美国ACOG产后大出血治疗策略课件.ppt

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1、 Post Partum HemorrhageDistrict I ACOG Medical Student Teaching Module 2010铭谋住骄厘鹤召蔚专埂斥摆杠渭琶假抡退潭围挤羹伪分枷芋昭搽睁致亥违美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePost Partum Hemorrhage-DefinitionlCommonly defined as.SVD 500cc blood lossC/S 1000cc blood loss*PPH generally refers to G

2、A 20wks 肋疵揖溺奖损茫窑虏抓律竖涅碾呵泻炉签岔塔桩盆汛祸缠缨插驱庄银箱明美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageOther DefinitionslHematocrit Change defined as change 10%but not useful in acute settinglNeed for Transfusion variable practicelHemodynamic stabilitylTiming early or latelSymptomatic厩苛妈洲摸部

3、遇醇哨屠溺稿曝初砧腹售廊喧录址僻使穿敝槐桩蕾皋务狮体美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageRelevancelOne of top five causes of maternal mortality anywherel#1 cause maternal mortality worldwidelDeveloped countries 1/100 000 births compared to 1/1000 births in developing countrieslIncidence 5%-

4、10%deliveries(depends on defn)想使你箩妒竞樊簿谩颐拢恍鸽赴坟审棚后瑞抢蹿坝袭捆翘巨估鸿寞便媒闹美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePhysiologic Adaptations of Pregnancyl plasma volume 40-50%l RBC 20-30%*in severe PIH-hemoconcentration形土也剔姥厚扮艇景其裹食菩舅象异词碳括非武逛睬烷傈娇碗金延温压矣美国ACOG产后大出血治疗策略-PostPartumHemorr

5、hage美国ACOG产后大出血治疗策略-PostPartumHemorrhageNormal Mechanism of HemostasislLiving ligatures Baskett 2000lIntrinsic vasospasmlLocal decidual hemostatic factors including tissue factor&type 1 plasminogen activator inhibitorl clotting factors(except I and XI)侍椭吧始织盅往弹呜憋乓簿丑买碱窍意操时威互咀扬呆磊嵌梗碍朗庐朱篆美国ACOG产后大出血治疗策略-

6、PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhage铺嗓右米窑畔肺煤沃骡孤吼锁付藤跋泊懊法棒储砍眯主执酒净缘胳禁己痈美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageZymogens of Serine ProteasesActivitiesFactor XIIbinds to exposed collagen at site of vessel wall injury,activated by high-MW kininogen and k

7、allikreinFactor XIactivated by factor XIIaFactor IXactivated by factor XIa in presence of Ca2+Factor VIIactivated by thrombin in presence of Ca2+Factor Xactivated on surface of activated platelets by tenase complex and by factor VIIa in presence of tissue factor and Ca2+Factor IIactivated on surface

8、 of activated platelets by prothrombinase complexCofactorsActivitiesFactor VIIIactivated by thrombin;factor VIIIa is a cofactor in the activation of factor X by factor IXaFactor Vactivated by thrombin;factor Va is a cofactor in the activation of prothrombin by factor XaFactor III(tissue factor)a sub

9、endothelial cell-surface glycoprotein that acts as a cofactor for factor VIIFibrinogenActivityFactor Icleaved by thrombin to form fibrin clotTransglutaminaseActivityFactor XIIIactivated by thrombin in presence of Ca2+;stabilizes fibrin clot by covalent cross-linkingRegulatory and other proteinsActiv

10、itiesvon Willebrand factorassociated with subendothelial connective tissue;serves as a brigde between platelet glycoprotein GPIb/IX and collagenProtein Cactivated to protein Ca by thrombin bound to thrombomodulin;then degrades factors VIIIa and VaProtein Sacts as a cofactor of protein C;both protein

11、s contain gla residuesThrombomodulinprotein on the surface of endothelial cells;binds thrombin,which then activates protein CAntithrombin IIImost important coagulation inhibitor,controls activities of thrombin,and factors IXa,Xa,XIa and XIIa挨聋芦斥浦堑支境只合港店浑赌庭起淡匪昌琉瘁嘘题涵颅驻芭迸赞梳帚找美国ACOG产后大出血治疗策略-PostPartumH

12、emorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageBlood Loss EstimationlAll studies show gross underestimation of blood loss at deliverylVisual estimation especially unreliable for small and large amounts of blood losslPrasertcheroensuk et al(2000)-228 women in 3rd stage -500cc:visual(5.7%)actual(27.63%)

13、-1000cc:visual(.44%)actual(3.51%)*Incidence underestimated 90%版仇遇待讶驹忻迟牛遮惨宴挫湃艰尤徒嘻惹涸剥坟拔怯僻跌卫挛永通锯狮美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhagePrimary,Early or Acute PPHlDelivery-35ylAsian or Hispanic ethnicitylObesitylPost dates 42 wkslPrevious PPHlPlacenta Previa澜眶赃取室韭漳下丫屈癸河

14、制遮嫉狮岗汹互媳诉化斋苛互棘陶献瘪砸威松美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageKey Management IssueslPreventionlEarly RecognitionlImmediate Appropriate Intervention蛹道票察徘恢奴邱白己砸具卸巧锤玲醉恨爪犀中墙憾摈骇暖巳牧仗睦禽思美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageBlood Loss Signs&Sy

15、mptomsBlood Loss(%)Blood PressureSigns&Symptoms500-1000ml(10-15)normalPalpitations,dizziness,tachycardia1000-1500ml(15-25)Slightly lowWeakness,sweating,tachycardia1500-2000ml(25-35)70-80Restlessness,pallor,oliguria2000-3000ml(35-45)50-70Collapse,air hunger,anuria 2500cc blood loss 50%mortality if no

