妊娠晚期出血、产后出血、 子宫破裂、异常产褥 浙江大学医学院附属妇产科医院 韩秀君. 2 Rationale (why we care … ) 4-5% of pregnancies complicated by 3rd trimester bleeding Immediate evaluation.

Presentation on theme: "妊娠晚期出血、产后出血、 子宫破裂、异常产褥 浙江大学医学院附属妇产科医院 韩秀君. 2 Rationale (why we care … ) 4-5% of pregnancies complicated by 3rd trimester bleeding Immediate evaluation."— Presentation transcript:

1 妊娠晚期出血、产后出血、 子宫破裂、异常产褥 浙江大学医学院附属妇产科医院 韩秀君

2 2 Rationale (why we care … ) 4-5% of pregnancies complicated by 3rd trimester bleeding Immediate evaluation needed Significant threat to mother & fetus (consider physiologic increase in uterine blood flow) Consider causes of maternal & fetal death Priorities in management (triage!)

3 3 normal hemorrhage Bloody show: - antepartum in active labor the consequence of effacement & dilatation of cervix tearing of small veins

4 4 Definition conditions The definition of obstetrical hemorrhage cannot be determined precisely Bleeding>500ml Need transfusion Hct drop of 10 vol%

5 5 Predisposing conditions Predisposing conditions cannot be determined precisely 3.9% in vaginal delivery 6~8% in cesarean delivery the high risk factors

6 6

7 7 Causes of hemorrhage 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)

8 8 OBSTETRICAL HEMORRHAGE Antepartum placental previa placetal abruption vasa previa Postpatrum uterine atony normal placentation genital tract laceration coagulation defects

9 9 PLACENTA PREVIA PLACENTA PREVIA Definition - the placenta is located over or very near the internal os of cervix total partial marginal low-lying

10 10 Etiology - 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 hypertrophy

11 11 Diagnosis The time of uterine bleeding during the later half of pregnancy  digital examination : torrential hemorrhage!!! sonography - placental location can almost be obtained - transabdominal - transvaginal - transperineal - MRI

12 12 Management may be considered as follows: 1. fetus is preterm 2. indication for delivery or in labor Have indication: partial, less bleeding →vaginal delivery 3. fetus is reasonably mature 4. hemorrhage is so severe as to mandate delivery despite fetal immaturity

13 13 Management : other considerations Must consider these diagnoses if previa present Placenta accreta, increta, percreta Cesarean delivery may be necessary History of uterine surgery increases risk Could require further evaluation, imaging (MRI considered now)

14 14 Delivery cesarean delivery incision (transverse or vertical) if incision extends through the placenta, maternal or fetal outcome: risk increase adequate transfusion and cesarean delivery : marked reduction in maternal mortality  fail…….. Hysterectomy !!!!!

15 15 PLACENTAL ABRUPTION Definition - the separation of the placenta from 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 later

16 16

17 17 Perinatal mortality Risk factors for intrauterine fetal death (1988-2009). placental abruption (OR 2.9, 95% CI 2.4-3.5, p<0.001 ） - perinatal mortality was 25-fold higher with placental abruption - so extensive as to kill the fetus

18 18 Ethiology risk factor relative risk increased age and parity 1.3~1.5 preeclampsia 2.1~4.0 chronic hypertension 1.8~3.0 PPROM 2.4~4.9 mutifetal gestation 2.1 hydramnios 2.0 smoking 1.4~1.9 thrombophilias 3~7 cocaine use NA prior abruption 10~25 uterine leiomyoma NA

19 19 Clinical diagnosis sign or symptom frequency(%) vaginal bleeding 78 uterine tenderness or back pain 66 fetal distress 60 preterm labor 22 high-frequency contractions 17 hypertonus 17 dead fetus 15

20 20 ultrasound - infrequently confirms negative finding do not exclude placental abruption

21 21 lab method Consumptive coagulopathy - most common - hypofibrinogenemia, FDP↑, D-dimer↑, coagulation factor↓ → 30%, enough to kill the fetus - major mechanism : coagulation intravascularly & retroplacentally → the activation of plasminogen to plasmin → maintaining patency of the microcirculation Anemia may be out of proportion to observed blood loss

22 22 Complication1 Renal failure - severe form of placental abruption : the consequence of massive hemorrhage : treatment of hypovolemia is delayed or incomplete - with preeclampsia : renal vasospasm is likely intensified - proteinuria is common without preeclampsia → blood & crystalloid solution apply !!!!!!

