“ObstetricsisBloodyBusiness”*PostpartumHemorrhage:*Cunningham,et.al:WilliamsObstetrics,21sted.,2001PPHistheleadingcauseofdeathrelatedtopregnancyworldwide…1“ObstetricsisBloodyBusinessMajorcausesofdeathforpregnancywomen

（maternalmortality)

Postpartumhemorrhage（28%)heartdiseasespregnancy-inducedhypertension(orAmnioticfluidembolism)infection2MajorcausesofdeathforpregDefinitionofPPHTheearlyPPHisdefinedasabloodlossexceeding500mlafterdeliveryoftheinfant<24hThelatePPH:occursafter24hourofdeliveryto6weeks3DefinitionofPPHTheearlyPPHMajorcausesUterineatony(90%)Lacerationsofthegenitaltract(6%)Retainedplacenta(3%-4%)Coagulationdefects(blooddyscrasia)

(4T:tone,tissue,trauma,thrombin)Etiology/prediction/prevention/management4MajorcausesUterineatony(901.UterineatonyLocalfactors:OverdistentionoftheuterineConditionthatinterferewithcontraction(leiomyoma)Complications(PIH,anemia,placentaprevia)Systemicfactors:NervousDrugsAbnormallaborHistoryofpreviousPPHPreeclampsia,abnormalplacentationEtiology/prediction/prevention/management51.UterineatonyLocalfactors:PathologyContractionconstrictingthespiralarteriesPreventingtheexcessivebleedingfromtheplacentaimplantationsiteUterineatonygiverisetoPPHwhennocontractionoccurEtiology/prediction/prevention/management6PathologyContractionconstrictMaincomplainHaveheartpalpitationsFeelfaintLightheadedBreathless…Etiology/prediction/prevention/management7MaincomplainHaveheartpalpit2.LacerationsofthegenitaltractCauses:Instrumenteddelivery(forceps)manipulativedelivery(breechextraction,precipitouslabor,macrosomia)Types:perineumlacerationvaginallacerationcervicallacerationEtiology/prediction/prevention/management82.Lacerationsofthegenital3.RetainedplacentaSeparationandexplosionofplacentaiscausedbystronguterinecontractionPlacentatissueremainingintheuteruspreventadequatecontractionandpredisposetoexcessivebleedingEtiology/prediction/prevention/management93.RetainedplacentaSeparation4.CoagulationdefectsAcquiredabnormalityinbloodclotting:abruptionplacenta,amnioticfluidembolismseverepreeclampsiaCongenitalabnormalityinbloodclotting:thrombocytopeniaseverehepaticdiseasesleukemiaEtiology/prediction/prevention/management104.CoagulationdefectsAcquireddisseminatedintravascularcoagulopathy(DIC)ifbleedingpersistsinspiteofallothertreatmentdescribed,DICshouldbesuspectedthebloodpassingfromthegenitaltractisnotclottingshock:reductionofeffectivecirculationinadequateperfusionofalltissuesoxygendepletiondepressionoffunctions11disseminatedintravascularcoaD.D.withPPHColor,order,amountRiskreasonsClot“Bloody”Etiology/prediction/prevention/management12D.D.withPPHColor,order,amoConsequencesofPPHHypovolemicshockBloodtransfusionanditsattendantcomplicationsSurgicalinjury,fever,renalandhepaticfailureAcuterespiratorydistresssyndromeDisseminatedintravascularcoagulopathyLossoffertility,andSheehan'ssyndrome13ConsequencesofPPHHypovolemicCASE36ysPrimiparity,acceptedC-sectionbecauseofmarginalplacentaandfibroidsAfterbirth,PPHhappenedimmediatelycausedbyuterineatony,Oxytocinwasusedwhilestitching,buthemorrhagewascontinue…14CASE36ysPrimiparity,acceptedRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

15RiskfactorsforPPHAdvancedmRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