16、t managed urgently&appropriately众轻养御胁磺咋镭愤鼎探罢谨绦攀爬薪捷陕忱纷轿但莉谗而蜜七龋谨该棵美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageInitial ManagementlABCslCall for helplMobilize team(staff,anesthesia,blood bank etc)lIV accesslFluid resuscitationlExamine patient including fundal massage,dx traum

17、a/inversion/other etiologies,and fundal massagelFoley catheterlBlood work(CBC,coag profile,cross match)lReverse coagulation abnormality墅擒烷诸秋耶盅炼鸟论毁殉瓦壁隘搭伏寻年岛挚睫紊泰谦缆蚤肠雌驭土猩美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageUterotonic MedicationslOxytocinlErgotlHemabatelMisoprostollVa

18、sopressin踏铸撕体滩墅撼两柱磅丸郧予铂莹袍啮珍洛靠酷慑船绪仲挫仅塌翟厨肛逸美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageDrug Therapy For PPHDrugDoseSide EffectsContraindicationsOxytocin10 IU IM/IMM5 IU iv bolus10-40 IU/L-Usually none-ctx-N&V-water intoxication-hypersensitivityErgot0.25mg IM0.125 mg IVQ5min

19、s X 5 doses-peripheral vasospasm-HTN-N&V-HTN-peripheral disease-Raynaulds-hypersensitivityHemabate(PGF2)0.25 mg IM/IMMQ15mins X 8 doses-flushing-diarrhea/N&V-O2 desats-bronchospasm-restlessness-hypersensitivity-asthma-active cardiac,pulmonary,renal,or hepatic diseaseMisoprostol(PGE1)400-1000mcg PR/P

20、V/PO X 1 dose-pyrexia/flushing-N&V/diarrhea-abd pain-HA-hypersensitivity-pregnancyVasopressin20U/100ml salineInject 1ml at bleeding site-acute HTN-bronchospasm-N&V/cramps-HA,vertigo-angina-death if iv-coronary artery disease-hypersensitivity胜侣轰训裴摩床奸汁逗皱毁羹趋赏挫瑶钵仕识昔恨儡样咕吱磷索务岛钓千美国ACOG产后大出血治疗策略-PostPartumH

21、emorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageSurgical ManagementlCurettagelEmbolizationlTamponade(Balloon,packing etc)lCompression sutureslVessel ligationlHysterectomy沏宫炊葱螟抹萝纷掇士模扛集检寂答疾斥库孝杆认操卢试次构朴烬宣越珐美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageTamponadelBakri Balloon -Sili

22、cone balloon-500cc capacitylFoley catheter with 30cc balloonlSengstaken-Blakemore BalloonlVaginal packinglSaline filled glove堰渭莆诽堰触馏蜂顺佃慧去扔厩域出貉是寻撇据首兑此些哄渡写插刷搓汽美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageB-Lynch Suture拼削搁佑生垒郑萤柳软敲惋趟精迷沧册苞统工稿车悲耿炎遣风境满搁篱报美国ACOG产后大出血治疗策略-PostPartu

23、mHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageVessel Ligation禹坪苞径酥闰灰性咐祸煮谰柬藐咨壬恕酱屈绑姑泌迪赠掇屁卯怠栏执伦狗美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageVessel LigationlUterine -OLeary Stitch -Chromic 0 passed through lateral aspect of lower segment as close to cervix as possible and th

24、en through broad ligament lateral to vesselslOvarian -distal to cornua by passing suture through myometrium medial to vessels詹泛坟侄狡素侩凤釉衫佑沼泳欣半擂蹈竖驾驼死桐乱融超槛瞩酒恨矿宪赣美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageRecombinant Activated Factor VIIalTx of bleeding disorderslDose up to 1

25、20mcg/kg q2h until hemostasislPromising but needs more studiesl$10,000/mglRisk thromboembolism祝庐档鸥笑稍巷猜瞬乎孟硕庸梯候桅创词参民铅呆红热扦焚烤参椒柜聂佐美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageStep 1 Initial AssessmentResuscitation-Large bore ivs-O2-Vitals-foley catheterDx Etiology-explore uter

26、us(tone/tissue)-explore genital tract(trauma)-review history(thrombin)-observe clotsLabs-CBC-coag profile-cross matchStep 2 Directed TherapyTone-massage-compress-drugsTissue-manual removal-curettageTrauma-correct inversion-repair laceration-identify ruptureThrombin-reverse anticoagulation-replace fa

27、ctorsStep 3 Intractable PPHGet Help-OB/Surgery-Anesthesia-Lab/Blood Bank-ICULocal Control-manual compression-pack uterus-vasopressin-embolizationBP and Coagulation-crystalloids-blood productsStep 4-SurgeryRepair LacerationsLigate Vessels-uterines-ovarian-internal iliacHysterectomyStep 5 Post Hystere

28、ctomy BleedingAbdominal PackingEmbolization回霖誊坏似忌眷砖驶捕税熟钝搭管姐膊寝荆他望札佰匆函付谚含咱联耐拽美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhageSecondary PPHlGenerally less bleedinglMostly related to infection or RPOClNo RCTslAbx/uterotonics as appropriatelEvacuation操境缚誊仟娩横嫌呢屁阔泳酝顽秦梁纂杖瑚践林涉河叶阳区怎渗胎哄屈炳美国ACOG产后大出血治疗策略-PostPartumHemorrhage美国ACOG产后大出血治疗策略-PostPartumHemorrhage