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OBSTETRICAL HEMORRHAGE

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Title: OBSTETRICAL HEMORRHAGE


1
????????????????????????
OBSTETRICAL HEMORRHAGE
  • ????????? ????? ??????????

2
??????????????????????????????????????????????????
?????????????? 763 ???
?????????????????? ????? ( ???????????)
Placental abruption 141(19)
Laceration/uterine rupture 125(16)
Uterine atony 115(15)
Coagulopathies 108(14)
3
?????????????????? ????? ( ???????????)
Placenta previa 50(7)
Uterine bleeding 47(6)
Placental adherens 44(6)
Retained placenta 32(4)
(Chichakli Colleagues,1999 as cited Cunningham
et al, 2005.)
4
  • ???????????????????
  • Antepartum Hemorrhage

5
Definition
  • ?????????????????? ??????? ?????????????????????
    ?????????? 20 ??????? (Cunningham, Leveno, Bloom,
    Hauth, Gilstrap Wenstrom, 2005)

6
  • ?????????
  • ????????????????????????????????????????????????
    ????????????????? ??????????????????????
    ?????????????????????? ??????????????

??????????? ?????? 3-5 ??????????
7
??????
  • ???????? 1 ??????????????????????????????????
    ??????
  • 1.1 ????????? ( Placenta previa )
  • 1.2 ????????????????? (Abruptio
    placentae)
  • 1.3 ???????? ( Rupture of the uterus)
  • 1.4 ????????? vasa previa
  • 1.5 ????????? marginal sinus
  • 1.6 Excessive bloody show

8
  • ???????? 2 Non obstetrics Cause ??????
  • 2.1 ????????????????????????????????
    ???????????
  • 2.2 Polyp ???? Erosion ???????????
  • 2.3 ??????????????????????????????
  • 2.4 ???????????????????????????????
    ????????????????
  • ??????????????
  • 2.5 ????????
  • 2.6 ?????????????

9
  • ?????????????????????

(Abruptio placentae)
10
?????????????????????
  • ????????
  • ????????????????? ??????? ??????????????????????
    ??????????????????????????????????????????????????
    ?????????? 20 ??????? ?????????????????
    (Larsen,2004 104 Cunnimgham et al, 2005)
  • ???????????
  • ???????? 0.5-1 ???????? 1 ?? 3
    ?????????????????????

11
  • ??????????????????????????????????
  • 1. Revealed hemorrhage ???? External hemorrhage
    ??????????? 80
  • 2 Concealed hemorrhage ???? Internal
    hemorrhage ???????????? 20
  • 3. Combined hemorrhage ???? Mixed ???
    ??????????????????? 1 ??? 2 ???????

(Cunningham et al., 2005)
12
?????????????????????????????????
13
  • ?????????????????????
  • ???????????????????????????????
  • ?????????????????????????????????????
  • ??????????????????????
  • ??????????????????????????
  • ????????????????????????

14
  • ?????????????????????
  • ???? thrombophillia
  • ???????????????????????
  • ?????????????????????????
  • ?????????????????????????????????????

15
  • ???????????
  • 1. ?????????????
  • ????????????????????????????????????????????????
    ???????????????? ?????????????????????????????????
    ?
  • 2. ??????????????
  • 2.1 ?????????????? ??????????????? ????????????
    ?????????
  • 2.2 ???????????? ????????????????????????
    ???????????????????????????????
    HF???????????????????

16
  • 2. ?????????????? (???)
  • 2.3 ???????????????????????????????
  • 2.4 ??????????????? ????????????????????????
    ?????????????? ???????????????????????
    ??????????????????????????????????
  • 3. ????????????????????????
  • 3.1 U/S ??????? Blood clot ?? Uterine cavity
  • 3.2 CBC , Hct, Fibrinogen in plasma

17
?????????????????
  • ??????????
  • Hypovolumic shock
  • Hypofibrinogenemia
  • DIC
  • Postpartum Hemorrhage
  • Renal failure
  • Sheehans syndrome

18
  • ?????????
  • Preterm birth
  • Fetal distress ??? Asphyxia ??????????????????????
    ???? Uteroplacenta insufficiency
  • ?????????????? ???????????????????????? Asphyxia

