Obstetrical Hemorrhage 产科出ccftp.scu.edu.cn/Download/20170921154417710.pdf · 2017-09-21 ·...

Obstetrical Hemorrhage 产科出⾎血

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)   Placental abruption(胎盘早剥)   Uterine bleeding(⼦子宫破裂)   Lower segment scar rupture （既往剖宫产瘢痕⼦子宫再次妊娠分娩）  rupture of other scars （⼦子宫肌瘤挖出术后瘢痕⼦子宫妊娠分娩）

  Cervical lesion(<5%)   Cervical erosion, cervicitis（⼦子宫颈炎）   cervical carcinoma (rare,but must be excluded)   Fetoplacental: 脐带帆状附着⾎血管前置 (very rare)

产前出⾎血（原因）

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

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

 辅助⽣生殖技术

High risk factors: increased maternal age, prior CS, multiparity（经产妇）, and smoking

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）

Diagnosis   High risk factors

  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

Placenta previa（前置胎盘）

中央性前置胎盘的超声影像

中央性前置胎盘的MRI影像

Maternal-fetal complications   Risk of postpartum hemorrage, shock, death

  Placenta accreta（粘连）, increta（植⼊入） ,

percreta（穿透）

  Anemia , infection

  Perinatal （围产）morbidity and mortality increased (prematurity、hemorrhage)

Placenta previa （前置胎盘）

Placenta accrete syndromes 正常位置胎盘：0.004% 前置胎盘: 9.3% 合并瘢痕⼦子宫的前置胎盘：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(糖⽪皮质激素) to promote fetal lung maturity : 24(28) ～34W   Fetal monitoring

  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 !

Placenta previa ( Management )

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

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）

Placental abruption （胎盘早剥）

Pathology: decidual hematoma

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(⾼高张) uterus

Ø  Vaginal bleeding: the symptoms could be out of proportion to the amount of hemorrhage

Ø  Fetal distress(胎⼉儿窘迫), 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

Placental abruption（胎盘早剥）

胎盘早剥超声影像

Complication   DIC   Uteroplacental apoplexy   Hemorrhage & shock   Amniotic fluid embolism   Renal failure   Fetal mortality (50～80 %)

Placental abruption （胎盘早剥）

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.

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

Placental abruption （胎盘早剥）

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

并发症 失血性休克、胎盘植入 子宫胎盘卒中、DIC、死胎

B 超 >95%的诊断率 有假阴性

Rupture of the uterus （⼦子 宫 破 裂）

Rupture of the uterus Etiology n  Prior hysterotomy Ø  CS Ø  myomectomy ( intramural

or submucous) n  Trauma Ø  Vehicle accident Ø  Obstetric trauma:

improper use of oxytocic agent, violent bearing-down efforts, obstructed labor

n  Placenta percreta

⼦子 宫 破 裂 诊断 n  高危因素

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 正常产后⽌止⾎血的机制

  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% (⼦子宫收缩乏⼒力)

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、植⼊入）

Thrombin Coagulation defects 1% （凝⾎血功能障碍）

 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

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 （产后出⾎血）

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

 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(⽌止⾎血)immediately according to the causes

  Blood transfusion

  Therapy for shock and prevention of infection Evalution of the amount of bleeding accurately !

Management of Postpartum hemorrhage

Hemostasis immediately according to the causes

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

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  Posterior pituitary extract n  Acts within 2.5 minutes , IM or IV n  Generally does not cause side effects

n  Ergometrine（⻨麦⾓角新碱） n  Preparation of ergo, IM n  Contraindicated in women with hypertension or

heart disease n  Misoprostol（⽶米索前列醇）: prostaglandin E1 analogue

Packing of the uterus

B-Lynch brace suture（背带缝合）

Uterine or internal iliac artery ligation

Angiographic embolization (⾎血管栓塞-介⼊入技术)

  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 （胎盘植⼊入）

Hemostasis immediately according to the causes

Manual removal of placenta

  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

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（新鲜冰冻⾎血浆） Ø  Cryoprecipitate packs（冷沉淀） Ø  Platelets （⾎血⼩小板） Ø  Fibrinogen（纤维蛋⽩白原）

Prevention

  Prenatal care

  Delivery management

Especially third/fourth stage management

Postpartum hemorrhage

Lin Wu