产后出血子宫破裂课件.ppt

1、妊娠晚期出血、产后出血、妊娠晚期出血、产后出血、子宫破裂、异常产褥子宫破裂、异常产褥浙江大学医学院附属妇产科医院浙江大学医学院附属妇产科医院韩秀君韩秀君1Rationale(why we care)4-5%of pregnancies complicated by 3rd trimester bleedingImmediate evaluation neededSignificant threat to mother&fetus(consider physiologic increase in uterine blood flow)Consider causes of maternal&fet

2、al deathPriorities in management(triage!)2normal hemorrhagelBloody show:-antepartum in active labor the consequence of effacement&dilatation of cervix tearing of small veins 3Definition conditionslThe definition of obstetrical hemorrhage cannot be determined preciselylBleeding500mllNeed transfusionl

3、Hct drop of 10 vol%4Predisposing conditionslPredisposing conditions cannot be determined preciselyl3.9%in vaginal deliveryl68%in cesarean delivery lthe high risk factors56 Causes of hemorrhage causes of hemorrhage number(%)Placental abruption 141(19)Laceration/uterine rupture 125(16)Uterine atony 11

4、5(15)Coagulopathies 108(14)Placental previa 50(7)Uterine bleeding 47(6)Placenta accreta/increta/percreta 44(6)Retained placenta 32(4)7OBSTETRICAL HEMORRHAGElAntepartumlplacental previalplacetal abruptionlvasa previalPostpatrumluterine atonylnormal placentationlgenital tract lacerationlcoagulation de

5、fects 8lDefinition -the placenta is located over or very near the internal os of cervix total partial marginal low-lying9Etiology -multiparity -multifetal gestations -prior cesarean delivery:1.9%(2 times c/sec)4.1%(3 times c/sec)prior uterine incision with a previa increases the incidence of cesarea

6、n hysterectomy -smoking :CO hypoxemia compensatory placetal hypertrophy10DiagnosislThe time of uterine bleeding lduring the later half of pregnancydigital examination:torrential hemorrhage!lsonography -placental location can almost be obtained -transabdominal -transvaginal -transperineal-MRI 11Manag

7、ementl may be considered as follows:1.fetus is preterm 2.indication for delivery or in laborHave indication:partial,less bleeding vaginal delivery 3.fetus is reasonably mature 4.hemorrhage is so severe as to mandate delivery despite fetal immaturity12Management:other considerationsMust consider thes

8、e diagnoses if previa presentPlacenta accreta,increta,percretaCesarean delivery may be necessaryHistory of uterine surgery increases riskCould require further evaluation,imaging(MRI considered now)13Deliverylcesarean deliverylincision(transverse or vertical)lif incision extends through the placenta,

9、maternal or fetal outcome:risk increaseladequate transfusion and cesarean delivery :marked reduction in maternal mortality fail.Hysterectomy!14lDefinition -the separation of the placenta from its site of implantation before delivery Frequency Incidence 0.5-1.5%of all pregnancies -total vs.partial ex

10、ternal vs.concealed :concealed-much greater maternal and fetal hazard -diagnosis typically is made later1516Perinatal mortalityRisk factors for intrauterine fetal death(1988-2009).placental abruption(OR 2.9,95%CI 2.4-3.5,p 500mL after completion of the third stage of labor-late postpartum hemorrhage

11、 :hemorrhage after the first 24 hours POSTPARTUM HEMORRHAGE32PPH Clinical characteristics -the effect of hemorrhage depend to :nonpregnant blood volume :magnitude of pregnancy induced hypervolemia :degree of anemia at the time of delivery :hypovolemic ex)normotensive hypertensive at initially hypert

12、ensive normotensive although remarkably hypovolemic 33PPH Clinical characteristics -with severe preeclampsia :not normally expanded blood volume :very sensitive and intolerant to blood loss :so,when excessive hemorrhage is suspected,prompt vigorous crystalloid and blood replacement 34Estimated blood

13、 losslexcept intrauterine&intravaginal accumulation of blood or intraperitoneal bleeding(uterine rupture)lweight methodlmeasure volumelarea-methodlocular estimatelHblSymptoms and physical findings 35EBLlShock index blood loseShock index blood lose（mlml）rate of blood rate of blood volume volumel 0.60

