monitoring

前置胎盘与胎盘早剥的鉴别诊断 前置胎盘胎盘早剥 高危因素经产妇血管病变或外伤史 腹痛无剧烈 阴道出血 外出血, 阴道出血量与全身失血症状成正比 内出血为主, 阴道出血量与全身失血症状不成正比, 血尿 子宫软, 与妊娠月份一致板样硬, 压痛, 可比妊娠月份大 胎位胎心 胎位清楚, 胎心音一般正常 胎位不清, 胎心音弱或消失不明原因死胎的常见原因 阴道检查 子宫口内可触及胎盘组织 无胎盘组织触及 B 超 >95% 的诊断率 有假阴性 并发症失血性休克 胎盘植入子宫胎盘卒中 DIC 死胎

Rupture of the uterus ( 子宫破裂 )

Rupture of the uterus Etiology n Prior hysterotomy Ø Ø CS myomectomy ( intramural or submucous) n Trauma Ø Ø Vehicle accident Obstetric trauma: improper use of oxytocic agent, violent bearing -down efforts, obstructed labor n Placenta percreta

诊断 n 高危因素 子宫破裂 n 产时加剧的耻骨上疼痛或压痛 n 宫缩突然停止伴 撕裂样 感 n 阴道流血或血尿 n 胎先露回缩 n 胎心异常 消失

Rupture of the uterus Treatment Laparotomy must be performed once uterine rupture being diagnosed n Hysterectomy: the preferred treatment for most cases of complete rupture n Uterine repair: childbearing necessary

Rupture of the uterus Preventation n Good judgment before labor to prenvent traumatic delivery n Correct use of oxytocic agent n Good closure of a CS incision

Postpartum hemorrhage ( 产后出 血 ) Bleeding from the genital tract in excess of 500ml ( 500ml) after the birth of fetus. CS 1000ml. q Early postpartum hemorrhage: blood lost during the first 24h after delivery q Late postpartum hemorrhage: blood lost between 24h and 6 weeks after delivery

Hemostasis at the placental bed 正常产后 止 血的机制 Contraction and retraction of the myometrium to compress the vessels surrounded by the interlacing myometrial fibers Pregnancy hypercoagulability:

Postpartum hemorrhage ( 原因 ) 4T Cause Rae Tone Uterine atony 70% ( 子宫收缩乏 力 ) Trauma Obstetric laceration 20% ( 软产道撕伤 ) n Tissue retained placental tissue 10% ( 胎盘滞留或胎盘胎膜残留 ) accreta, increta, percreta ( 胎盘粘连 植 入 ) Thrombin Coagulation defects 1% ( 凝 血功能障碍 )

Coagulation defects Causes of coagulopathy in pregnancy Ø Placenta abruption Ø Pre-eclampsia Ø Amniotic fluid embolism Ø Retained dead fetus Ø Sepsis Hematological disorders & Liver dysfunction diseases

Postpartum hemorrhage ( 产后出 血 ) Clinical feature vaginal bleeding After fetal delivery : n Laceration (fresh-red, immediately, firm uterine) n Placental factors After placental delivery: n Uterine atony n Retained placental fragments Bleeding without clotting :coagulopathy shock, Sheehan s syndrom

Postpartum hemorrhage ( Diagnosis) Evalution of the amount of bleeding accurately! 称重法容积法休克指数 = 脉搏 / 收缩压 (mmhg) Hb 测量 : 下降 10g 约 400~500ml

Management of Postpartum hemorrhage Close observation to find the cause: Evaluation of the uterine tone first Check up the entire birth canal carefully Inspection of every placenta after delivery If the hemorrhage with clot? Hemostasis( 止 血 )immediately according to the causes Blood transfusion Therapy for shock and prevention of infection Evalution of the amount of bleeding accurately!

Hemostasis immediately according to the causes n n n n n n Uterine atony bimanual uterine compression and massage oxytocic agent packing of the uterus B-Lynch brace suture uterine or internal iliac artery ligation angiographic embolization n prompt hysterectomy ( 子宫切除术 )

Bimanual uterine compression and massage 腹部按摩法 腹部 - 阴道联合按压法

Oxytocic agent n Oxytocin( 缩宫素 ) n n n Posterior pituitary extract Acts within 2.5 minutes, IM or IV Generally does not cause side effects n Ergometrine( 麦 角新碱 ) n n Preparation of ergo, IM Contraindicated in women with hypertension or heart disease n Misoprostol( 米索前列醇 ): prostaglandin E 1 analogue

Packing of the uterus

B-Lynch brace suture( 背带缝合 )

Uterine or internal iliac artery ligation

Angiographic embolization ( 血管栓塞 - 介 入技术 )

Hemostasis immediately according to the causes Placental factors Inspection of every placenta after delivery Manual removal of placenta ( 手取胎盘 ) Curettage ( 清宫术 ) Packing of the uterus (placental adhesion) Prompt hysterectomy ( 胎盘植 入 )

Manual removal of placenta

Hemostasis immediately according to the causes Obstetric lacerations Check up the entire birth canal carefully surgical repair of laceration or episiotomy immediately find out if there is hematoma (ligature & drainage) hysterectomy (rupture of the uterine)

Hemostasis immediately according to the causes Coagulation defects Prompt elimination of the cause of coagulopathy Correction of coagulation defects Ø Fresh whole blood/ fresh frozen plasma( 新鲜冰冻 血浆 ) Ø Cryoprecipitate packs( 冷沉淀 ) Ø Platelets ( 血 小板 ) Ø Fibrinogen( 纤维蛋 白原 )

Postpartum hemorrhage Prevention Prenatal care Delivery management Especially third/fourth stage management

Lin Wu