4-产前及产后出血.ppt

1、产前及产后出血Antepartum and Postpartum Hemorrhage,赵晓东 北京医院妇产科,产前及产后出血-概论,产前和产后出血是孕产妇死亡的首位原因。 Antepartum and postpartum hemorrhage remain one of the leading causes of obstetric morbidity and mortality throughout the world. Between 17 and 25 percent of all pregnancy-related deaths can be directly attributed

2、 to hemorrhage. 我国统计，占40%-50%的孕产妇死亡原因,产前及产后出血-概论,机体为适应产时生理性失血的生理性改变： 1.The average singleton pregnancy has a 40- to 50-percent increase in plasma volume, which occurs by the 30th week of gestation. 2.Red blood cell mass can be expected to increase 20 to 30 percent by the end of pregnancy. 3.Cardiac

3、output is 30 to 50 percent above nonpregnant levels. 4.Fibrinogen and the majority of procoagulant blood factors (I, VII, VIII, IX, and X) increase during pregnancy.,产前及产后出血-概论,关于产后出血量的统计： 美国统计：阴道分娩平均500ml(50%500ml),剖宫产1000ml，急诊子宫切除术3500ml，严重的出血（HCT降10%或需输血）约为阴道分娩中的4%，剖宫产中6%。 我国产后出血治疗组的统计,阴道分娩失血量24小

4、时为398238ml,36%的正常阴道分娩400ml,剖宫产475.3263.2ml。 WHO产后出血技术小组提出：靠临床估计和测量比实际失血量低估30-50%。,产前及产后出血-概论,产科出血的定义： 我国产后出血的定义：500ml。 美国等：按失血量的比例定义。 The average 60-kg pregnant woman maintains a blood volume of 6,000 ml by 30 weeks gestation. Class 1 hemorrhage：900-ml blood loss（15%）. Asymptomatic. Class 2 hemorrha

5、ge:1,200- to 1,500-ml blood loss（20%- 25%）.Tachycardia, tachypnea, narrowed pulse pressure, orthostatic hypotension, delayed hypothenar refilling Class 3 hemorrhage: 1,800 to 2,100 ml (30% to 35%). Worsening tachycardia (120 to 160 beats/minute), tachypnea (30 to 50 breaths/minute), overt hypotensio

6、n, and cool extremities. Class 4 hemorrhage: more than a 2,400-ml blood loss (40%). Shock, oliguria/anuria,产前及产后出血-原因,1、产前流产、异位妊娠、胎盘疾病（前置胎盘、胎盘早剥、边缘血窦破裂、前置血管破 裂）、子宫破裂、宫颈阴道病变、血液病等内科疾病。 2、产后 早期（24小时内）子宫迟缓、胎盘组织残留或粘连植入、产道损伤、DIC、子宫破裂、血液病等内科疾病。 晚期（24小时42天）： 子宫复旧不良、胎膜胎盘残留、副胎盘、会阴伤口感染裂开、剖宫产子宫切口感染裂开等。,产前及产后出血-

7、前置胎盘 （ placenta previa ）,定义： Placenta previa is defined as the presence of placental tissue over or adjacent to the cervical os. Traditionally three variations of placenta previa are recognized: complete, partial, and marginal. Contemporary classification of placenta previa consists of two variation

8、s: placenta previa, in which the cervical os is covered by placental tissue, and marginal placenta previa, in which the placenta lies within 2 to 3 cm of the cervical os but does not cover it. 孕28周后诊断？孕28周前诊断前置胎盘状态？ 发生率： The overall reported incidence of placenta previa at delivery is 4/1,000 delive

9、ries.,产前及产后出血-前置胎盘 （ placenta previa ）,病因及高危因素： Increasing parity Increasing maternal age Cigarette smoking Residence in higher altitude Multiple gestations Previous placenta previa Prior curettage Prior cesarean delivery: In the pregnancy following a cesarean delivery, the risk of placenta previa h

10、as been reported to be between 1 and 4 percent. In patients with four or more cesarean deliveries, the risk of placenta previa approaches 10 percent.,产前及产后出血-前置胎盘 （ placenta previa ）,临床表现及诊断： Placenta previa typically presents as painless vaginal bleeding in the second or third trimester. 出血多了会有母亲和胎

11、儿的相应异常表现。 Sonography ： Although transabdominal ultrasound can detect at least 95 percent of placenta previa cases, transvaginal ultrasound has a reported diagnostic accuracy approaching 100 percent. More than 90 percent of the cases of placenta previa diagnosed in the midtrimester resolve by term. C

