Transcript 幻灯片 1

Postpartum Hemorrhage
Xiong yu
Obstetric & Gynecology Hospital, Fudan University

Blood loss in excess of 500 ml following birth within
the first 24 hours of delivery
◦ Serious intrapartum complication
◦ The most significant cause of maternal death worldwide,
mortality : 140 000 per year (1 maternal death every 4
minutes)
◦ Incidence: 4–6% of pregnancies
◦ Actual incidence: more high because of inaccurate,
significant underreporting

Primary PPH
◦ Occurring within the first 24 hours of delivery
◦ 4–6% of pregnancies
◦ Caused by uterine atony in 80% or more of cases

Secondary PPH
◦ Occurring between 24 hours and 6–12 weeks postpartum
◦ 1% of pregnancies

4“T”
◦ Tone:
uterine atony
◦ Tissue: retained placenta
◦ Trauma: vaginal, cervical, or uterine injury
◦ Thrombin: coagulopathy (pre-existing or
acquired)
——SOGC guideline (number 235, October 2009): Active
Management of the Third Stage of Labor: Prevention and
Treatment of Postpartum Hemorrhage

The most common and important cause of PPH

The primary protective mechanism for immediate
hemostasis after delivery:
◦ Myometrial contraction causing occlusion of uterine blood
vessels ——living ligatures of the uterus
◦ Blood flow from the vascular space to the uterine cavity via
the myometrium is impeded
Etiologic category and process
Clinical risk factors
Overdistension of uterus
Polyhydramnios, Multiple
gestation, Macrosomia
Uterine muscle exhaustion
Rapid labor, Prolonged labor,
High parity, Oxytocin use
Intra-amniotic infection
Fever, Prolonged rupture of
membranes
Functional/anatomic distortion of
uterus
Fibroids, Placenta previa,
Uterine anomalies
Uterine-relaxing medications
Halogenated anesthetics,
Nitroglycerin
Bladder distension
Placenta previa
Placenta abruption
胎儿
子宫内膜
出血
脐带
胎盘
宫颈
Twin pregnancy
fibroid
胎盘
脐带
脐带
胎儿
胎儿
宫颈
肌壁间肌
瘤
带蒂
浆膜下肌
瘤
阴道
Uterine
anomalies
带蒂
内膜下肌
瘤
浆膜下肌
瘤
内膜下肌
瘤
Etiologic category and
process
Avulsed lobule,
Succenturiate lobe
Abnormally adhered:
Accreta,
Increta,
Percreta
Clinical risk factors
Incomplete placenta at delivery
Placenta previa with or without
previous uterine surgery,
Prior myomectomy,
Prior cesarean delivery,
Asherman’s syndrome,
Submucous leiomyomata,
Maternal age older than 35 years
Succenturiate lobe
Accreta
Placenta villi attach
to the myometrium
Increta
Percreta
Placenta villi invade Placenta villi penetrate
into the myometrium through the myometrium
Etioiogic category and
process
Lacerations of the cervix,
vaginal, or perineum
Puerperal Hematomas
Clinical risk factors
Precipitous delivery
Operative delivery
Nulliparity, episiotomy, and
forceps delivery
I
Laceration of cervix
III
Lacerations of perineum
II
Etioiogic category and process
Clinical risk factors
Pre-existing states
Primary thrombocytopenia
Aplastic anemia
Acquired in pregnancy
HELLP syndrome
Abruption placenta
Prolonged intrauterine fetal demise
Sepsis
Amniotic fluid embolism
Significant hemorrhage
Elevated blood pressure
Antepartum hemorrhage
Fetal demise
Fever
Sudden collapse

Vaginal bleeding
◦ Bleeding with characteristic soft, poorly contracted (“boggy”) uterus on
bimanual pelvic examination
——uterine atony
◦ Bleeding while the uterus is firmly contracted
—— retained placenta
——genital tract laceration
◦ Bleeding without clot
——coagulopathy
◦ Pelvic or rectal pressure and pain
——genital tract hematomas

Hypovolemic shock
 Irritable,pallor and clamminess of skin, tachycardia,
narrow pulse pressure
——mild degree of shock

Weight method:
◦ Blood loss(ml)=(dressing wet weight after birth-dressing dry weight
before birth)/1.05(specific gravity of blood)

