logo
head-banner

指南速递 | 2019昆士兰临床指导:原发性产后出血

2019-06-05 19:50 来源: 中国妇产科网 作者: 中国妇产科网 浏览量: 15533

翻译:杨泓 何泽琳 邓诗蕾 黄启涛(南方医科大学南方医院妇产科 )

审校:陈继明(南京医科大学常州临床医学院妇产科学教研室;南京医科大学附属常州第二人民医院妇产科)

温馨提示:本文多为图片内容,建议单击图片放大后进行阅读。


流程图:对产后出血的初始响应

1_副本.jpg

流程图:大规模出血方案(MHP)

2_副本.jpg

1.1定义

3.jpg

1.3病因

产后出血的常见原因被称为“四个T”(妊娠相关物残留、宫缩异常、创伤、凝血),但可能存在不止一个原因(如宫缩异常和妊娠相关物残留)。

4.jpg

2.1 风险因素

2.2 产前风险管理

7.jpg

2.3 产时风险管理

8.jpg

2.3.1 第三产程管理

在第三和第四产程期间提供的护理有助于预防或早期发现和治疗产后出血。参考昆士兰临床指南:第三产程常规管理的正常出生(41)。

9.jpg

2.3.2麦角新碱

10.jpg

2.3.3卡贝缩宫素

11.jpg

2.4第四产程监护

如果发现产后出血(PPH)的高危因素,应在胎儿出生后立即监护一到两个小时。

12.jpg

2.5 产后风险管理

13.jpg


3.治疗

在没有血流动力学改变的情况下,大出血可在分娩时可迅速发展。因此,对所有产妇的密切监护、早期诊断和迅速反应是至关重要的1。

3.1 失血量估计


14.jpg

3.3 复苏

对PPH的最初应对需要多科室的共同参与1,12来恢复产妇的血流动力学状态,同时确定出血的原因并进行治疗。一旦确认PPH,立即通知有经验的资深产科医生(并要求立即出席)。


17-1.png

17-2.png

3.3.1 氨甲环酸

在PPH发病后尽快给予氨甲环酸56,最好在PPH后3小时内给予。

17.jpg

3.3.2 PPH期间的支持

18.jpg

3.4 宫缩异常

必须清空子宫腔以促子宫收缩。最初的临床和机械措施包括:

按摩子宫底,刺激宫缩4,11,12,29

评估是否需要双手加压4,11

检查胎盘和胎膜是否完整

排出子宫内血块

插入留置尿管,排空膀胱11,12

3.4.1 治疗宫缩乏力的一线药物

19.jpg

20.jpg

21.png


3.4.2 治疗宫缩乏力的二线药物

22.png

3.4.3 难治性产后出血

23.png

24.png

3.5 创伤

创伤是PPH的第二大常见原因,可能涉及子宫,宫颈,阴道或会阴。

3.5.1 生殖道创伤

25.png

3.5.2 子宫颈创伤

26.png

3.5.3 子宫破裂

子宫破裂可以自行发生或与先前的产科手术有关,出血的严重程度取决于破裂的程度。

27.png

3.5.4子宫内翻

子宫内翻与即刻危及生命的出血和休克有关,延迟治疗将增加死亡风险。在尝试重新定位底部之前考虑麻醉。

28.png

28-1.png

3.6妊娠相关物残留


29.png

29-1.png

3.7凝血功能障碍

晚期诊断或低估出血量可能与凝血病有关72。如果怀疑是凝血病,请咨询血液学家或输血专家,以获得血液成分替换,实验室检测和结果解释方面的建议1。

30.png

3.7.1目标结果

尽早和频繁地测量以下参数。治疗成功后,数值应趋于正常1。

31.png

3.7.2凝血障碍处理原则

32.png

5.产后出血后的护理

35.png

35-1.png

附录B:PPH药物和血液制品

有关适应症、注意事项、禁忌症和相互作用的详细信息,请参阅药典。

B.png

参考文献

1.   National Blood Authority (NBA). Patient blood management guidelines: module 5 obstetrics and maternity. Canberra Australia: NBA; 2015.