19
?????????????????????????????
  • ????????? hypovolemia ??? electrolyte
  • ??????? ?????????????? consumptive coagulopathy
  • ????????????????
  • - ???????????????????????????????
  • - Oxytocin
  • - ????????????????? continuous fetal heart
    rate monitoring ?????????????????????
  • - ????????????????????????????????????
  • - ?????????????????????????????????????????
  • - Expectant

20
  • ?????????
  • Placenta previa

21
Definition
  • ????????????????????????????????????????????????
    ???????????????????????????(Lower uterine
    segment) ?????????????????????????????????????????
    ????????????????? (Genovese, 2000 849
    Pillitteri, 1999 382)

22
  • ???????????
  • ?????? 1200 ??????????

23
  • ????????????????
  • Low lying placenta ??????? internal os ?????????
    2 ??.
  • Marginal placenta previa ?????????????????????????
    os ?????? 2 ??.
  • Partial placenta previa ????????????????????????
    internal os ????????????
  • Complete placenta previa ????????????????????????
    internal os ???????

24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
  • ??????????????
  • ????????????? 40 ??
  • ?????????????????????????
  • ?????????
  • ???????????????????????????
  • ?????????????????
  • ??????????????? ?
  • ?????????????????

28
  • ???????????
  • ??????????????? ???????????? ????????????????????
  • Ultrasound sensitivity ?????? 95
  • Double setup

29
?????????????????
  • ??????????
  • Threatened abortion ?????????? Abortion
  • PROM
  • ??????????????????????????? ????????????????
  • Embolism
  • ??????????????????
  • ?????????
  • ???????????
  • ??????????????????????????????????
  • ???????????????????????????????????????????

30
  • ?????????
  • ????????????????
  • ?????????????????????
  • ?????????????????????????

31
?????????????????????????
  1. ?????????????????????????????? ???????? expectant
    ?????????????????????? ???????????????????????????
    ??????????
  2. ???????????????????? ?????????????????????
  3. ??????????????????? ???????????????
    ?????????????????
  4. ??????????????????? ??????????????????????????????
    ????????
  5. ?????????????? ???? fetal distress
    ????????????????????????????????????

32
  • 6. Expectant
  • 6.1 bed rest
  • 6.2 Record ??????????????, FHS
  • 6.3 ????????????????????? 12-14
    ??????????????????????????? ??????????????????????
    ???????????????????? 2 -3 ???
  • 6.4 ???????????????????? ???????????????????????
    ???????? ?????????????????????????????????????????
    ??????????????
  • 6.5 ????????????? ?????????????????????

33
???????? ( uterine rupture )
  • Perinatal and mothernal motarity

34
  • Definition
  • uterine wall tear after fetal viability

35
  • Type
  • - Complete rupture
  • - Incomplete rupture
  • rupture - dehiscence

36
  • Incident 1 100 1 11,000

37
  • Causes
  • - previous scar
  • - difficult obstetrics procedure
  • - severe abdominal trauma
  • - grand multiparity
  • - oxytocic drugs
  • - obstructed labor
  • - placenta percreta or increta

38
  • Diagnosis
  • 1. sign and symptom
  • 1.1 threatened uterine rupture
  • - tetanic contraction
  • - suprapubic tenderness
  • - Bandls ring

39
  • 1.2 uterine rupture
  • - decrease pain
  • - tear sensation
  • - with shock?
  • - FHB loss
  • - fetal part
  • - PV float , become higher station
  • - hematuria

40
  • DDx
  • - Abruptio placenta
  • -Placenta previa
  • -Ectopic pregnancy
  • -tetanic uterine contraction
  • -colpotthexis

41
  • Rx - keep in mild
  • - get rid of threatened uterine
    rupture
  • - Rx shock
  • - Exploratory laparotomy
  • - hypogastric arteries ligation
  • - blood tranfusion
  • - antibiotic

42
  • Complication
  • - APH PPH
  • - Infection
  • - increase perinatal- mothernal
    mortality
  • - fetal asphyxia

