美国ACOG产后大出血治疗策略-PostPartumHemorrhage.ppt
Post Partum Hemorrhage,District I ACOG Medical Student Teaching Module 2010,Post Partum Hemorrhage - Definition,Commonly defined as. SVD 500cc blood loss C/S 1000cc blood loss *PPH generally refers to GA 20wks,Other Definitions,Hematocrit Change defined as change 10% but not useful in acute setting Need for Transfusion variable practice Hemodynamic stability Timing early or late Symptomatic,Relevance,One of top five causes of maternal mortality anywhere #1 cause maternal mortality worldwide Developed countries 1/100 000 births compared to 1/1000 births in developing countries Incidence 5% - 10% deliveries (depends on defn),Physiologic Adaptations of Pregnancy, plasma volume 40-50% RBC 20-30% *in severe PIH - hemoconcentration,Normal Mechanism of Hemostasis,Living ligatures Baskett 2000 Intrinsic vasospasm Local decidual hemostatic factors including tissue factor & type 1 plasminogen activator inhibitor clotting factors (except I and XI),Blood Loss Estimation,All studies show gross underestimation of blood loss at delivery Visual estimation especially unreliable for small and large amounts of blood loss Prasertcheroensuk et al (2000) - 228 women in 3rd stage - 500cc : visual (5.7%) actual (27.63%) - 1000cc: visual (.44%) actual (3.51%) *Incidence underestimated 90%,Primary, Early or Acute PPH,Delivery - 24h PP 90% PPH cases Associated with more bleeding,Secondary or Late PPH,24h 12 weeks postpartum Affects 1-3% of all deliveries Common causes include: - infection - RPOC - Abnormal uterine involution,Etiology,4 Ts -Tone -Tissue -Trauma -Thrombin,Uterine Atony,75-90% PPH Mostly associated with 10 PPH 6% after c/s Risk factors after c/s incl multiples, Hispanic ethnicity, induced/augmented labor, macrosomia, and chorioamnionitis,Tissue,Retained placenta 10% PPH cases 10% placentas have fundal implantation Placenta accreta 0.005% of all deliveries 90% of accretas have PPH and 50% of these have hyst,Trauma,10 cause PPH in 20% cases Injury to genital tract during delv OR 1.7 65% uterine inversions have PPH 48% uterine inversions have bld transfusion,Thrombin,1% cases of PPH Known association with coagulation failure - abruption - PIH - sepsis - IUFD - incompatible blood - abortion,Risk Factors in PPH,Factors Associated With PPH,Retained Placenta (OR 3.5) Failure to Progress 2nd Stage (OR 3.4) Placenta Accreta (OR 3.3) Lacerations (OR 2.4) Instrumental Delivery (OR 2.3) Large For GA Newborn (OR 1.9) Hypertensive Disorders (OR 1.7) Induction of Labor (OR 1.4) Augmentation of Labor With Oxytocin (OR 1.4),Factors Associated With PPH,DM 30-35% compared to 5-10% Inherited coagulopathies most common is VWB (1-3% prevalence) - 70% have type 1 ( factor VIII, vW Ag, vW factor activity) - risk PPH 22% with vWD & 18% hemophilia,Additional Risk Factors,Age 35y Asian or Hispanic ethnicity Obesity Post dates 42 wks Previous PPH Placenta Previa,Key Management Issues,Prevention Early Recognition Immediate Appropriate Intervention,Blood Loss Signs & Symptoms,2500cc blood loss 50% mortality if not managed urgently & appropriately,Initial Management,ABCs Call for help Mobilize team (staff, anesthesia, blood bank etc) IV access Fluid resuscitation Examine patient including fundal massage, dx trauma/ inversion/ other etiologies, and fundal massage Foley catheter Blood work (CBC, coag profile, cross match) Reverse coagulation abnormality,Uterotonic Medications,Oxytocin Ergot Hemabate Misoprostol Vasopressin,Drug Therapy For PPH,Surgical Management,Curettage Embolization Tamponade (Balloon, packing etc) Compression sutures Vessel ligation Hysterectomy,Tamponade,Bakri Balloon - Silicone balloon - 500cc capacity Foley catheter with 30cc balloon Sengstaken-Blakemore Balloon Vaginal packing Saline filled glove,B-Lynch Suture,Vessel Ligation,Vessel Ligation,Uterine - OLeary Stitch - Chromic 0 passed through lateral aspect of lower segment as close to cervix as possible and then through broad ligament lateral to vessels Ovarian - distal to cornua by passing suture through myometrium medial to vessels,Recombinant Activated Factor VIIa,Tx of bleeding disorders Dose up to 120mcg/kg q2h until hemostasis Promising but needs more studies $10,000/mg Risk thromboembolism,Step 1 Initial Assessment,Resuscitation Large bore ivs O2 Vitals ±foley catheter,Dx Etiology -explore uterus (tone/tissue) -explore genital tract (trauma) -review history (thrombin) -observe clots,Labs -CBC -coag profile -cross match,Step 2 Directed Therapy,Tone -massage -compress -drugs,Tissue -manual removal -curettage,Trauma -correct inversion -repair laceration -identify rupture,Thrombin -reverse anticoagulation -replace factors,Step 3 Intractable PPH,Get Help -OB/Surgery -Anesthesia -Lab/Blood Bank -ICU,Local Control -manual compression -±pack uterus -±vasopressin -±embolization,BP and Coagulation -crystalloids -blood products,Step 4 - Surgery,Repair Lacerations,Ligate Vessels -uterines -ovarian -internal iliac,Hysterectomy,Step 5 Post Hysterectomy Bleeding,Abdominal Packing,Embolization,Secondary PPH,Generally less bleeding Mostly related to infection or RPOC No RCTs Abx/uterotonics as appropriate Evacuation,