2.   Alexander J, Thomas PW, Sanghera J. Treatments for secondary postpartum haemorrhage. Cochrane Database of Systematic Reviews. 2002; Issue 1. Art. No.: CD002867. Available from: http://onlinelibrary.wiley.com/store/10.1002/14651858.CD002867/asset/CD002867.pdf?v=1&t=jdxsme5c&s=e7d17500a3fea54 f89ddd84f5ba93907ab24d7fd DOI:10.1002/14651858.CD002867.

3.   Australian Institute of Health and Welfare. National maternity data development project: primary postpartum haemorrhage: research brief no.8. Cat. no. PER 82. [Internet]. 2016 [cited 2017 June 09]. Available from: http://www.aihw.gov.au.

4.   World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. [Internet]. 2012 [cited 2017 April 10]. Available from: http://www.who.int

5.   Ford JB, Roberts CL, Simpson JM, Vaughan J, Cameron CA. Increased postpartum hemorrhage rates in Australia. Int J Gynaecol Obstet 2007;98(3):237-43.

6.   Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle MH, Ford JB, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009;9:55.

7.   Kramer MS, Berg C, Abenhaim H, Dahhou M, Rouleau J, Mehrabadi A, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013;209(5):449 e1-7.

8.   Australian Institute of Health and Welfare, Humphrey M, Bonello M, Chughtai A, Macaldowie A, Harris K, et al. Maternal deaths in Australia 2008-2012. cat no Per 70. Maternal deaths series number 5. [Internet]. 2015 [cited 2017 June 09]. Available from: http://www.aihw.gov.au.

9.   American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists. No. 76. Postpartum hemorrhage. Obstetrics and Gynecology 2006 (reaffirmed 2015);108(4):1039- 47.

10. Begley C, Gyte G, Devane D, McGuire W, Weeks A. Active versus expectantmanagement for women in the third stage of labour. Cochrane Database of Systematic Reviews. 2015; Issue 3. Art. No.: CD007412. DOI:10.1002/14651858.CD007412.pub4.

11. The Royal Australian and New Zealand College of Obsetricians and Gynaecologists. Management of postpartum haemorrhage. [Internet]. 2016 [cited 2017 June 09]. Available from: www.ranzcog.edu.au.

12. Mavrides E, Allard S, Chandraharan E, Collins P, et al, on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG 2016;124:e106-2149.

13. The Australian Council on Healthcare Standards. Clinical indicator user manual 2012: obstetrics version 7.

14. World Health Organization. International Statistical Classification of Diseases and Related Health Problems 10th Revision. ICD-10 Version: 2016. [Internet][cited 2017 November 22]. Available from: http://www.who.int/classifications/icd/en/.

15. Rizvi F, Mackey R, Barrett T, McKenna P, Geary M. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG 2004;111(5):495-8.

16. Royal College of Obstetricians and Gynaecologists. Blood transfusions in obstetrics. Green-top Guideline No.47. [Internet]. 2015 [cited 2017 June 02]. Available from: http://www.rcog.org.uk/

17. Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to clinical deterioration. [Internet]. 2010 [cited 2017 June 09]. Available from: https://www.safetyandquality.gov.au.

18. Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol 2015;212(3):272-80.

19. Dilla AJ, Waters JH, Yazer MH. Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet Gynecol 2013;122(1):120-6.

20. Wetta LA, Szychowski JM, Seals S, Mancuso MS, Biggio JR, Tita AT. Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery. Am J Obstet Gynecol 2013;209(1):51 e1-6.

21. Oberg AS, Hernandez-Diaz S, Palmsten K, Almqvist C, Bateman BT. Patterns of recurrence of postpartum hemorrhage in a large population-based cohort. Am J Obstet Gynecol 2014;210(3):229 e1-8.