16RiskfactorsforPPHAdvancedmPreventionandtreatmentTheplacentashouldbeexaminedcarefullymanualremovalofplacentahysterectomyisrequiredforplacentauterinecontractiondrugsEtiology/prediction/prevention/management17PreventionandtreatmentTheplPreventionuterineatonyAdministrationofmedicine:promotescontractionoftheuterinecorpusdecreasesthelikelihoodofuterineatonyOxytocinagentsProstaglandinEtiology/prediction/prevention/management18PreventionuterineatonyAdminimanagementVaginalexaminationsoonafterdelivery

repair:cervicallaceration>2cminlengthandbeactivelybleedinglacerationofvaginalandperineumEtiology/prediction/prevention/management19managementVaginalexaminationRecord:Pulse—shockindexbloodpressurematernalheartratecentralvenouspressureurineoutputEtiology/prediction/prevention/management20Record:Etiology/prediction/preLabtests:Hb,BT(bleedingtime),CT(clottingtime),plateletscountfibrinogenprothrombintimeandpatialthromboplastintimeFDPwomen’sbloodgroupandcross-matchingEtiology/prediction/prevention/management21Labtests:Etiology/prediction/Treatment:thekeyiscorrectingthecoagulationdefectresuscitationmustbestartedassoonaspossibleinfusionofcrystalloid(saline)andDextranisstartedfirstlywhilearrangingthebloodtransfusionbloodtransfusionisessentialinfusionofredcells,platelets,freshfrozenplasma,FDP,clottingfactors,Etiology/prediction/prevention/management22Treatment:Etiology/prediction/Perineumvaginalandcervicallaceration

onlyskinandaminorpartoftheperinealbodyperinealbodyandvaginaanalsphincterandanalcanalEtiology/prediction/prevention/management23PerineumvaginalandcervicalStimulationofuterinecontractionMassage

ofuterusthroughtheabdomenandbimanualcompressionintrauterinepackingEtiology/prediction/prevention/management24StimulationofuterinecontracSurgicaltherapycausinguterinecontractionorcompressiontamponadetheuterinecavitydecreasebloodsupplytotheuterusremovetheuterus.Etiology/prediction/prevention/management25SurgicaltherapycausinguterinSurgicalmethodsIfmassageandagentsareunsuccessful:LigationorembolizationoftheuterinearteriesHysterectomy

Etiology/prediction/prevention/management26SurgicalmethodsIfmassageandadherenceofplacenta(accretaincretapericreta)Etiology/prediction/prevention/management27adherenceofplacenta(accretaPotentialcomplicationsofPPHPostpartuminfectionAnemiaTransfusionhepatitis,Sheehan’ssyndromeAsherman’ssyndromeThebestmanagementofPPHisprevention

Etiology/prediction/prevention/management28PotentialcomplicationsofPPHResuscitationforPPH

callanassistantresuscitatethepatientvigorouslyWhatisthestateofherperipheralcirculation?Howmuchbloodhasshelost?Isitclottingnormallyinthereceiverusedtocollectit?Whathasbeendonesofar?Monitorthevolumeofbloodshecontinuestoloseherperipheries,pulseandbloodpressure,andherurineoutput.29ResuscitationforPPH

callanSummary:remember4Ts“TONE”RuleoutUterineAtonyPalpatefundus.Massageuterus.Oxytocin20U/500cc.ProstaglandinHemabateIMq15min30Summary:remember4Ts“TONE”PaSummary:remember4Ts“Tissue”R/OretainedplacentaInspectplacentaformissingcotyledons.Exploreuterus.Treatabnormalimplantation.31Summary:remember4Ts“Tissue”Summary:remember4Ts“TRAUMA”R/ocervicalorvaginallacerations.Obtaingoodexposure.Inspectcervixandvagina.Worryaboutslowbleeders.Treathematomas.32Summary:remember4Ts“TRAUMA”Summary:remember4Ts“THROMBIN”Checklabsifsuspicious.33Summary:remember4Ts“THROMBICase-237ys,multiparity,wasadmittedinher40+2wksforirregularcontractionwithoutanyabnormalsign.Twohrslater,thecontractionbecamestrongerandmembranesrupturedwhenhwithmeconium-stainedamnioticfluidI