12、omplete placenta previa will persist in 26 percent of cases, whereas marginal placenta previa will persist in only 2.5 percent of cases.,产前及产后出血-前置胎盘 （ placenta previa ）,鉴别诊断： 应与胎盘早剥、宫颈病变等鉴别,产前及产后出血-前置胎盘（ placenta previa ）,处理： 根据有母亲的情况、无阴道流血、阴道流血量多少、胎儿情况、孕周、胎位、分娩条件、是否临产等做出决定。 1.期待疗法 立即评估母亲、胎儿情况，如果母亲

13、、胎儿情况都好、出血不太多、未足月，可以暂时期待，延长孕周，改善胎儿预后。 严密监护、评估母亲、胎儿情况； 地塞米松促胎肺成熟； 抑制宫缩（硫酸镁或安宝等）； 补血或输血； Rh阴性、未致敏母亲给予免疫球蛋白预防； 做好新生儿抢救、输血的准备； 适时分娩；,产前及产后出血-前置胎盘（ placenta previa ）,处理： 2.终止妊娠： （1）终止妊娠指征：发病时母亲或胎儿有危险者；发病时胎龄达36周以后或胎儿成熟度检查提示胎儿肺成熟者；期待治疗中病情加重影响母亲或胎儿者。 （2）剖宫产术：除极少部分边缘性、出血少、产时安全者，绝大部分前置胎盘以剖宫产终止妊娠。备血2-4u；提防胎盘植入

14、等罕见情况的发生；注意产后出血的预防和及时处理。,产前及产后出血-胎盘早剥 （ placenta abruption ）,定义： Placental abruption, or abruptio placenta, refers to the premature separation of a normally implanted placenta from the uterus. 妊娠20周后或分娩期，正常位置的胎盘在胎儿娩出前，部分或全部从子宫剥离，称胎盘早剥（placental abruption）。 发病率：Placental abruption complicates 1 in 75

15、 to 1 in 226 deliveries. Approximately one third of all antepartum bleeding can be attributed to placental abruption. 妊娠结局：围产儿死亡20%-30%，早产增加4倍。母亲产后出血、DIC、子宫切除率显著增加。,产前及产后出血-胎盘早剥 （ placenta abruption ）,病因及高危因素： Increasing parity and/or maternal age Cigarette smoking Cocaine abuse Trauma Maternal hype

16、rtension: the most consistently identified risk factor, 40 to 50 percent of grade 3 abruption cases have underlying hypertensive disease. Preterm premature rupture of membranes Multiple gestation or Polyhydramnios with rapid uterine decompression Uterine malformations or fibroids Previous abruption,

17、产前及产后出血-胎盘早剥 （ placenta abruption ）,临床表现及诊断：孕期任何腹痛、持续宫缩、阴道流血、胎儿情况不佳者，均需要排查胎盘早剥，超声检查和凝血系统检查是必要的辅助检查。 临床表现： 一般分3度： 1度：约占40%，轻度剥离，阴道出血少，宫缩轻，母亲血压正常，母亲纤维蛋白原正常，胎心正常。 2度：占45%，部分剥离，阴道出血轻到中度，宫缩显著，母亲血压正常，但心率加快或体位性低血压，母亲纤维蛋白原正常或轻度下降，胎心不好。 3度：占15%，大部或全部剥离，阴道出血中到重度，宫缩显著，常有腹痛（尤其是10%-20%的隐性出血者），母亲血压降低，母亲纤维蛋白原下降，胎儿

18、多死亡。,产前及产后出血-胎盘早剥 （ placenta abruption ）,超声表现：检出率不是很高，尤其是显性出血者。 表现为3型： Subchorionic (between the placenta and the membranes) Retroplacental (between the placenta and the myometrium) Preplacental (between the placenta and the amniotic fluid),产前及产后出血-胎盘早剥 （ placenta abruption ）,实验室检查： 血常规、尿常规、生化、肝肾功能等

19、基本检查 凝血系统检查是必须的，虽然大部分病例没有改变 若可疑DIC，进行血小板计数、凝血酶原时间、纤维蛋白原测定、3P试验、FDP定量等。,产前及产后出血-胎盘早剥 （ placenta abruption ）,处理： 根据临床表现、母亲和胎儿的情况、孕周、宫颈条件等综合判断终止妊娠的时机和方式。 对于足月或胎儿已经成熟病例，应立即终止妊娠。 对于2/3度早剥者，应立即终止妊娠。 对于远离预产期的1度早剥者，可以短期观察，延长孕周，以期改善胎儿预后。 严密观测母亲及胎儿的各项指标； 给予宫缩抑制剂； 给予地塞米松促胎肺成熟； 结局：有大样本报道，1/3病人48小时内终止妊娠，1/3病人推迟小