14、.60.9 5000.9 500750 20%750 20%l=1.0 1000=1.0 10001500 201500 2030%30%l=1.5 1500=1.5 15002500 302500 3050%50%l2.0 25002.0 25003500 503500 5070%70%36Uterine atonysame overall mgmt regardless of delivery typeRecognitionUterine explorationlblood may not escape vaginally-adherent pieces of placenta or la

15、rge blood clots prevent effective contraction and retractionUterine massage37Bleeding unresponsive to medicinesl1.bimanual uterine compression 2.help!3.2nd IV line:crystalloid with medicines 4.blood transfusion 5.explore uterine cavity manually :placental remnant or laceration 6.inspect the cervix a

16、nd vagina 7.foley keep:urine output check(renal perfusion)3839Uterine atonyMedical mgmt:Pitocin(20-80 u in 1 L NS)Long-acting Pitocin(100 iv)Methergine(ergonovine maleate 0.2 mg IM)Not advised for use if hypertensionHemabate(prostaglandin F2)40Uterine atonyB-lynch suture(to compress uterus)Uterine p

17、ackingUterine artery ligationInternal iliac artery ligationUterine artery embolizationHysterectomy(last resort)Anesthesia involvedWhether in L&D room or the OR!41宫腔填塞42Internal iliac artery ligationl-reduce the hemorrhage technically difficult,successful in less than half -nonabsorbable material sut

18、ure -mechanism :85%reduction in pulse pressure in those arteries distal to the ligation :more amenable to hemostasis via simple clot formation -bilateral:dose not interfere subsequent reproduction4344Under what circumstances is arterial embolization indicated?lA patient with stable vital signs and p

19、ersistent bleeding,especially if the rate of loss is not excessive,may be a candidate for arterial embolization.lRadiographic identification of bleeding vessels allows embolization with Gelfoam,coils,or glue.lBalloon occlusion is also a technique used in such circumstances.lEmbolization can be used

20、for bleeding that continues after hysterectomy or can be used as an alternative to hysterectomy to preserve fertility.45Proposed Performance MeasureIf hysterectomy is performed for uterine atonythere should be documentation of other therapy attempts.46Lacerations:RecognitionPerineal,vaginal,cervical

21、,UterineAll can be rather bloody!AssistanceLightingAppropriate repairControl of bleedingIdentify apex for initial stitch placement4748Uterine inversion:ManagementCall for helpManual replacement of uterusUterotonics and Appropriate anesthesia to necessary to relax uterus&allow thorough manual explora

22、tion of uterine cavityConcern for shock to be discussed(and managed by the help youve called into the room!)Exploratory laparotomy may be necessary4950Amniotic fluid embolismlImprove hyoxemialAntiallergiclManagement of shocklPrevention and cure DIClPrevent renal failurelPrevent infectionlManagement

23、of obstetrics51Amniotic fluid embolismHigh index of suspicionRecognitionAgain call for help!Supportive treatmentReplete blood,coagulation factors as ablePlan for delivery(if diagnose antepartum)if able to stabilize mom first52ManagementDeliveryVaginally unless other obstetrical indication,i.e.fetal

24、distress,herpes（HSV),etc.Best to stabilize mother before initiating labor or going to delivery 53子宫破裂子宫破裂54 定义（定义（Definition）l在妊娠期晚期或分娩期子宫体部或子宫下在妊娠期晚期或分娩期子宫体部或子宫下段发生破裂段发生破裂l子宫破裂是产科严重并发症之一子宫破裂是产科严重并发症之一l处理不及时易造成母胎死亡处理不及时易造成母胎死亡 55病因（病因（etiology）l梗阻性难产梗阻性难产l臀位：臀牵引臀位：臀牵引l横位：内倒转横位：内倒转l巨大儿巨大儿l缩宫剂缩宫剂应用不当（

25、米索）应用不当（米索）l不适当的难产手术：不适当的难产手术：l如产钳，宫口未开全时行术或强行牵拉易造成破裂如产钳，宫口未开全时行术或强行牵拉易造成破裂l暴力压腹助产暴力压腹助产l第二产程中助产人员粗暴按压腹部助产时造成子宫破裂第二产程中助产人员粗暴按压腹部助产时造成子宫破裂56病因（病因（etiology）：）：瘢痕子宫瘢痕子宫l妊娠中、晚期可能发生子宫破裂，甚至于自发性妊娠中、晚期可能发生子宫破裂，甚至于自发性破裂破裂l曾行剖宫产手术曾行剖宫产手术(特别是古典式剖宫产特别是古典式剖宫产)l曾行子宫肌瘤剔除术的产妇曾行子宫肌瘤剔除术的产妇l1996年年Chabpmah报告前次中期妊娠发生子宫破

