妇产科学课件：产后出血（英文版)

1、,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Post partum hemorrhage,Case,Healthy 32 yo G2P1.,Augmented vaginal delivery,no tears.,Nurse calls you one hour after delivery because of heavy bleeding.,What do you do?,What do you order?,Post partum hemorrhage,Past partum hemorrhage denotes excessive bleeding(,500ml in vaginal delivery)during the first 24 hours after delivery,Common cause of death and diseases in pregnant women globally,Leading cause of death in pregnant women in China,Incidence 2%-3%

2、of total number of deliveries,Etiology,Uterine atony:70%,Obstetric lacerations:20%,Retained placental tissue:10%,Coagulation:1%,Uterine atony,General factors:,extreme nervousness,sedative,anesthesia,tocolytics,weak,Obstetric factors:,prolonged labour,fatigue,placenta previa,placenta abruptio,severe anemia,Uterine factors:,uterine muscular fiber underdevelopment,such as uterine deformity or myoma;uterine overstretched,such as macrosomia,multiple pregnancy,polyhydramnios,Placental factors,Incomple

3、te placental separation,Retained placenta,Placental incarceration（,嵌顿）,Placental adhesion,Placental implantation(accreta,increta,percreta),Residual placenta and amniotic membrane,Birth canal injury,Laceration during labour are usually associated with:,Poor vulval elasticity,Strong labour force,emergency delivery,macrosomia,Inadequate skills at assisted vaginal delivery,Inadequate cessation of bleeding during episiotomy repair,missing out tears at cervix or fornices,Coagulation disorder,Complicat

4、ions associated with obstetric:amniotic fluid embolism,pregnancy induced hypertensive diseases,placenta abruptio and intrauterine demise,Pregnancy liver disease:acute fatty liver,severe hepatitis,Hematology diseases:primary thrombocytopenic purpura,aplastic anemia etc,Clinical presentation,Vaginal bleeding:,If bleeding occurs immediately after delivery of baby,consider birth canal injury,If bleeding occurs minutes after delivery of baby,consider placenta factors,If bleeding occurs minutes after

5、delivery of placenta,main reasons are uterine atony or retained products of conception,Persistent bleeding and blood do not coagulate,consider coagulation disorder causing PPH,Clinical presentation,Vaginal bleeding or hematoma,Shock:dizziness,paleness,weak pulse,low blood pressure etc,Diagnosis,Estimation of blood loss,Ascertain cause of post partum hemorrhage,Estimation of blood loss,Visual observation:only 50%-70%of blood loss,Container:kidney dish,measuring cup,Surface area:blood stained 10cm

6、x10cm=10ml,Weighing:1.05g=1ml,Hct1000ml,Hourly urine output 2500ml,Shock index=pulse rate/systolic pressure,Shock index(SI),SI=0.5,normal blood volume,SI=0.5-1,blood loss 20%,500-750ml,SI=1,blood loss 20-30%,1000-1500ml,SI=1.5,blood loss 30-50%,1500-2500ml,SI=2,blood loss 50-70%,2500-3500ml,Ascertain cause,Uterine atony,Fundus goes up,Uterine consistency soft,water bag like,After uterine massage or using oxytocin,uterus harden,per vaginal bleeding lessen,Categorize into primary and secondary,wit

7、h direct and indirect causes,Ascertain cause,Placental factors:,Placenta not delivered within 10 minutes of delivery of baby,with massive per vaginal bleed,consider placental factors,Residual placenta is a common cause of post partum hemorrhage,Must examine the placenta and membrane carefully,Ascertain cause,Birth canal injury,Cervical tear,Vaginal tear,Vulval tear,Degree of vulval tear,Degree I:vulval skin and vaginal opening mucosa tear,not reaching muscular layer,Degree II:tear into perineal

8、body muscular layer,involving posterior vaginal wall mucosa,may extend up on both sides,making it hard to recognise original anatomy,Degree III:external anal sphincter tear,may involve vaginal rectal septum and anterior rectal wall,Degree of vulval tear,Ascertain cause,Coagulation disorder:,Patients with blood disorder or DIC caused by delivery etc,Sustained per vaginal bleeding,non-clotting,difficulty in hemostasis,May have bleeding at any parts of the body,Diagnose based on history,bleeding ch

9、aracteristics,platelet count,prothrombin time,fibrinogen etc tests,Management,Principal of management for post partum hemorrhage is:,Rapid hemostasis according to the cause,Replenish volume,correct shock,Prevent infection,Management of uterine atony,Remove cause,Uterine massage:,Abdominal fundus massage,Abdominal-vaginal bimanual uterine massage,Uterotonic agents:,oxytocin/,ergot derivatives/prostaglandins,Uterine packing,Pelvis vessel ligation,B-Lynch suture,Arterial embolism,Hysterectomy,Uteri

10、ne massage,Management of uterine atony,Remove cause,Uterine massage:,Abdominal fundus massage,Abdominal-vaginal bimanual uterine massage,Uterotonic agents:,oxytocin/,ergot derivatives/prostaglandins,Uterine packing,Pelvis vessel ligation,B-Lynch suture,Arterial embolism,Hysterectomy,Management of uterine atony,Remove cause,Uterine massage:,Abdominal fundus massage,Abdominal-vaginal bimanual uterine massage,Uterotonic agents:,oxytocin/,ergot derivatives/prostaglandins,Uterine packing,Pelvis vesse

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