23 23 Complication2 Couvelaire uterus (uteroplacental apoplexy) - extravasation of blood into the uterine musculature and beneath the uterine serosa, broad ligament - interfere with uterine contraction : severe postpartum hemorrhage but, not an indication for hysterectomy

24 24 Management depending on gestational age, maternal & fetal status severe form - blood & crystalloid and prompt delivery milder or common form - expectant management in preterm pregnancy : tocolytics, close observation …… : but, fetal distress was seen → prompt delivery & immediate treatment Available anesthesia, OR team for stat cesarean delivery

25 25 Delivery Vaginal delivery - fetal death, no obstetrical complication, in labor - coagulation defect (incision site bleeding) Cesarean delivery 1. fetus : alive but in distress : rapid delivery : decision time is an important factor in neonatal outcome

26 26 Cesarean delivery 2.fetus is dead or previable timing of delivery after severe placental abruption - there is no evidence that establishing a time limit fro delivery is necessary 3.maternal outcome - depends on adequate fluid and blood replacement therapy rather than on the interval to delivery

27 27 vasa previa the fetal vessels course through membranes and present at the cervical os

28 28 Vasa previa: incidence 0.1-1.0% Greater in multiple gestations Singleton - 0.2% Twins - 6-11% Triplets - 95%

29 29 Vasa previa: symptoms, findings, diagnosis Painless vaginal bleeding Ultrasound Routine vs at time of symptoms Fetal bleeding Positive Kleihauer Betke test

30 30 Vasa previa: management If bleeding, plan for emergent delivery If persistent bleeding, nonreassuring fetal status, STAT cesarean… not a time for conservative mgmt! Fetal blood loss NOT tolerated

31 31 POSTPARTUM HEMORRHAGE

32 32 Definition - traditionally, > 500mL after completion of the third stage of labor - late postpartum hemorrhage : hemorrhage after the first 24 hours POSTPARTUM HEMORRHAGE

33 33 PPH 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 hypertensive → normotensive although remarkably hypovolemic

34 34 PPH 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

35 35 Estimated blood loss except intrauterine & intravaginal accumulation of blood or intraperitoneal bleeding (uterine rupture) weight method measure volume area-method ocular estimate Hb Symptoms and physical findings

36 36 EBL Shock index blood lose （ ml ） rate of blood volume 0.6 － 0.9 <500 － 750 <20% =1.0 1000 － 1500 20 － 30% =1.5 1500 － 2500 30 － 50% ≥2.0 2500 － 3500 ≥50 － 70%

37 37 Uterine atony same overall mgmt regardless of delivery type Recognition Uterine exploration blood may not escape vaginally - adherent pieces of placenta or large blood clots prevent effective contraction and retraction Uterine massage

38 38 Bleeding unresponsive to medicines 1. bimanual uterine compression 2. help ! 3. 2 nd 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)

39 39

40 40 Uterine atony Medical 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 hypertension Hemabate (prostaglandin F 2  )

41 41 Uterine atony B-lynch suture (to compress uterus) Uterine packing Uterine artery ligation Internal iliac artery ligation Uterine artery embolization Hysterectomy (last resort) Anesthesia involved Whether in L&D room or the OR!!!

42 42 宫腔填塞

43 43 Internal iliac artery ligation - reduce the hemorrhage technically difficult, successful in less than 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 reproduction

44 44

45 45 Under what circumstances 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 occlusion 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.