26、报告前次中期妊娠发生子宫破裂的危险为裂的危险为3.8%l1991年年Farmer等报告在等报告在11000例前次剖宫产后的例前次剖宫产后的妊娠中，三分之二试产妊娠中，三分之二试产VBAC，子宫破裂的发生，子宫破裂的发生率为率为0.08%。l前次剖宫产后伴有高热、宫腔感染、伤口愈合不前次剖宫产后伴有高热、宫腔感染、伤口愈合不良者可能性增加良者可能性增加57病因（病因（etiology）l子宫肌壁原有病理改变，妊娠后因子宫肌壁菲子宫肌壁原有病理改变，妊娠后因子宫肌壁菲薄，偶有可能发生自发性破裂薄，偶有可能发生自发性破裂l子宫畸形子宫畸形l子宫发育不良子宫发育不良l子宫穿孔史因子宫肌层受损而妊娠晚期

27、发生子子宫穿孔史因子宫肌层受损而妊娠晚期发生子宫破裂宫破裂l双子宫破裂术后双子宫破裂术后l宫腔镜电切割、宫角妊娠宫腔镜电切割、宫角妊娠58诊断诊断l先兆子宫破裂：先兆子宫破裂：l烦躁不安、下腹剧痛烦躁不安、下腹剧痛l病理性缩复环病理性缩复环l血尿血尿l子宫破裂子宫破裂l撕裂样疼痛撕裂样疼痛l疼痛缓解疼痛缓解l整个下腹压痛、反跳痛整个下腹压痛、反跳痛l阴道少量血阴道少量血59处理：先兆子宫破裂处理：先兆子宫破裂先兆子先兆子宫破裂宫破裂立即采取有立即采取有效措施抑制效措施抑制子宫收缩子宫收缩尽快行剖宫尽快行剖宫产术产术术中注意检术中注意检查子宫是否查子宫是否已有破裂已有破裂静脉或全静脉或全麻、肌肉

28、麻、肌肉注射度冷注射度冷丁丁100mg60处理：子宫破裂处理：子宫破裂l积极纠正休克积极纠正休克l迅速剖腹取胎迅速剖腹取胎l子宫去留问题：子宫去留问题：l孕妇生命体征、出血量孕妇生命体征、出血量l裂伤部位、程度、时间裂伤部位、程度、时间l是否感染是否感染l子宫下段破裂者，应注意检查膀胱、输尿管、子宫下段破裂者，应注意检查膀胱、输尿管、宫颈及阴道，若有损伤，应及时修补。宫颈及阴道，若有损伤，应及时修补。l术中、术后应用较大剂量广谱抗生素控制感染术中、术后应用较大剂量广谱抗生素控制感染61预防预防l加强产前检查加强产前检查l提倡自然分娩，降低剖宫产率提倡自然分娩，降低剖宫产率l高危因素，估计分娩可

29、能有困难，有难产史，高危因素，估计分娩可能有困难，有难产史，有剖宫产史者，应提早住院分娩有剖宫产史者，应提早住院分娩l提高观察产程进展能力，根据产科指征及前次提高观察产程进展能力，根据产科指征及前次手术经过决定分娩方式。手术经过决定分娩方式。l严格掌握应用缩宫素的指征、用法、用量，同严格掌握应用缩宫素的指征、用法、用量，同时应有专人守护时应有专人守护62预防预防l对有子宫瘢痕、子宫畸形的产妇试产，要严密对有子宫瘢痕、子宫畸形的产妇试产，要严密观察产程并放宽剖宫产指征观察产程并放宽剖宫产指征;严密观察产程，严密观察产程，l对于先露高、有胎位异常的孕妇试产更应仔细对于先露高、有胎位异常的孕妇试产更