22. Nyflot LT, Sandven I, Stray-Pedersen B, Pettersen S, Al-Zirqi I, Rosenberg M, et al. Risk factors for severe postpartum hemorrhage: a case-control study. BMC Pregnancy Childbirth 2017;17(1):17.

23. Fyfe EM, Thompson JM, Anderson NH, Groom KM, McCowan LM. Maternal obesity and postpartum haemorrhage after vaginal and caesarean delivery among nulliparous women at term: a retrospective cohort study. BMC Pregnancy Childbirth 2012;12:112.

24. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010;110(5):1368-73.

25. Bais JM, Eskes M, Pel M, Bonsel GJ, Bleker OP. Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 2004;115(2):166-72.

26. Sosa CG, Althabe F, Belizan JM, Buekens P. Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin- American population. Obstet Gynecol 2009;113(6):1313-9.

27. Royal College of Obstetricians and Gynaecologists. Placenta praevia, praevia accreta and vasa praevia: diagnosis and management Green-top Guideline No.27. [Internet]. 2011 [cited 2017 May 30]. Available from: http://www.rcog.org.uk/

28. Fan D, Xia Q, Liu L, Wu S, Tian G, Wang W, et al. The incidence of postpartum hemorrhage in pregnant women with placenta previa: a systematic review and meta-analysis. PLoS One 2017;12(1):e0170194.

29. Sentilhes L, Vayssiere C, Deneux-Tharaux C, Aya A, Bayoumeu F, Bonnet M, et al. Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF) in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). European Journal of Obstetrics & Gynecology and Reproductive Biology 2016;198:12-21.

30. Queensland Clinical Guidelines. Induction of labour. Guideline No. MN17.22-V5-R22. [Internet]. Queensland Health. 2017. [cited 2017 December 10]. Available from: http://www.health.qld.gov.au

31. Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee. Jehovah's Witnesses and blood transfusion. [Internet]; Available from: http://www.transfusionguidelines.org

32. Currie J, Hogg M, Patel N, Madgwick K, Yoong W. Management of women who decline blood and blood products in pregnancy. The Obstetrician and Gynaecologist 2010;12:13-20.

33. Queensland Clinical Guidelines. Preterm labour and birth. Guideline No. MN14.6-V7-R19. [Internet]. Queensland Health. 2014. [cited 2017 October 10]. Available from: http://www.health.qld.gov.au

34. Cheng YW, Delaney SS, Hopkins LM, Caughey AB. The association between the length of first stage of labor, mode of delivery, and perinatal outcomes in women undergoing induction of labor. Am J Obstet Gynecol 2009;201(5):477 e1-7.

35. Looft E, Simic M, Ahlberg M, Snowden JM, Cheng YW, Stephansson O. Duration of second stage of labour at term and pushing time: risk factors for postpartum haemorrhage. Paediatr Perinat Epidemiol 2017;31(2):126-33.

36. Le Ray C, Fraser W, Rozenberg P, Langer B, Subtil D, Goffinet F, et al. Duration of passive and active phases of the second stage of labour and risk of severe postpartum haemorrhage in low-risk nulliparous women. Eur J Obstet Gynecol Reprod Biol 2011;158(2):167-72.

37. Queensland Clinical Guidelines. Vaginal birth after caesarean section (VBAC). Guideline No. MN15.12-V4-R20. [Internet]. Queensland Health. 2017. [cited 2017 December 10]. Available from: http://www.health.qld.gov.au

38. Queensland Clinical Guidelines. Perineal care. Guideline No. MN12.30-V2-R17. [Internet]. Queensland Health. 2012. [cited 2017 April 10]. Available from: http://www.health.qld.gov.au

39. Australian Medicines Handbook. Carbetocin. [Internet]. Adelaide: Australian Medicines Hanbook Pty Ltd; 2017 [cited 2017 May 30]. Available from: http://amhonline.amh.net.au/

40. Abedi P, Jahanfar S, Namvar F, Lee J. Breastfeeding or nipple stimulation for reducing postpartum haemorrhage in the third stage of labour (Review). Cochrane Database of Systematic Reviews. 2013; Issue 1. Art. No.: CD010845. DOI:10.1002/14651858.CD010845.pub2.

