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1、1,“Obstetrics is Bloody Business”*,Postpartum Hemorrhage:,*Cunningham, et. al: Williams Obstetrics, 21st ed., 2001,PPH is the leading cause of death related to pregnancy worldwide,2,Major causes of death for pregnancy women（maternal mortality),Postpartum hemorrhage（28%)heart diseasespregnancy-induce
2、d hypertension(or Amniotic fluid embolism )infection,3,Definition of PPH,The early PPH is defined as a blood loss exceeding 500ml after delivery of the infant 24 hThe late PPH: occurs after 24 hour of delivery to 6 weeks,4,Major causes,Uterine atony (90%)Lacerations of the genital tract(6%) Retained
3、 placenta(3%-4%)Coagulation defects (blood dyscrasia) (4T: tone, tissue, trauma, thrombin),Etiology/prediction/prevention/management,5,1. Uterine atony,Local factors:Overdistention of the uterine Condition that interfere with contraction (leiomyoma)Complications (PIH, anemia, placenta previa)Systemi
4、c factors:NervousDrugs Abnormal labor History of previous PPHPreeclampsia, abnormal placentation,Etiology/prediction/prevention/management,6,Pathology,Contraction constricting the spiral arteriesPreventing the excessive bleeding from the placenta implantation siteUterine atony give rise to PPH when
5、no contraction occur,Etiology/prediction/prevention/management,7,Main complain,Have heart palpitationsFeel faintLightheadedBreathless,Etiology/prediction/prevention/management,8,2. Lacerations of the genital tract,Causes:Instrumented delivery (forceps)manipulative delivery (breech extraction, precip
6、itous labor, macrosomia)Types:perineum lacerationvaginal lacerationcervical laceration,Etiology/prediction/prevention/management,9,3. Retained placenta,Separation and explosion of placenta is caused by strong uterine contractionPlacenta tissue remaining in the uterus prevent adequate contraction and
7、 predispose to excessive bleeding,Etiology/prediction/prevention/management,10,4. Coagulation defects,Acquired abnormality in blood clotting:abruption placenta,amniotic fluid embolismsevere preeclampsiaCongenital abnormality in blood clotting:thrombocytopeniasevere hepatic diseasesleukemia,Etiology/
8、prediction/prevention/management,11,disseminated intravascular coagulopathy (DIC),if bleeding persists in spite of all other treatment described, DIC should be suspected the blood passing from the genital tract is not clottingshock: reduction of effective circulation inadequate perfusion of all tiss
9、ues oxygen depletion depression of functions,12,D.D. with PPH,Color, order, amountRisk reasonsClot,“Bloody”,Etiology/prediction/prevention/management,13,Consequences of PPH,Hypovolemic shockBlood transfusion and its attendant complicationsSurgical injury, fever, renal and hepatic failureAcute respir
10、atory distress syndromeDisseminated intravascular coagulopathyLoss of fertility, and Sheehans syndrome,14,CASE,36ys Primiparity, accepted C-section because of marginal placenta and fibroids After birth, PPH happened immediately caused by uterine atony, Oxytocin was used while stitching, but hemorrha
11、ge was continue,15,Risk factors for PPH,Advanced maternal ageMultifetal gestationsProlonged laborPolyhydramniosInstrumental deliveryFetal demisePlacental abruptionAnticoagulation therapy,MultiparityFibroidsProlonged use of oxytocinMacrosomiaCesarean deliveryPlacenta previa and accretaChorioamnioniti
12、sGeneral anesthesia,16,Risk factors for PPH,Advanced maternal ageMultifetal gestationsProlonged laborPolyhydramniosInstrumental deliveryFetal demisePlacental abruptionAnticoagulation therapy,MultiparityFibroidsProlonged use of oxytocinMacrosomiaCesarean deliveryPlacenta previa and accretaChorioamnio
13、nitisGeneral anesthesia,17,Prevention and treatment,The placenta should be examined carefullymanual removal of placentahysterectomy is required for placenta uterine contraction drugs,Etiology/prediction/prevention/management,18,Prevention uterine atony,Administration of medicine: promotes contractio
14、n of the uterine corpus decreases the likelihood of uterine atonyOxytocin agentsProstaglandin,Etiology/prediction/prevention/management,19,management,Vaginal examination soon after delivery repair:cervical laceration 2cm in length and be actively bleedinglaceration of vaginal and perineum,Etiology/p