30、应仔细观察观察l避免损伤性大的阴道助产及操作避免损伤性大的阴道助产及操作l中高位产钳中高位产钳l宫口未开全即助产宫口未开全即助产l忽略性肩先露行内倒转术忽略性肩先露行内倒转术l胎盘植入时强行挖取胎盘植入时强行挖取63异常产褥异常产褥64产褥感染产褥感染l定义定义(definition)l产褥感染产褥感染:是指分娩时及产褥期生殖道受到病原体是指分娩时及产褥期生殖道受到病原体感染，引起局部和全身的炎性变化。发病率为感染，引起局部和全身的炎性变化。发病率为1%7.2%l产褥病率产褥病率(puerperal morbidity)：分娩：分娩24小时以小时以后的后的10日内口表每日测量日内口表每日测量4

31、次，体温有次，体温有2次达到或次达到或超过超过38l产褥病率的大部分原因是产褥感染产褥病率的大部分原因是产褥感染l但也包括生殖道以外的感染但也包括生殖道以外的感染l例如：乳腺炎例如：乳腺炎,上呼吸道感染上呼吸道感染,泌尿系感染泌尿系感染65病因病因(etiology)l分娩降低或破坏生殖道的防御功能和自净作用分娩降低或破坏生殖道的防御功能和自净作用l增加病原体侵入生殖道的机会增加病原体侵入生殖道的机会l产妇体质虚弱、孕期贫血、胎膜早破、产科手术产妇体质虚弱、孕期贫血、胎膜早破、产科手术操作、产程延长、产后出血过多等操作、产程延长、产后出血过多等66病原体病原体l需氧菌需氧菌l-溶血性链球菌：重

32、症感染溶血性链球菌：重症感染l大肠杆菌、大肠杆菌、粘质沙雷氏菌粘质沙雷氏菌l葡萄球菌葡萄球菌l厌氧菌厌氧菌l消化球菌、消化链球菌（咽峡链球菌）消化球菌、消化链球菌（咽峡链球菌）l杆菌杆菌l产气荚膜杆菌产气荚膜杆菌l支原体、衣原体支原体、衣原体67临床表现临床表现 (Clinical manifestation)l急性外阴、阴道、宫颈炎急性外阴、阴道、宫颈炎l急性子宫内膜炎、子宫肌炎急性子宫内膜炎、子宫肌炎l急性盆腔结缔组织炎、急性输卵管炎急性盆腔结缔组织炎、急性输卵管炎l急性盆腔腹膜炎及弥漫性腹膜炎急性盆腔腹膜炎及弥漫性腹膜炎l血栓静脉炎血栓静脉炎l盆腔血栓性静脉盆腔血栓性静脉l下肢血栓性静脉

33、：股白肿下肢血栓性静脉：股白肿l颅内血栓性静脉炎颅内血栓性静脉炎l脓毒血症及败血症脓毒血症及败血症68诊断诊断l病史病史l体征体征l辅助检查辅助检查l血尿常规、血尿常规、CRP、ESR、降钙素原、降钙素原l培养培养+药敏药敏lB超、超、CT、MRI69治疗治疗l一般治疗一般治疗l半卧位以利脓液流于骨盆腔半卧位以利脓液流于骨盆腔l重症患者应少量多次输新鲜血或血浆、白蛋白，以重症患者应少量多次输新鲜血或血浆、白蛋白，以提高机体免疫力提高机体免疫力l抗感染治疗抗感染治疗l首选广谱高效抗生素：足量、有效首选广谱高效抗生素：足量、有效l提高机体的应急能力提高机体的应急能力l病情危重者可短期加用肾上腺皮质

34、激素病情危重者可短期加用肾上腺皮质激素70治疗治疗l血栓性静脉炎的治疗血栓性静脉炎的治疗l抗感染同时，加用肝素，维持抗感染同时，加用肝素，维持47日日l亦可加用活血化瘀中药以及溶栓类药物亦可加用活血化瘀中药以及溶栓类药物l尿激酶尿激酶l治疗血栓栓塞的有效溶栓药物治疗血栓栓塞的有效溶栓药物l直接催化纤溶酶原转化成纤溶酶直接催化纤溶酶原转化成纤溶酶l降解已形成的纤维蛋白降解已形成的纤维蛋白l宫腔残留：宫腔残留：清宫清宫l脓肿：脓肿：切排引流切排引流l严重的子宫感染严重的子宫感染l经积极的抗感染治疗无效，病情继续扩展恶化者，尤其是出经积极的抗感染治疗无效，病情继续扩展恶化者，尤其是出现败血症、脓毒血