20、于1周，1/3病人推迟超过1周，没有胎儿死亡发生。 要小心母亲、胎儿情况，一旦恶化，立即终止妊娠。,产前及产后出血-胎盘早剥 （ placenta abruption ）,处理： 终止妊娠的方式多选择剖宫产。注意产后出血。注意宫缩乏力与DIC的并存。按压子宫、应用缩宫剂是必须的；补充纤维蛋白原、血小板、血浆等，应用抗纤溶药物，有时是非常必要的；有时需要手术止血，甚至切除子宫。 8%的病人可发现子宫胎盘卒中（Couvelaire uterus ） 40%的重度早剥会发生DIC 重度早剥8小时后纤维蛋白原开始下降 终止妊娠后，纤维蛋白原大体上以10mg/dl/h的速度上升,产前及产后出血-胎盘早剥

21、 （ placenta abruption ）,处理： 阴道分娩：以显性出血为主，宫口已开大，经产妇，一般情况较好，估计短时间内能结束分娩者可经阴道分娩。先行破膜减张，使羊水缓慢流出，用腹带包裹腹部，压迫胎盘使其不再继续剥离，并可促进子宫收缩，必要时静脉滴注缩宫素缩短产程。分娩过程中，密切观察血压、脉搏、宫底高度、宫缩与出血情况，仔细听取胎心，用胎儿电子监测仪监护。早期发现异常情况及时处理，必要时改行剖宫产。,产前及产后出血-胎盘植入 （ placenta accreta ）,定义：粘连、植入、穿透 Placenta accreta represents the abnormal attach

22、ment of the placenta to the uterine lining due to an absence of the deciduas basalis and an incomplete development of the fibrinoid layer. Variations of placenta accreta include placenta increta and placenta percreta, in which the placenta extends to and through the uterine myometrium, respectively.

23、 The overall incidence of placenta accreta or one of its variations is 1 in 533 deliveries.,产前及产后出血-胎盘植入 （ placenta accreta ）,病因及高危因素： Placenta previa Prior cesarean delivery The risk of placenta accreta dramatically increases with one or more cesarean deliveries. Other risk factors: Increasing pari

24、ty and maternal age Prior uterine surgery Endometrial defects.,Risk of Placenta Accreta with Placenta Previa and Prior Cesarean Delivery,产前及产后出血-胎盘植入 （ placenta accreta ）,临床表现和诊断： 一般表现为胎盘娩出困难或仅仅娩出部分，伴有产后出血。 产前超声诊断的敏感性和特异性可达85%和90%，表现为：正常胎盘-子宫肌层低回声交界消失、断裂;紧贴子宫浆膜下存在与胎盘回声相同的扩张的块样组织回声，可见丰富血供;胎盘组织的回声影直接延

25、伸至子宫浆膜层外胎盘穿透的特异表现。 MRI在判断膀胱是否累及和子宫后、侧壁的植入性胎盘较有价值 对于前置胎盘，尤其有剖宫产史的患者，要特别注意是否有胎盘植入问题。,产前及产后出血-胎盘植入 （ placenta accreta ）,处理： 至少2/3需要子宫切除，有学者建议断脐带后将胎盘留在原地，直接切除子宫，可以大大减少产后出血。 对于保留生育能力者，根据植入的程度，可以直接剥离胎盘、创面缝合或填塞；可以留下胎盘，动脉栓塞及MTX治疗。,产前及产后出血-胎盘血管前置 （ Vasa Previa ）,定义： Vasa previa is defined as the velamentous

26、insertion of fetal vessels over the cervical os. The overall perinatal mortality for vasa previa is between 58 and 73 percent. The incidence of vasa previa has been reported as 1/2,000 to 5,000 deliveries.,产前及产后出血-胎盘血管前置 （ Vasa Previa ）,病因及高危因素： 胎盘形态异常 low-lying placentas Pregnancies resulting from

27、in vitro fertilization Multiple gestations History of second-trimester placenta previa.,产前及产后出血-胎盘血管前置 （ Vasa Previa ）,临床表现和诊断： 通常是事后发现：Acute onset of vaginal bleeding and subsequent fetal bradycardia or death after membrane rupture 产前评估先露状态时偶然发现：Palpation of the fetal vessels within the membranes d

28、uring labor 产前超声检查：先露前发现脐血流,产前及产后出血-胎盘血管前置 （ Vasa Previa ）,处理： 产时发现：立即剖宫产，抢救胎儿 产前发现：交待病情；孕晚期住院；促胎肺；密切观测；预计胎儿成熟剖宫产,产后出血 （POSTPARTUM HEMORRHAGE ）,定义：不同地区定义不同，有的有固定标准（如我国500ml）；有的定义为血球压积减少10%；有的定义为需要输血 The average blood loss for a vaginal delivery, cesarean delivery is 500 ml and 1,000 ml respectively.