degree.7:33cyanochroiahappenedwithbreathlessandlossofconsciousnessinasecond.34Case-237ys,multiparity,wasWhatisthediagnosis8:20pmstill-birthweight3.2kg.PPHemergedassoonasplacentadeliveredwithoutanyclot.Thepatientwasinthestateofunconsciousnessandbecamepale…35Whatisthediagnosis8:20pmstHysterectomyHysterectomywasdonesoonafterresuscitation.Theamountwasabout4000ml.Redcellwastransfused1600ml,freshplasma400ml,platelet20u,cryoprecipitate10u.TransfusionwascontinuedafterOP1800ml.36HysterectomyHysterectomywasd，Hb38g/L,APTT43.4秒，PT45.0(正常11-14sec),PT比例3.52(正常0.85-1.15)，F(xiàn)bg0.976g(正常2-4g/L),APTT不凝，TT44.Tsec(正常14-21sec)。FDP（+），D-2聚集體（+），3P試驗（+）。尿常規(guī)Pro2+,比重1.000,RBC10-15/HP,可見顆粒管型。37，Hb38g/L,APTT43.4秒，PT45.0(正常1術(shù)后41小時拔除氣管插管，并停用多巴胺，生命體征平穩(wěn)。術(shù)后40小時發(fā)現(xiàn)左上肢皮膚感覺減退，運動受限。頭部MRI：左側(cè)小腦半球、雙側(cè)枕、頂葉及右側(cè)丘腦多發(fā)腦梗塞，胸部CT：兩肺紋理明顯增多，兩下肺見散在斑點狀致密影，心影增大，兩則胸腔積液，兩側(cè)胸腔積液。術(shù)后18天復查血、尿常規(guī)、凝血功能除Hb102g/L外，均正常。胸部CT：正常。頭部MRI：梗塞灶明顯縮小。左上肢皮膚感覺功能恢復，但肌力仍低下。術(shù)后5個月恢復正常。38術(shù)后41小時拔除氣管插管，并停用多巴胺，生命體征平穩(wěn)。術(shù)后4UterinepathologyCervicalbloodcampexpansion,congestionandthesmallfocal-likebleedinginthesmallvesselsseenintheamnioticfluidcomposition.Subclavianveinbloodsmearinspection,microscopicexaminationshowslikematerialandalittlemeconiumkeratosis-likematerial.39UterinepathologyCervicalb術(shù)后15天復查頭部MRT表現(xiàn)右頂葉及丘腦病灶范圍縮小。原雙側(cè)枕葉，左頂葉及左小腦半球病灶已吸收消散，胸部CT提示原病灶及胸腔積液均已消失。40術(shù)后15天復查頭部MRT表現(xiàn)右頂葉及丘腦病灶范圍縮小。原雙側(cè)AmnioticfluidembolismClinicalcharacter

HeartandlungfailureBleedinginducedbyDICAcuterenalfailureDiagnosis“amnioticfluidcomposition”incirculationortissue41AmnioticfluidembolismClinicaKeywordsUterineatonythedefinitionofPPHAmnioticfluidembolismPROM42Keywords42QuestionsafterclassWhenyoumeetapatientwithPPH,whatyoucandoasanintern?HowcanyoufindthetruereasonsforPPHinthelaborroom?43QuestionsafterclassWhenyou

謝謝44

“ObstetricsisBloodyBusiness”*PostpartumHemorrhage:*Cunningham,et.al:WilliamsObstetrics,21sted.,2001PPHistheleadingcauseofdeathrelatedtopregnancyworldwide…45“ObstetricsisBloodyBusinessMajorcausesofdeathforpregnancywomen

（maternalmortality)