41. Queensland Clinical Guidelines. Normal birth. Guideline No. MN17.25-V2-R22. [Internet]. Queensland Health. 2017. [cited 2017 December 10]. Available from: http://www.health.qld.gov.au

42. Westhoff G, Cotter A, Tolosa J. Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage (Review). Cochrane Database of Systematic Reviews. 2013; Issue 10. Art. No.: CD001808. DOI:10.1002/14651858.CD001808.pub2.

43. Gulmezoglu AM, Lumbiganon P, Landoulsi S, Widmer M, Abdel-Aleem H, Festin M, et al. Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. Lancet 2012;379(9827):1721-7.

44. Soltani H, Hutchon D, Poulose T. Timing of prophylactic uterotonics for the third stage of labour after vaginal birth. Cochrane Database of Systematic Reviews. 2010; Issue 8. Art. No.: CD006173. DOI:10.1002/14651858.CD006173.pub2.

45. Adnan N, Conlan-Trant R, McCormick C, Boland F, Murphy DJ. Intramuscular versus intravenous oxytocin to prevent postpartum haemorrhage at vaginal delivery: randomised controlled trial. BMJ 2018;362:k3546.

46. McDonald S, Middleton P, Dowswell T, Morris P. Effect of timing of umbilical cord clamping of terminfants on maternal and neonatal outcomes (Review). Cochrane Database of Systematic Reviews. 2013; Issue 7. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub3.

47. Sentilhes L, Merlot B, Madar H, Sztark F, Brun S, Deneux-Tharaux C. Postpartum haemorrhage: prevention and treatment. Expert Rev Hematol 2016;9(11):1043-61.

48. Gallos ID, Papadopoulou A, Man R, Athanasopoulos N, Tobias A, Price MJ, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database of Systematic Reviews. 2018; Issue 12. Art. No.: CD011689 DOI:10.1002/14651858.CD011689.pub3.

49. McDonald S, Abbott J, Higgins S. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour (Review). Cochrane Database of Systematic Reviews. 2004; Issue 1. Art. No.: CD000201. DOI:10.1002/14651858.CD000201.pub2.

50. National Institute for Health and Care Excellence (NICE). Intrapartum care for healthy women and babies. CG190. [Internet]. 2014 [cited 2017 June 09]. Available from: www.nice.org.uk.

51. International Federation of Gynaecology and Obstetrics. Misoprostol - only: recommended regimens 2017. [Internet]. 2017 [cited 2017 November 20]. Available from: www.figo.org.

52. Natrella M, Di Naro E, Loverro M, Benshalom-Tirosh N, Trojano G, Tirosh D, et al. The more you lose the more you miss: accuracy of postpartum blood loss visual estimation. A systematic review of the literature. J Matern Fetal Neonatal Med 2017:1-13.

53. Hancock A, Weeks AD, Lavender DT. Is accurate and reliable blood loss estimation the 'crucial step' in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth 2015;15:230.

54. Wikkelsø A, Wetterslev J, Møller A, Afshari A. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database of Systematic Reviews. 2016; Issue 8. Art. No.: CD007871. DOI:10.1002/14651858.CD007871.pub3.

55. Miller TE. New evidence in trauma resuscitation - is 1:1:1 the answer? Perioper Med (Lond) 2013;2(1):13.

56. Collaborators WT. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017;389(10084):2105-16.

57. Australian Medicines Handbook. Ergometrine. [Internet]. Adelaide: Australian Medicines Hanbook Pty Ltd; 2017 [cited 2017 June 15]. Available from: http://amhonline.amh.net.au/

58. MIMS Online. Ergometrine full product information. [Internet]: MIMS Australia; June 2017 [cited 2017 June 09]. Available from: https://www.mimsonline.com.au.

59. Queensland Health. List of approved medicines (LAM): effective 01 June 2017. [Internet]. 2017 [cited 2017 June 09]. Available from: https://www.health.qld.gov.au.