29、 发生率：一般5%,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 定义：the inability of the uterine myometrium to contract effectively 发生率：1 in 20 deliveries,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 病因及高危因素： Uterine overdistention (multiple gestation, polyhydramnios, fetal macrosomia) Prolong

30、ed oxytocin use Rapid or prolonged labor Grand multiparity Chorioamnionitis Placenta previa Use of uterine-relaxing agents,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 诊断：rapid uterine bleeding associated with a lack of myometrial tone 处理： 预防：识别高危人群；active management of the third stage of la

31、bor （prophylactic oxytocin ）；spontaneous delivery of the placenta after cesarean delivery,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 处理： 如果预防措施无效，出现产后出血，开始按摩子宫（ bimanual uterine massage）和用宫缩剂（uterotonic therapy）,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 处理： 各种宫缩剂： Oxytocin:10-80

32、 units in 1,000 ml of crystalloid solution, Continuous , Initial treatment starts with 10 to 20 units of oxytocin in 1,000 ml of crystalloid solution. Higher doses (80 units in 1,000 ml) have proven safe and efficacious, with a 20-percent reduction in the need for additional uterotonic therapy when

33、compared with standard dosing. Side effect: water intoxication,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 处理： 各种宫缩剂： 15-Methyl Prostaglandin F2(Hemabate) :0.25 mg , Every 15-90 min (8-dose maximum) Recurrent doses (250 g) can be administered every 15 minutes, if needed, to a maximum of eig

34、ht doses (2 mg). Asthma is a strong contraindication,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 处理： 各种宫缩剂： 卡孕栓（Methyl Carboprost Suppositories）：PGE2；1mg,单剂或每2小时1mg，共3-5mg； 不良反应较多（unfavorable side effect profile that includes fever/chills, nausea/vomiting, diarrhea, and headaches） Misoprost

35、ol (Cytotec) :PGE1；600-1000 mcg , Single dose；不良反应较少（Tachycardia, fever ）,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 处理： 如果缩宫剂无效，阴道分娩者考虑填宫纱（ tamponade ），12-24小时后取出，填塞时别留死腔，填塞后密切观察患者血像，判断效果 如果填宫纱无效，阴道分娩者考虑动脉栓塞，有报道有效率可达97%,产后出血 （POSTPARTUM HEMORRHAGE ）,一、宫缩乏力（Uterine atony ） 处理： 如果上述动脉栓塞无效或没

36、有条件开展，或剖宫产出血按摩药物无效，考虑手术干预： 子宫动脉上行支结扎、卵巢动脉子宫支结扎、卵巢动脉结扎、髂内动脉结扎等结扎术； B-Lynch等子宫缝合术； 子宫切除术。,B-Lynch缝合法,产后出血 （POSTPARTUM HEMORRHAGE ）,二、产道裂伤（Genital tract lacerations ） 定义： The most common lower genital tract lacerations are perineal, vulvar, vaginal, and cervical. Upper genital tract lacerations are typ

37、ically associated with broad ligament and retroperitoneal hematomas.,产后出血 （POSTPARTUM HEMORRHAGE ）,二、产道裂伤（Genital tract lacerations ） 病因及高危因素： Operative vaginal delivery Fetal malpresentation Fetal macrosomia Precipitous delivery Prior cerclage placement Shoulder dystocia,产后出血 （POSTPARTUM HEMORRHAGE

38、 ）,二、产道裂伤（Genital tract lacerations ） 临床表现及诊断： It should be suspected if bleeding persists after delivery despite adequate uterine tone. 逐个部位检查,产后出血 （POSTPARTUM HEMORRHAGE ）,二、产道裂伤（Genital tract lacerations ） 处理： 依赖于损伤部位和严重程度 一般直接缝合 会阴3/4度裂伤、宫颈或引导穹窿裂伤较难缝合 腹膜后血肿最危险，常常出现血压不稳、危及生命时才被发现。,产后出血 （POSTPARTU

39、M HEMORRHAGE ）,三、胎盘、胎膜因素（Retained Products of Conception ） 定义： Retained products of conception, namely placental tissue and amniotic membranes, can inhibit the uterus from adequate contraction and result in hemorrhage. 发生率：1 in 100 to 1 in 200 deliveries,产后出血 （POSTPARTUM HEMORRHAGE ）,三、胎盘、胎膜因素（Retai