15、rediction/prevention/management,20,Record:Pulseshock indexblood pressurematernal heart ratecentral venous pressureurine output,Etiology/prediction/prevention/management,21,Lab tests:Hb,BT(bleeding time), CT( clotting time),platelets countfibrinogenprothrombin time and patial thromboplastin timeFDPwo
16、mens blood group and cross-matching,Etiology/prediction/prevention/management,22,Treatment:the key is correcting the coagulation defectresuscitation must be started as soon as possibleinfusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusionblood transfusio
17、n is essentialinfusion of red cells, platelets, fresh frozen plasma, FDP , clotting factors,Etiology/prediction/prevention/management,23,Perineum vaginal and cervical laceration,only skin and a minor part of the perineal bodyperineal body and vaginaanal sphincter and anal canal,Etiology/prediction/p
18、revention/management,24,Stimulation of uterine contraction,Massage of uterus through the abdomen and bimanual compression intrauterine packing,Etiology/prediction/prevention/management,25,Surgical therapy,causing uterine contraction or compressiontamponade the uterine cavity decrease blood supply to
19、 the uterus remove the uterus.,Etiology/prediction/prevention/management,26,Surgical methods,If massage and agents are unsuccessful:Ligation or embolization of the uterine arteriesHysterectomy,Etiology/prediction/prevention/management,27,adherence of placenta (accreta increta pericreta),Etiology/pre
20、diction/prevention/management,28,Potential complications of PPH,Postpartum infectionAnemiaTransfusion hepatitis,Sheehans syndromeAshermans syndromeThe best management of PPH is prevention,Etiology/prediction/prevention/management,29,Resuscitation for PPH,call an assistantresuscitate the patient vigo
21、rously 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 peripheries, pulse and blood pressure, and her urine output.,30,Summary: re
22、member 4 Ts,“TONE”Rule out Uterine Atony,Palpate fundus.Massage uterus.Oxytocin 20U/500cc.Prostaglandin Hemabate IM q 15min,31,Summary: remember 4 Ts,“Tissue”R/O retained placenta,Inspect placenta for missing cotyledons.Explore uterus.Treat abnormal implantation.,32,Summary: remember 4 Ts,“TRAUMA”R/
23、o cervical or vaginal lacerations.,Obtain good exposure.Inspect cervix and vagina.Worry about slow bleeders.Treat hematomas.,33,Summary: remember 4 Ts,“THROMBIN”,Check labs if suspicious.,34,Case-2,37ys, multiparity, was admitted in her 40+2wks for irregular contraction without any abnormal sign.Two
24、 hrs later, the contraction became stronger and membranes ruptured when h with meconium-stained amniotic fluid I degree.7:33 cyanochroia happened with breathless and loss of consciousness in a second.,35,What is the diagnosis,8:20pm still-birth weight 3.2kg.PPH emerged as soon as placenta delivered
25、without any clot.The patient was in the state of unconsciousness and became pale,36,Hysterectomy,Hysterectomy was done soon after resuscitation.The amount was about 4000ml.Red cell was transfused 1600ml, fresh plasma 400ml, platelet 20u, cryoprecipitate 10u. Transfusion was continued after OP 1800ml
26、.,37,，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。,38,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：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，
27、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。,39,Uterine pathology,Cervical blood camp expansion, congestion and the small focal-like bleeding in the small vessels seen in the amniotic fluid composition. Subclavian vein blood smear inspection, mic
28、roscopic examination shows like material and a little meconium keratosis-like material.,40,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。,41,Amniotic fluid embolism,Clinical character Heart and lung failure Bleeding induced by DIC Acute renal failure Diagnosis “amniotic fluid composition” in circulation or tissue,42,Key words,Uterine atonythe definition of PPHAmniotic fluid embolism PROM,43,Questions after class,When you meet a patient with PPH, what you can do as an intern?How can you find the true reasons for PPH in the labor room?,44,谢 谢,
