1、妊娠晚期出血、產(chǎn)后出血、子宮破裂、異常產(chǎn)褥浙江大學(xué)醫(yī)學(xué)院附屬婦產(chǎn)科醫(yī)院韓秀君1妊娠晚期出血、產(chǎn)后出血、子宮破裂、異常產(chǎn)褥浙江大學(xué)醫(yī)學(xué)院附屬Rationale (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 & fetal

2、 deathPriorities in management (triage!)2Rationale (why we care)4-5% onormal hemorrhageBloody show: - antepartum in active labor the consequence of effacement & dilatation of cervix tearing of small veins 3normal hemorrhageBloody show:3Definition conditionsThe definition of obstetrical hemorrhage ca

3、nnot be determined preciselyBleeding500mlNeed transfusionHct drop of 10 vol%4Definition conditionsThe defiPredisposing conditionsPredisposing conditions cannot be determined precisely3.9% in vaginal delivery68% in cesarean delivery the high risk factors5Predisposing conditionsPredisp66 Causes of hem

4、orrhage causes of hemorrhage number(%) Placental abruption 141(19) Laceration/uterine rupture 125(16) Uterine atony 115(15) Coagulopathies 108(14) Placental previa 50(7) Uterine bleeding 47(6) Placenta accreta/increta/percreta 44(6) Retained placenta 32(4)7 Causes of hemorrhage causes OBSTETRICAL HE

5、MORRHAGEAntepartumplacental previaplacetal abruptionvasa previaPostpatrumuterine atonynormal placentationgenital tract lacerationcoagulation defects 8OBSTETRICAL HEMORRHAGEAntepart PLACENTA PREVIADefinition - the placenta is located over or very near the internal os of cervix total partial marginal

6、low-lying9 PLACENTA PREVIADefinition9Etiology - 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 cesarean hysterectomy - smoking : CO hypoxemia compensatory placetal hypertrophy1

7、0Etiology - multiparity 10DiagnosisThe time of uterine bleeding during the later half of pregnancydigital examination : torrential hemorrhage! sonography - placental location can almost be obtained - transabdominal - transvaginal - transperineal - MRI 11DiagnosisThe time of uterine bManagement may b

8、e 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 may be considered aManagement :other consid

9、erationsMust consider these diagnoses if previa presentPlacenta accreta, increta, percretaCesarean delivery may be necessaryHistory of uterine surgery increases riskCould require further evaluation, imaging (MRI considered now)13Management :other consideratiDeliverycesarean deliveryincision (transve

10、rse or vertical)if incision extends through the placenta, maternal or fetal outcome: risk increaseadequate transfusion and cesarean delivery : marked reduction in maternal mortality fail. Hysterectomy !14Deliverycesarean delivery14PLACENTAL ABRUPTION Definition - the separation of the placenta from

11、its site of implantation before delivery Frequency Incidence 0.5-1.5% of all pregnancies - total vs. partial external vs. concealed : concealed - much greater maternal and fetal hazard - diagnosis typically is made later15PLACENTAL ABRUPTION Definition1616Perinatal mortalityRisk factors for intraute

12、rine 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 : hemorrhage after the first 24 hours POSTPARTUM HEMORRHAGE32DefinitionPOSTPARTUM HEMORRHAGPPH Clinical characteristics - the effect of hemorrha

13、ge depend to : nonpregnant blood volume : magnitude of pregnancy induced hypervolemia : degree of anemia at the time of delivery : hypovolemic ex) normotensive hypertensive at initially hypertensive normotensive although remarkably hypovolemic 33PPH Clinical characteristics33PPH Clinical characteris

14、tics - 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 34PPH Clinical characteristics Estimated blood lossexcept intrauterine & intravaginal acc

15、umulation of blood or intraperitoneal bleeding (uterine rupture)weight methodmeasure volumearea-methodocular estimateHbSymptoms and physical findings 35Estimated blood lossexcept intEBLShock index blood lose（ml） rate of blood volume 0.60.9 500750 20% =1.0 10001500 2030% =1.5 15002500 3050%2.0 250035

16、00 5070%36EBLShock index blood loseUterine atonysame overall mgmt regardless of delivery typeRecognitionUterine explorationblood may not escape vaginally- adherent pieces of placenta or large blood clots prevent effective contraction and retractionUterine massage37Uterine atonysame overall mgmtBleed

17、ing unresponsive to medicines1. 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 and vagina 7. foley keep : urine output check (renal perfusion)38Bleeding

18、 unresponsive to medic3939Uterine 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 atonyMedical mgmt:40Uterine atonyB-lynch suture (to compress uterus)Uterine pack

19、ingUterine artery ligationInternal iliac artery ligationUterine artery embolizationHysterectomy (last resort)Anesthesia involvedWhether in L&D room or the OR!41Uterine atonyB-lynch suture (t宮腔填塞42宮腔填塞42Internal iliac artery ligation- reduce the hemorrhage technically difficult, successful in less th