46 46 Proposed Performance Measure If hysterectomy is performed for uterine atony there should be documentation of other therapy attempts.

47 47 Lacerations: Recognition Perineal, vaginal, cervical, Uterine All can be rather bloody! Assistance Lighting Appropriate repair Control of bleeding Identify apex for initial stitch placement

48 48

49 49 Uterine inversion: Management Call for help Manual replacement of uterus Uterotonics and Appropriate anesthesia to necessary to relax uterus & allow thorough manual exploration of uterine cavity Concern for shock… to be discussed (and managed by the help you’ve called into the room!) Exploratory laparotomy may be necessary

50 50

51 51 Amniotic fluid embolism Improve hyoxemia Antiallergic Management of shock Prevention and cure DIC Prevent renal failure Prevent infection Management of obstetrics

52 52 Amniotic fluid embolism High index of suspicion Recognition Again… call for help! Supportive treatment Replete blood, coagulation factors as able Plan for delivery (if diagnose antepartum) if able to stabilize mom first

53 53 Management Delivery Vaginally unless other obstetrical indication, i.e. fetal distress, herpes （ HSV), etc. Best to stabilize mother before initiating labor or going to delivery

54 子宫破裂

55 定义（ Definition ） 在妊娠期晚期或分娩期子宫体部或子宫下 段发生破裂 子宫破裂是产科严重并发症之一 处理不及时易造成母胎死亡

56 病因（ etiology ） 梗阻性难产 臀位：臀牵引 横位：内倒转 巨大儿 缩宫剂应用不当（米索） 不适当的难产手术： 如产钳，宫口未开全时行术或强行牵拉易造成破裂 暴力压腹助产 第二产程中助产人员粗暴按压腹部助产时造成子宫破裂

57 病因（ etiology ）：瘢痕子宫 妊娠中、晚期可能发生子宫破裂，甚至于自发性 破裂 曾行剖宫产手术 ( 特别是古典式剖宫产 ) 曾行子宫肌瘤剔除术的产妇 1996 年 Chabpmah 报告前次中期妊娠发生子宫破 裂的危险为 3.8% 1991 年 Farmer 等报告在 11000 例前次剖宫产后的 妊娠中，三分之二试产 VBAC ，子宫破裂的发生 率为 0.08% 。 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

58 病因（ etiology ） 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 子宫畸形 子宫发育不良 子宫穿孔史因子宫肌层受损而妊娠晚期发生子 宫破裂 双子宫破裂术后 宫腔镜电切割、宫角妊娠

59 诊断 先兆子宫破裂： 烦躁不安、下腹剧痛 病理性缩复环 血尿 子宫破裂 撕裂样疼痛 疼痛缓解 整个下腹压痛、反跳痛 阴道少量血

60 处理：先兆子宫破裂 先兆子 宫破裂 立即采取有效 措施抑制子宫 收缩 尽快行剖宫产 术 术中注意检查 子宫是否已有 破裂 静脉或全麻、 肌肉注射度 冷丁 100mg

61 处理：子宫破裂 积极纠正休克 迅速剖腹取胎 子宫去留问题： 孕妇生命体征、出血量 裂伤部位、程度、时间 是否感染 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。 术中、术后应用较大剂量广谱抗生素控制感染

62 预防 加强产前检查 提倡自然分娩，降低剖宫产率 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 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。 严格掌握应用缩宫素的指征、用法、用量，同 时应有专人守护

63 预防 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 ; 严密观察产程， 对于先露高、有胎位异常的孕妇试产更应仔细 观察 避免损伤性大的阴道助产及操作 中高位产钳 宫口未开全即助产 忽略性肩先露行内倒转术 胎盘植入时强行挖取

64 异常产褥

65 产褥感染 定义 (definition) 产褥感染 : 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 1% ～ 7.2% 产褥病率 (puerperal morbidity) ：分娩 24 小时以 后的 10 日内口表每日测量 4 次，体温有 2 次达到或 超过 38 ℃ 产褥病率的大部分原因是产褥感染 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