43
Vasa Previa rupture
  • Definition
  • umbilical or placental vv.insert
    at fetal membrane pass internal cervical os (
    velamentous insertion )

44
  • Incident 1 2000-3000

45
  • Diagnosis
  • - Pre- rom PV synchronous pulse
  • amnioscopy
  • u /s
  • - Post- rom fetal hemoglobin (alkali
    denaturation test )
  • placental and membrane
    exam
  • color flow Droppler u/s

46
  • DDx
  • prolapse of the umbilical cord
  • placenta previa

47
  • Rx keep in mind
  • c/s in pre-rom period Dx
  • rom case rapid termination of
    labor

48
  • Prognosis fetal dead 60-70

49
??????????????????? Postpartum hemorrhage
50
Definition
  • ?????????????????????????????????????????????????
    ???????????????????????????????????????????????
    500 ????
  • ???????????
  • 1. Early PPH
  • 2. Late PPH
  • ???????? ?????????????????????
    ??????????????????????????? 30-50

51
??????????????????????????????????????????????????
???????????????
???????????(??????) ???????????? (??.????) ?????????????????
500-1000CC (10-15) ???? ?????? ????? ?????????????
1000-1500 CC (15-25) ??????????? ?????? Systolic 80-100 ??????? ????????? ?????????
1500-2000 CC (25-35) 70-80 ????????????? ??? ??????????????
2000-3000 CC (35-45) 50-70 ?????? ???????? ????????????
52
????????????????????????????????????????
?????????????? ??????, ?????, ??????, ?????? ???
??????? (Sheir, Sarid, Levy, Seidman Hallak,
2005 ) ???????????????????????????????????????????
? ????????
1. Retained placenta
2. Failed to progress during 2nd stage of labor
3. Placenta accreta
4. Laceration
53
????????????????????????????????????????
5. Instrumental delivery
6. Large size newborn
7. Hypertensive disorder
8. Induction of labor
9.Augmentation of labor with oxytocin
54
  • ?????????????? ??????, ???????????, ????????
    (Stone, Paterson Saunder, 1993)
    ?????????????????????????????????????? ??????
  • 1. Prolonged labor
  • 2. Augmentation labor
  • 3. History of postpartum hemorrhage
  • 4. Episiotomy, Especially mediolateral
  • 5. Preeclamsia

55
  • ?????????????????????????????????????? (???)
  • 6. Over distension uterus
  • 7. Operative delivery
  • 8. Asia or Hispanic ethnicity
  • 9. Chorioamniotis

56
???????????????????????????
57
A Stepwise Approach to the Prevent of Postpartum
Hemorrhage
58
A Stepwise Approach to the Management of
Postpartum Hemorrhage
59
A Stepwise Approach to the Management of
Postpartum Hemorrhage
  • Resuscitation
  • large bore IV (s)
  • oxygen by mask
  • monitor BP,PR,RR,I/O
  • retained Foley catheter
  • /- oxygen saturation
  • Laboratory Tests
  • CBC
  • coagulation screen
  • M/G
  • Assess Etiology
  • Tone
  • Tissue
  • Trauma
  • Thrombin

60
A Stepwise Approach to the Management of
Postpartum Hemorrhage
  • Tone
  • massage
  • compress
  • drugs
  • manual removal
  • curettage

Tissue
61
A Stepwise Approach to the Management of
Postpartum Hemorrhage
4 ????????????????????????
62
DRUG THERAPY FOR PPH
  • Oxytocin IV 10-40 unit ?????????? ????
    Lactated Ringer 1 L ???????????? IM 10 unit
  • Methylergonovine IM ???? IV ??? ? 0.2 ?? .
    ????????? 2-4 ???????
  • 15 - methyl PGF2a 0.25 ??. IM ????????? 15-90
    ???? ??????? 8 ?????

63
  • Dinoprostone ??????????? ???? ???????? 20 ??.
    ????????? 2 ???????
  • Sulprostone 500 ????????? IV ????? 100
    ???????????? ???????
  • Misoprostol 800-1,000 ????????? ??????????????

64
Bimanual compression
65
Uterine packing
66
B lynch sutures
67
Uterine artery ligation
68
Right hypogastric artery ligation
69
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