Volume method:
◦ Collect blood using a container

Area method:
◦ 10cm*10cm gause soak blood = 10ml blood
Shock index =heart rate/systolic pressure(mmHg)
(normal <0.5)

shock index
0.6~0.9
=1.0
=1.5
≥2.0
estimate loss of blood(ml) loss of blood volume
<500~750
1000~1500
1500~2500
2500~3500
<20%
20~30%
30~50%
≥50~70%

The initial goal
◦ Identifying and treating the cause of blood loss
◦ Instituting resuscitative measures to maintain hemodynamic
stability and oxygen perfusion of the tissues


Call for help
Resuscitation
◦
◦
◦
◦
◦
◦

Assess the “ABC”
Monitor BP, P, R
Empty bladder, monitor urine output
IV line
Crystalloid, isotonic fluid replacement
Oxygen by mask
Laboratory tests
◦ Complete blood count
◦ Coagulation screen
◦ Blood grouping and cross
——SOGC 2009

Uterine massage
◦ Diminish bleeding, expel blood and clots, and allow time for
other measures to be implemented

Uterotonic drugs
◦ Ongoing blood loss in the setting of decreased uterine tone
requires the administration of additional uterotonics as the
first-line treatment for hemorrhage
Drug
Oxytocin
Dose/Route
IV: 10–40 units in 1
liter normal saline
or lactated Ringer’s
solution
IM: 10 units
Carbetocin
IV/IM:
100 μg
Ergometrine
IM: 0.2 mg
Frequency
Comment
Continuous
Avoid undiluted
rapid IV
infusion, which
causes
hypotension
Every 2–4 h
Avoid if patient
is hypertensive
Drug
Dose/Route
Frequency Comment
15-methyl
PGF2α
(Hemabate)
IM: 0.25 mg
Every 15–
90 min, 8
doses
maximum
Avoid in asthmatic
patients
Diarrhea, fever,
tachycardia can
occur
Dinoprostone
(PGE2)
Suppository:
vaginal or
rectal 20 mg
Every 2 h
Avoid if patient is
hypotensive. Fever
is common.
Misoprostol
(PGE1)
800–1,000
mcg rectally



Uterine tamponade
Exploratory laparotomy
Uterine artery embolization

Indication:uterotonics fail to cause sustained uterine
contractions and satisfactory control of hemorrhage after
vaginal delivery
Technique
Comment
—Packing
—4-inch gauze; can soak with
5,000 units of thrombin in 5 mL of
sterile saline
—Foley catheter
—Insert one or more bulbs; instill
60–80 mL of saline
—Sengstaken–Blakemore tube
—SOS Bakri tamponade balloon
—Insert balloon; instill 300–500
mL of saline
Packing
Bakri Balloon tamponade

Indication:When uterotonic agents with or without
tamponade measures fail to control bleeding in a patient who
has given birth vaginally

Techniques
◦ Compression sutures
◦ Artery ligation
◦ Hysterectomy

B-Lynch technique
◦ First reported by B-lynch in 1993
◦ Compress the uterine corpus and decrease bleeding
◦ Rare Complication:uterine ischemic necrosis with
peritonitis

Modified B-Lynch
◦ e.g. Hemostatic multiple square suturing
◦ For postpartum hemorrhage caused by uterine atony,
placenta previa, or placenta accreta
◦ Eliminateing space in the uterine cavity by suturing both
anterior and posterior uterine walls

Bilateral uterine arteries ligation

Bilateral internal iliac arteries ligation

Bilateral ovarian arteries ligation
Uterine arteries ligation
Internal iliac arteries ligation



Diminish the pulse pressure of blood flowing to the
uterus
The timing of this intervention is important: it must
be done without delay, before excessive blood loss
has occurred
Surgical skill is required to avoid failure and
complications such as damage to other vascular
structures and the ureters


Indication: massive hemorrhage has not responded to
previous interventions
Notice: If hysterectomy is performed for uterine
atony, there should be documentation of other therapy
attempts
Hysterectomy
cavity
cavity
uterus
salpinx
endometrium
overy
myometrium
subtotal
cervix
bladder
vagina
total

Indication: stable vital signs , persistent bleeding,
especially if the rate of loss is not excessive

Used for bleeding that continues after hysterectomy
Used as an alternative to hysterectomy to preserve
fertility



Radiographic identification of bleeding vessels
Embolization with gelfoam, coils, or glue, or balloon
occlusion
H.A.E.M.O.S.T.A.S.I.S.