66 病因 (etiology) 分娩降低或破坏生殖道的防御功能和自净作用 增加病原体侵入生殖道的机会 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

67 病原体 需氧菌 β- 溶血性链球菌：重症感染 大肠杆菌、粘质沙雷氏菌 葡萄球菌 厌氧菌 消化球菌、消化链球菌（咽峡链球菌） 杆菌 产气荚膜杆菌 支原体、衣原体

68 临床表现 (Clinical manifestation) 急性外阴、阴道、宫颈炎 急性子宫内膜炎、子宫肌炎 急性盆腔结缔组织炎、急性输卵管炎 急性盆腔腹膜炎及弥漫性腹膜炎 血栓静脉炎 盆腔血栓性静脉 下肢血栓性静脉：股白肿 颅内血栓性静脉炎 脓毒血症及败血症

69 诊断 病史 体征 辅助检查 血尿常规、 CRP 、 ESR 、降钙素原 培养 + 药敏 B 超、 CT 、 MRI

70 治疗 一般治疗 半卧位以利脓液流于骨盆腔 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 抗感染治疗 首选广谱高效抗生素：足量、有效 提高机体的应急能力 病情危重者可短期加用肾上腺皮质激素

71 治疗 血栓性静脉炎的治疗 抗感染同时，加用肝素，维持 4 ～ 7 日 亦可加用活血化瘀中药以及溶栓类药物 尿激酶 治疗血栓栓塞的有效溶栓药物 直接催化纤溶酶原转化成纤溶酶 降解已形成的纤维蛋白 宫腔残留：清宫 脓肿：切排引流 严重的子宫感染 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、脓毒血症者 果断及时地行子宫切除术

72 领域中目前存在的主要 问题及研究发展趋势

73 羊水栓塞 amnionic fluid embolism 诊断 临床症状、体征 急性低血压和 / 或心脏骤停 急性缺氧 ( 呼吸困难, 发绀和 / 或呼吸停止 ) 凝血障碍 ( 弥散性血管内凝血和 / 或严重出血 ) 昏迷和痉挛 发病急骤者，可于数分钟内死亡 实验室检查 心电图、心超、胸片 血氧饱和度、 BP 突然下降 凝血功能的检查 母体循环或肺组织中羊水成份的检测 尸检

74 诊断进展 母血清及肺组织中的神经氨酸 -N- 乙酰氨基半乳糖 （ SialylTn ）抗原检测 用灵敏的放射免疫竞争检测法定量测定血清中的 SialylTn 抗 原 简单、敏感、非创伤性 可用于羊水栓塞的早期诊断 组织抗凝因子的测定 羊水中的有形成分不是引起羊水栓塞的主要原因 组织因子样促凝物质、白三烯等 发生后大约 40% 的患者出现致死性的 DIC 组织因子的凝血活性可被抗组织因子蛋白拮抗 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 DIC 的依据

75 诊断进展 肺组织中肥大细胞的测定 发生机理是机体对羊水中的胎儿成分产生过敏 反应 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 类胰蛋白酶是一种中性蛋白酶，是 T 细胞和肥大细 胞分泌颗粒的主要成分。

76 诊断进展 肺组织中肥大细胞的测定 Fineschi 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 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 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。 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

77 Amnionic fluid embolism 诊断进展 Amniotic Fluid Embolism Pathophysiology Suggests the New Diagnostic Armamentarium: β-Tryptase and Complement Fractions C3-C4 Are the Indispensable Working Tools. 羊水栓塞病理生理学表明, 新的诊断医疗 设备 :β-Tryptase 类胰蛋白酶和补体片段 C3-C4 是不可或缺的工具 Busardò FP Busardò FP 1, Frati P 2,3, Zaami S 4, Fineschi V 5. 2015, 16(3), 6557-6570; doi:10.3390/ijms16036557Frati PZaami SFineschi V10.3390/ijms16036557

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