60. Hofmeyr G, Gülmezoglu A, Novikova N, Lawrie T. Postpartum misoprostol for preventing maternal mortality and morbidity (Review). Cochrane Database of Systematic Reviews. 2013; Issue 7. Art. No.: CD008982. DOI:10.1002/14651858.CD008982.pub2.

61. International Confederation of Midwives (ICM) and Internal Federation of Gynaecology and Obstetrics (FIGO): Joint statement. Misoprostol for the treatment of postpartum haemorrhage in low resource settings. [Internet]. 2014 [cited 2017 June 09]. Available from: www.figo.org.

62. Mousa H, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database of Systematic Reviews. 2014; Issue 2. Art. No.: CD003249 DOI:10.1002/14651858.CD003249.pub3.

63. Tunçalp Ö, Hofmeyr G, Gülmezoglu A. Prostaglandins for preventing postpartum haemorrhage (Review). Cochrane Database of Systematic Reviews. 2012; Issue 8. Art. No.: CD000494. DOI:10.1002/14651858.CD000494.pub4.

64. Micromedex 1.0 (Healthcare Series)(electronic version). Carboprost. [Internet]. Greenwood Village, Colorado, USA 2017 [cited 2017 June 19]. Available from: http://www.micromedexsolutions.com/.

65. Pfizer Canada Inc. Product mongraph hemabate (carborprost tromethamine injection USP). [Internet]. 2017 [cited 2017 June 19]. Available from: www.pfizer.ca.

66. National Blood Authority (NBA). Patient blood management guidelines: module 1 critical bleeding massive transfusion. Canberra Australia: NBA; 2011.

67. Labarta R, Recarte P, Luque A, Prieto J, Martin P, Leyte G, et al. Outcomes of pelvic arterial embolization in the management of postpartum haemorrhage: a case series study and systematic review. Eur J Obstet Gynecol Reprod Biol 2016;206:12-21.

68. Ronel D, Wiznitzer A, Sergienko R, Zlotnik A, Sheiner E. Trends, risk factors and pregnancy outcome in women with uterine rupture. Arch Gynecol Obstet 2012;285(2):317-21.

69. Paterson-Brown S, Howell C, editors. Managing Obstetric Emergencies And Trauma: The MOET Course Manual. 3rd ed. United Kingdom: Cambridge University Press; 2014.

70. Australia and New Zealand College of Anaesthetists (ANZCA). Guidelines on sedation and/or analgesia for diagnostic and interventional medical, dental or surgical procedures. [Internet]. 2014 [cited 2017 November 20]. Available from: http://www.anzca.edu.au.

71. Nardin J, Weeks AD, Carroli G. Umbilical vein injection for management of retained placenta (Review). Cochrane Database of Systematic Reviews. 2013; Issue 5. Art. No.: CD001337. DOI:10.1002/14651858.CD001337.pub2.

72. Collins P, Abdul-Kadir R, Thachil J, Subcommittees on Women' s Health Issues in thrombosis haemostasis on disseminated intravascular coagulation. Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. J Thromb Haemost 2016;14(1):205-10.

73. Carvalho M, Rodrigues A, Gomes M, Carrilho A, Nunes AR, Orfao R, et al. Interventional algorithms for the control of coagulopathic bleeding in surgical, trauma, and postpartum settings: recommendations from the Share Network Group. Clin Appl Thromb Hemost 2016;22(2):121-37.

74. Wise A, Clark V. Challenges of major obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol 2010;24(3):353-65.

75. Queensland Clinical Guidelines. Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium. Guideline No. MN14.9-V5-R19. [Internet]. Queensland Health. 2017. [cited 2017 December 10]. Available from: http://www.health.qld.gov.au

76. Eckerdal P, Kollia N, Lofblad J, Hellgren C, Karlsson L, Hogberg U, et al. Delineating the association between heavy postpartum haemorrhage and postpartum depression. PLoS One 2016;11(1):e0144274.




中国妇产科网.jpg