H: Ask for help
A: Assess (vital parameters, blood loss) and
resuscitate
E: Establish etiology and check medication
supply (oxytosin, ergometrine) and availability
of blood
M: Massage uterus
O: Oxytocin infusion, prostaglandins
(intravenous, rectal, intramuscular, intramyometrial)






S: Shift to operating room, exclude retained
products and trauma, bimanual compression
T: Tamponade balloon, uterine packing
A: Apply compression sutures
S: Systematic pelvic devascularization (uterine,
ovarian, internal iliac)
I: Intervention radiologist, uterine artery
embolization if appropriate
S: Subtotal or total abdominal hysterectomy
——ICM/FIGO guideline 2006: Postpartum hemorrhage today: initiative 2004—2006


Diagnosis: detection of an echogenic mass in the uterus
by ultrasonography
Directed therapy
◦ Whole placenta in uterus:manual removal
◦ Incomplete separation (avulsed lobule, succenturiate lobe):
gentle curettage
◦ Placenta accreta




curettage
wedge resection
medical management
hysterectomy

Lacerations of perineum, vagina, or cervix

Genital tract hematomas

Identification and proper repair of lacerations
◦
◦
◦
◦
◦
Transfer to a well-equipped operating room
Proper patient positioning
Adequate operative assistance
Good lighting
Appropriate instrumentation (eg, Simpson or Heaney
retractors)
◦ Adequate anesthesia



May not be recognized until hours after the delivery
Sometimes occur in the absence of vaginal or
perineal lacerations
The main symptoms are pelvic or rectal pressure and
pain

Directed therapy
◦ Draining the blood within the hematoma (sometimes placing
a drain in situ)
◦ Suturing the incision
◦ Packing the vagina
◦ Interventional radiology

Directed therapy
◦ Appropriate testing
◦ Blood products infused as indicated
◦ Simultaneous surgery if the coagulopathy caused or
perpetuated by the hemorrhage

Baseline studies
◦
◦
◦
◦
◦
Complete blood count with platelets
Prothrombin time
Activated partial thromboplastin time
Fibrinogen
A type and cross order

Be ordered when excessive blood loss is suspected and should
be repeated periodically as clinical circumstances warrant

Response to hemorrhage before laboratory results are known

A simple measure of fibrinogen
◦ A volume of 5 mL of the patient’s blood is placed into a
clean, red-topped tube and observed frequently. Normally,
blood will clot within 8–10 minutes and will remain intact
◦ If the fibrinogen concentration is low, generally less than
150 mg/dL, the blood in the tube will not clot, if it does, it
will undergo partial or complete dissolution in 30–60
minutes

AMTSL (active management of the third stage of
labor)
◦ Routine use of uterotonics
◦ Early cord clamping, controlled cord traction
◦ Appropriate uterine massage after delivery of the placenta




Subinvolution of placental site
Retained products of conception
Infection
Inherited coagulation defects



The extent of bleeding usually is less than that seen
with primary postpartum hemorrhage
Ultrasound evaluation can help identify intrauterine
tissue or subinvolution of the placental site
Treatment may include uterotonic agents, antibiotics,
and curettage

Management may vary greatly among patients, depending on
etiology and available treatment options, and often a
multidisciplinary approach is required

Balancing the use of conservative management techniques
with the need to control the bleeding and achieve hemostasis

Uterotonic agents should be the first-line treatment for
postpartum hemorrhage due to uterine atony

When uterotonics fail following vaginal delivery, exploratory
laparotomy is the next step





Williams Obstetrics, 23rd Edition
ACOG Practice Bulletin No. 76. 2006. Postpartum
hemorrhage
ICM/FIGO guideline 2006: Postpartum hemorrhage today:
initiative 2004—2006
SOGC guideline (number 235, October 2009): Active
Management of the Third Stage of Labor: Prevention and
Treatment of Postpartum Hemorrhage
RCOG Green-top Guideline No. 52 May 2009:Prevention and
management of postpartum haemorrhage
THANKS!