20、an half - nonabsorbable material suture - 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 reproduction43Internal iliac artery ligation4444Under what circumstances

21、is arterial embolization indicated?A patient with stable vital signs and persistent bleeding, especially if the rate of loss is not excessive, may be a candidate for arterial embolization. Radiographic identification of bleeding vessels allows embolization with Gelfoam, coils, or glue. Balloon occlu

22、sion is also a technique used in such circumstances. Embolization can be used for bleeding that continues after hysterectomy or can be used as an alternative to hysterectomy to preserve fertility.45Under what circumstances is arProposed Performance MeasureIf hysterectomy is performed for uterine ato

23、nythere should be documentation of other therapy attempts.46Proposed Performance MeasureIfLacerations:RecognitionPerineal, vaginal, cervical, UterineAll can be rather bloody!AssistanceLightingAppropriate repairControl of bleedingIdentify apex for initial stitch placement47Lacerations:Recognition4748

24、48Uterine inversion:ManagementCall for helpManual replacement of uterusUterotonics and Appropriate anesthesia to necessary to relax uterus & allow thorough manual exploration of uterine cavityConcern for shock to be discussed (and managed by the help youve called into the room!)Exploratory laparotom

25、y may be necessary49Uterine inversion:Management495050Amniotic fluid embolismImprove hyoxemiaAntiallergicManagement of shockPrevention and cure DICPrevent renal failurePrevent infectionManagement of obstetrics51Amniotic fluid embolismImproveAmniotic fluid embolismHigh index of suspicionRecognitionAg

26、ain call for help!Supportive treatmentReplete blood, coagulation factors as ablePlan for delivery (if diagnose antepartum) if able to stabilize mom first52Amniotic fluid embolismHigh inManagementDeliveryVaginally unless other obstetrical indication, i.e. fetal distress, herpes（HSV), etc. Best to sta

27、bilize mother before initiating labor or going to delivery 53ManagementDelivery53子宮破裂54子宮破裂54 定義（Definition）在妊娠期晚期或分娩期子宮體部或子宮下段發(fā)生破裂子宮破裂是產(chǎn)科嚴重并發(fā)癥之一處理不及時易造成母胎死亡55 定義（Definition）在妊娠期晚期或分娩期子宮體部或病因（etiology）梗阻性難產(chǎn)臀位：臀牽引橫位：內(nèi)倒轉(zhuǎn)巨大兒縮宮劑應(yīng)用不當（米索）不適當?shù)碾y產(chǎn)手術(shù)：如產(chǎn)鉗，宮口未開全時行術(shù)或強行牽拉易造成破裂暴力壓腹助產(chǎn)第二產(chǎn)程中助產(chǎn)人員粗暴按壓腹部助產(chǎn)時造成子宮破裂56病因（et

28、iology）梗阻性難產(chǎn)56病因（etiology）：瘢痕子宮妊娠中、晚期可能發(fā)生子宮破裂，甚至于自發(fā)性破裂曾行剖宮產(chǎn)手術(shù)(特別是古典式剖宮產(chǎn))曾行子宮肌瘤剔除術(shù)的產(chǎn)婦1996年Chabpmah報告前次中期妊娠發(fā)生子宮破裂的危險為3.8%1991年Farmer等報告在11000例前次剖宮產(chǎn)后的妊娠中，三分之二試產(chǎn)VBAC，子宮破裂的發(fā)生率為0.08%。前次剖宮產(chǎn)后伴有高熱、宮腔感染、傷口愈合不良者可能性增加57病因（etiology）：瘢痕子宮妊娠中、晚期可能發(fā)生子宮破病因（etiology）子宮肌壁原有病理改變，妊娠后因子宮肌壁菲薄，偶有可能發(fā)生自發(fā)性破裂子宮畸形子宮發(fā)育不良子宮穿孔史因子宮

29、肌層受損而妊娠晚期發(fā)生子宮破裂雙子宮破裂術(shù)后宮腔鏡電切割、宮角妊娠58病因（etiology）子宮肌壁原有病理改變，妊娠后因子宮肌診斷先兆子宮破裂：煩躁不安、下腹劇痛病理性縮復(fù)環(huán)血尿子宮破裂撕裂樣疼痛疼痛緩解整個下腹壓痛、反跳痛陰道少量血59診斷先兆子宮破裂：59處理：先兆子宮破裂先兆子宮破裂立即采取有效措施抑制子宮收縮盡快行剖宮產(chǎn)術(shù)術(shù)中注意檢查子宮是否已有破裂靜脈或全麻、肌肉注射度冷丁100mg60處理：先兆子宮破裂先兆子宮破裂立即采取有效措施抑制子宮收縮盡處理：子宮破裂積極糾正休克迅速剖腹取胎子宮去留問題：孕婦生命體征、出血量裂傷部位、程度、時間是否感染子宮下段破裂者，應(yīng)注意檢查膀胱、輸尿