35、症者现败血症、脓毒血症者l果断及时地行子宫切除术果断及时地行子宫切除术71领域中目前存在的主要领域中目前存在的主要问题及研究发展趋势问题及研究发展趋势72羊水栓塞羊水栓塞amnionic fluid embolism诊断诊断l临床症状、体征临床症状、体征l急性低血压和急性低血压和/或心脏骤停或心脏骤停l急性缺氧急性缺氧(呼吸困难呼吸困难,发绀和发绀和/或呼吸停止或呼吸停止)l凝血障碍凝血障碍(弥散性血管内凝血和弥散性血管内凝血和/或严重出血或严重出血)l昏迷和痉挛昏迷和痉挛l发病急骤者，可于数分钟内死亡发病急骤者，可于数分钟内死亡l实验室检查实验室检查l心电图、心超、胸片心电图、心超、胸片l血

36、氧饱和度、血氧饱和度、BP突然下降突然下降l凝血功能的检查凝血功能的检查l母体循环或肺组织中羊水成份的检测母体循环或肺组织中羊水成份的检测l尸检尸检73诊断进展诊断进展l母血清及肺组织中的神经氨酸母血清及肺组织中的神经氨酸-N-乙酰氨基半乳糖乙酰氨基半乳糖（SialylTn）抗原检测）抗原检测l用灵敏的放射免疫竞争检测法定量测定血清中的SialylTn抗原l简单、敏感、非创伤性l可用于羊水栓塞的早期诊断l组织抗凝因子的测定组织抗凝因子的测定l羊水中的有形成分不是引起羊水栓塞的主要原因l组织因子样促凝物质、白三烯等l发生后大约40%的患者出现致死性的DICl组织因子的凝血活性可被抗组织因子蛋白拮

37、抗l理论上可以通过检测母血中的组织因子作为区分理论上可以通过检测母血中的组织因子作为区分其他产科其他产科DICDIC的依据的依据74诊断进展诊断进展l肺组织中肥大细胞的测定肺组织中肥大细胞的测定l发生机理是机体对羊水中的胎儿成分产生过敏发生机理是机体对羊水中的胎儿成分产生过敏反应反应l导致肥大细胞脱颗粒释放组织胺类胰蛋白酶和导致肥大细胞脱颗粒释放组织胺类胰蛋白酶和其他介质，引起机体发生严重的病理生理改变其他介质，引起机体发生严重的病理生理改变l类胰蛋白酶是一种中性蛋白酶，是类胰蛋白酶是一种中性蛋白酶，是T细胞和肥大细细胞和肥大细胞分泌颗粒的主要成分。胞分泌颗粒的主要成分。75诊断进展诊断进展l

38、肺组织中肥大细胞的测定肺组织中肥大细胞的测定lFineschi等用特殊的免疫组化方法检测肺循环等用特殊的免疫组化方法检测肺循环中肥大细胞类胰蛋白酶中肥大细胞类胰蛋白酶l发现因羊水栓塞和过敏性休克死亡者肺组织中发现因羊水栓塞和过敏性休克死亡者肺组织中肥大细胞数量都明显升高，两者之间无差异肥大细胞数量都明显升高，两者之间无差异l死于创伤性休克者肺组织肥大细胞数量明显低死于创伤性休克者肺组织肥大细胞数量明显低于羊水栓塞和过敏性休克者，存在显著的差异。于羊水栓塞和过敏性休克者，存在显著的差异。l表明用免疫组化检测肺肥大细胞类胰蛋白酶可表明用免疫组化检测肺肥大细胞类胰蛋白酶可早期诊断羊水栓塞早期诊断羊水

39、栓塞76Amnionic fluid embolism诊断进展诊断进展lAmniotic Fluid Embolism Pathophysiology Suggests the New Diagnostic Armamentarium:-Tryptase and Complement Fractions C3-C4 Are the Indispensable Working Tools.l羊水栓塞病理生理学表明,新的诊断医疗设备:-Tryptase类胰蛋白酶和补体片段C3-C4是是不可或缺的工具Busard FP1,Frati P2,3,Zaami S4,Fineschi V5.2015,16(3),6557-6570;doi:10.3390/ijms160365577778