Postpartumhemorrhage（28%)heartdiseasespregnancy-inducedhypertension(orAmnioticfluidembolism)infection46MajorcausesofdeathforpregDefinitionofPPHTheearlyPPHisdefinedasabloodlossexceeding500mlafterdeliveryoftheinfant<24hThelatePPH:occursafter24hourofdeliveryto6weeks47DefinitionofPPHTheearlyPPHMajorcausesUterineatony(90%)Lacerationsofthegenitaltract(6%)Retainedplacenta(3%-4%)Coagulationdefects(blooddyscrasia)

(4T:tone,tissue,trauma,thrombin)Etiology/prediction/prevention/management48MajorcausesUterineatony(901.UterineatonyLocalfactors:OverdistentionoftheuterineConditionthatinterferewithcontraction(leiomyoma)Complications(PIH,anemia,placentaprevia)Systemicfactors:NervousDrugsAbnormallaborHistoryofpreviousPPHPreeclampsia,abnormalplacentationEtiology/prediction/prevention/management491.UterineatonyLocalfactors:PathologyContractionconstrictingthespiralarteriesPreventingtheexcessivebleedingfromtheplacentaimplantationsiteUterineatonygiverisetoPPHwhennocontractionoccurEtiology/prediction/prevention/management50PathologyContractionconstrictMaincomplainHaveheartpalpitationsFeelfaintLightheadedBreathless…Etiology/prediction/prevention/management51MaincomplainHaveheartpalpit2.LacerationsofthegenitaltractCauses:Instrumenteddelivery(forceps)manipulativedelivery(breechextraction,precipitouslabor,macrosomia)Types:perineumlacerationvaginallacerationcervicallacerationEtiology/prediction/prevention/management522.Lacerationsofthegenital3.RetainedplacentaSeparationandexplosionofplacentaiscausedbystronguterinecontractionPlacentatissueremainingintheuteruspreventadequatecontractionandpredisposetoexcessivebleedingEtiology/prediction/prevention/management533.RetainedplacentaSeparation4.CoagulationdefectsAcquiredabnormalityinbloodclotting:abruptionplacenta,amnioticfluidembolismseverepreeclampsiaCongenitalabnormalityinbloodclotting:thrombocytopeniaseverehepaticdiseasesleukemiaEtiology/prediction/prevention/management544.CoagulationdefectsAcquireddisseminatedintravascularcoagulopathy(DIC)ifbleedingpersistsinspiteofallothertreatmentdescribed,DICshouldbesuspectedthebloodpassingfromthegenitaltractisnotclottingshock:reductionofeffectivecirculationinadequateperfusionofalltissuesoxygendepletiondepressionoffunctions55disseminatedintravascularcoaD.D.withPPHColor,order,amountRiskreasonsClot“Bloody”Etiology/prediction/prevention/management56D.D.withPPHColor,order,amoConsequencesofPPHHypovolemicshockBloodtransfusionanditsattendantcomplicationsSurgicalinjury,fever,renalandhepaticfailureAcuterespiratorydistresssyndromeDisseminatedintravascularcoagulopathyLossoffertility,andSheehan'ssyndrome57ConsequencesofPPHHypovolemicCASE36ysPrimiparity,acceptedC-sectionbecauseofmarginalplacentaandfibroidsAfterbirth,PPHhappenedimmediatelycausedbyuterineatony,Oxytocinwasusedwhilestitching,buthemorrhagewascontinue…58CASE36ysPrimiparity,acceptedRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

59RiskfactorsforPPHAdvancedmRiskfactorsforPPHAdvancedmaternalage

Multifetalgestations

Prolongedlabor

Polyhydramnios

Instrumentaldelivery

Fetaldemise

Placentalabruption

Anticoagulationtherapy

Multiparity

FibroidsProlongeduseofoxytocin

Macrosomia

Cesareandelivery

PlacentapreviaandaccretaChorioamnionitis

Generalanesthesia

60RiskfactorsforPPHAdvancedmPreventionandtreatmentTheplacentashouldbeexaminedcarefullymanualremovalofplacentahysterectomyisrequiredforplacentauterinecontractiondrugsEtiology/prediction/prevention/management61PreventionandtreatmentTheplPreventionuterineatonyAdministrationofmedicine:promotescontractionoftheuterinecorpusdecreasesthelikelihoodofuterineatonyOxytocinagentsProstaglandinEtiology/prediction/prevention/management62PreventionuterineatonyAdminimanagementVaginalexaminationsoonafterdelivery