30、管、宮頸及陰道，若有損傷，應(yīng)及時修補。術(shù)中、術(shù)后應(yīng)用較大劑量廣譜抗生素控制感染61處理：子宮破裂積極糾正休克61預(yù)防加強產(chǎn)前檢查提倡自然分娩，降低剖宮產(chǎn)率高危因素，估計分娩可能有困難，有難產(chǎn)史，有剖宮產(chǎn)史者，應(yīng)提早住院分娩提高觀察產(chǎn)程進展能力，根據(jù)產(chǎn)科指征及前次手術(shù)經(jīng)過決定分娩方式。嚴格掌握應(yīng)用縮宮素的指征、用法、用量，同時應(yīng)有專人守護62預(yù)防加強產(chǎn)前檢查62預(yù)防對有子宮瘢痕、子宮畸形的產(chǎn)婦試產(chǎn)，要嚴密觀察產(chǎn)程并放寬剖宮產(chǎn)指征;嚴密觀察產(chǎn)程，對于先露高、有胎位異常的孕婦試產(chǎn)更應(yīng)仔細觀察避免損傷性大的陰道助產(chǎn)及操作中高位產(chǎn)鉗宮口未開全即助產(chǎn)忽略性肩先露行內(nèi)倒轉(zhuǎn)術(shù)胎盤植入時強行挖取63預(yù)防對有子宮

31、瘢痕、子宮畸形的產(chǎn)婦試產(chǎn)，要嚴密觀察產(chǎn)程并放寬剖異常產(chǎn)褥64異常產(chǎn)褥64產(chǎn)褥感染定義 (definition)產(chǎn)褥感染:是指分娩時及產(chǎn)褥期生殖道受到病原體感染，引起局部和全身的炎性變化。發(fā)病率為1%7.2%產(chǎn)褥病率(puerperal morbidity)：分娩24小時以后的10日內(nèi)口表每日測量4次，體溫有2次達到或超過38產(chǎn)褥病率的大部分原因是產(chǎn)褥感染但也包括生殖道以外的感染例如：乳腺炎,上呼吸道感染,泌尿系感染65產(chǎn)褥感染定義 (definition)65病因 (etiology)分娩降低或破壞生殖道的防御功能和自凈作用增加病原體侵入生殖道的機會產(chǎn)婦體質(zhì)虛弱、孕期貧血、胎膜早破、產(chǎn)科手術(shù)操

32、作、產(chǎn)程延長、產(chǎn)后出血過多等66病因 (etiology)分娩降低或破壞生殖道的防御功能和自病原體需氧菌-溶血性鏈球菌：重癥感染大腸桿菌、粘質(zhì)沙雷氏菌葡萄球菌厭氧菌消化球菌、消化鏈球菌（咽峽鏈球菌）桿菌產(chǎn)氣莢膜桿菌支原體、衣原體67病原體需氧菌67臨床表現(xiàn)(Clinical manifestation)急性外陰、陰道、宮頸炎急性子宮內(nèi)膜炎、子宮肌炎急性盆腔結(jié)締組織炎、急性輸卵管炎急性盆腔腹膜炎及彌漫性腹膜炎血栓靜脈炎盆腔血栓性靜脈下肢血栓性靜脈：股白腫顱內(nèi)血栓性靜脈炎膿毒血癥及敗血癥68臨床表現(xiàn)(Clinical manifestatio診斷病史體征輔助檢查血尿常規(guī)、CRP、ESR、降鈣素原培

33、養(yǎng)+藥敏B超、CT、MRI69診斷病史69治療一般治療半臥位以利膿液流于骨盆腔重癥患者應(yīng)少量多次輸新鮮血或血漿、白蛋白，以提高機體免疫力抗感染治療首選廣譜高效抗生素：足量、有效提高機體的應(yīng)急能力病情危重者可短期加用腎上腺皮質(zhì)激素70治療一般治療70治療血栓性靜脈炎的治療抗感染同時，加用肝素，維持47日亦可加用活血化瘀中藥以及溶栓類藥物尿激酶治療血栓栓塞的有效溶栓藥物直接催化纖溶酶原轉(zhuǎn)化成纖溶酶降解已形成的纖維蛋白宮腔殘留：清宮膿腫：切排引流嚴重的子宮感染經(jīng)積極的抗感染治療無效，病情繼續(xù)擴展惡化者，尤其是出現(xiàn)敗血癥、膿毒血癥者果斷及時地行子宮切除術(shù)71治療血栓性靜脈炎的治療71領(lǐng)域中目前存在的主要問題及研究發(fā)展趨勢72領(lǐng)域中目前存在的主要問題及研究發(fā)展趨勢72羊水栓塞amnionic flui