40、ned Products of Conception ） 病因及高危因素： Midtrimester delivery Chorioamnionitis Accessory placental lobes,产后出血 （POSTPARTUM HEMORRHAGE ）,三、胎盘、胎膜因素（Retained Products of Conception ） 临床表现和诊断： Uterine bleeding, often associated with atony, may be due to retained products of conception.,产后出血 （POSTPARTUM HEM

41、ORRHAGE ）,三、胎盘、胎膜因素（Retained Products of Conception ） 处理： 手取胎盘 刮宫,产后出血 （POSTPARTUM HEMORRHAGE ）,四、子宫破裂（Uterine Rupture ） 定义： Uterine rupture refers to the complete nonsurgical disruption of all uterine layers (endometrium, myometrium, and serosa) . The severity of hemorrhage and maternal-fetal morbi

42、dity depends upon the extent of the rupture. 围产儿死亡2%-10%；孕妇死亡极罕见；子宫切除率4%-13%,产后出血 （POSTPARTUM HEMORRHAGE ）,四、子宫破裂（Uterine Rupture ） 发生率： 1 in 2,000 deliveries A prior low transverse uterine incision: 0.2- to 1.5-percent risk of uterine rupture a classical: 4- to 9-percent T-shaped incision and low v

43、ertical incision: 1- to 7-percent,产后出血 （POSTPARTUM HEMORRHAGE ）,四、子宫破裂（Uterine Rupture ） 病因及高危因素： Trial of labor after a prior cesarean delivery, especially interdelivery interval less than 18 months, postpartum fever after prior cesarean delivery or one-layer closure of a prior uterine incision,产后出

44、血 （POSTPARTUM HEMORRHAGE ）,四、子宫破裂（Uterine Rupture ） 病因及高危因素： Other risk factors： Prior myomectomy Maternal age and multiparity Fetal malpresentation Obstructed labor Multiple gestation Uterine manipulation (e.g., internal podalic version) Mid- to high-operative vaginal delivery,产后出血 （POSTPARTUM HEMO

45、RRHAGE ）,四、子宫破裂（Uterine Rupture ） 临床表现和诊断： 母亲持续腹痛、腹痛拒按、子宫下端压痛、腹型改变、血尿、阴道出血、休克等严重出血表现 胎心减速、甚至消失,产后出血 （POSTPARTUM HEMORRHAGE ）,四、子宫破裂（Uterine Rupture ） 处理： 立即剖腹探查，尽量修补，多层缝合,产后出血 （POSTPARTUM HEMORRHAGE ）,五、子宫内翻（Uterine Inversion ） 定义： Uterine inversion refers to the collapse of the fundus into the uter

46、ine cavity. Uterine inversion may be incomplete, complete, or prolapsed. 发生率： 1 in 2,500 deliveries.,产后出血 （POSTPARTUM HEMORRHAGE ）,五、子宫内翻（Uterine Inversion ） 病因及高危因素： The two most commonly proposed etiologies for uterine inversion include excessive umbilical cord traction with a fundally attached pl

47、acenta and fundal pressure in the setting of a relaxed uterus.,产后出血 （POSTPARTUM HEMORRHAGE ）,五、子宫内翻（Uterine Inversion ） 病因及高危因素： Uterine overdistention Fetal macrosomia Prolonged labor Uterine malformations Invasive placentation Short umbilical cord Tocolysis, oxytocin use Manual extraction of the p

48、lacenta,产后出血 （POSTPARTUM HEMORRHAGE ）,五、子宫内翻（Uterine Inversion ） 临床表现和诊断： Sudden onset of brisk vaginal bleeding in association with an absent palpable fundus abdominally and maternal hemodynamic instability. The diagnosis is made clinically with bimanual examination, during which the uterine fundus

49、 is palpated in the lower uterine segment or within the vagina.,产后出血 （POSTPARTUM HEMORRHAGE ）,五、子宫内翻（Uterine Inversion ） 处理： 纠正母亲一般情况，同时在宫缩抑制剂和麻醉下试着将子宫翻回，如果无效，开腹牵拉园韧带，甚至切开子宫复位。,产后出血 （POSTPARTUM HEMORRHAGE ）,六、凝血功能异常（Coagulopathy ） 定义： Coagulopathy represents an imbalance between the clotting and fibrinolytic systems. 临床上多为继发性的 发生概率较低，但在特殊情况下必须考虑到，如胎盘早剥、AFLP等。,产后出血 （POSTPARTUM HEMORRHAGE ）,六、凝血功能异常（Coagulopathy ） 病因及高危因素： Severe preeclampsia Placental abruption Massive antepartum or postpartum hemorrhage Sepsis Amniotic f