repair:cervicallaceration>2cminlengthandbeactivelybleedinglacerationofvaginalandperineumEtiology/prediction/prevention/management63managementVaginalexaminationRecord:Pulse—shockindexbloodpressurematernalheartratecentralvenouspressureurineoutputEtiology/prediction/prevention/management64Record:Etiology/prediction/preLabtests:Hb,BT(bleedingtime),CT(clottingtime),plateletscountfibrinogenprothrombintimeandpatialthromboplastintimeFDPwomen’sbloodgroupandcross-matchingEtiology/prediction/prevention/management65Labtests:Etiology/prediction/Treatment:thekeyiscorrectingthecoagulationdefectresuscitationmustbestartedassoonaspossibleinfusionofcrystalloid(saline)andDextranisstartedfirstlywhilearrangingthebloodtransfusionbloodtransfusionisessentialinfusionofredcells,platelets,freshfrozenplasma,FDP,clottingfactors,Etiology/prediction/prevention/management66Treatment:Etiology/prediction/Perineumvaginalandcervicallaceration

onlyskinandaminorpartoftheperinealbodyperinealbodyandvaginaanalsphincterandanalcanalEtiology/prediction/prevention/management67PerineumvaginalandcervicalStimulationofuterinecontractionMassage

ofuterusthroughtheabdomenandbimanualcompressionintrauterinepackingEtiology/prediction/prevention/management68StimulationofuterinecontracSurgicaltherapycausinguterinecontractionorcompressiontamponadetheuterinecavitydecreasebloodsupplytotheuterusremovetheuterus.Etiology/prediction/prevention/management69SurgicaltherapycausinguterinSurgicalmethodsIfmassageandagentsareunsuccessful:LigationorembolizationoftheuterinearteriesHysterectomy

Etiology/prediction/prevention/management70SurgicalmethodsIfmassageandadherenceofplacenta(accretaincretapericreta)Etiology/prediction/prevention/management71adherenceofplacenta(accretaPotentialcomplicationsofPPHPostpartuminfectionAnemiaTransfusionhepatitis,Sheehan’ssyndromeAsherman’ssyndromeThebestmanagementofPPHisprevention

Etiology/prediction/prevention/management72PotentialcomplicationsofPPHResuscitationforPPH

callanassistantresuscitatethepatientvigorouslyWhatisthestateofherperipheralcirculation?Howmuchbloodhasshelost?Isitclottingnormallyinthereceiverusedtocollectit?Whathasbeendonesofar?Monitorthevolumeofbloodshecontinuestoloseherperipheries,pulseandbloodpressure,andherurineoutput.73ResuscitationforPPH

callanSummary:remember4Ts“TONE”RuleoutUterineAtonyPalpatefundus.Massageuterus.Oxytocin20U/500cc.ProstaglandinHemabateIMq15min74Summary:remember4Ts“TONE”PaSummary:remember4Ts“Tissue”R/OretainedplacentaInspectplacentaformissingcotyledons.Exploreuterus.Treatabnormalimplantation.75Summary:remember4Ts“Tissue”Summary:remember4Ts“TRAUMA”R/ocervicalorvaginallacerations.Obtaingoodexposure.Inspectcervixandvagina.Worryaboutslowbleeders.Treathematomas.76Summary:remember4Ts“TRAUMA”Summary:remember4Ts“THROMBIN”Checklabsifsuspicious.77Summary:remember4Ts“THROMBICase-237ys,multiparity,wasadmittedinher40+2wksforirregularcontractionwithoutanyabnormalsign.Twohrslater,thecontractionbecamestrongerandmembranesrupturedwhenhwithmeconium-stainedamnioticfluidI

degree.7:33cyanochroiahappened