美国ACOG产后大出血治疗策略-PostPartumHemorrhage.pptVIP

Recombinant Activated Factor VIIa Tx of bleeding disorders Dose up to 120mcg/kg q2h until hemostasis Promising but needs more studies $10,000/mg Risk thromboembolism Step 1 – Initial Assessment Resuscitation Large bore iv’s O2 Vitals ±foley catheter Dx Etiology -explore uterus (tone/tissue) -explore genital tract (trauma) -review history (thrombin) -observe clots Labs -CBC -coag profile -cross match Step 2 – Directed Therapy Tone -massage -compress -drugs Tissue -manual removal -curettage Trauma -correct inversion -repair laceration -identify rupture Thrombin -reverse anticoagulation -replace factors Step 3 – Intractable PPH Get Help -OB/Surgery -Anesthesia -Lab/Blood Bank -ICU Local Control -manual compression -±pack uterus -±vasopressin -±embolization BP and Coagulation -crystalloids -blood products Step 4 - Surgery Repair Lacerations Ligate Vessels -uterines -ovarian -internal iliac Hysterectomy Step 5 – Post Hysterectomy Bleeding Abdominal Packing Embolization Secondary PPH Generally less bleeding Mostly related to infection or RPOC No RCT’s Abx/uterotonics as appropriate Evacuation Post Partum Hemorrhage District I ACOG Medical Student Teaching Module 2010 Post Partum Hemorrhage - Definition Commonly defined as…. SVD 500cc blood loss C/S 1000cc blood loss *PPH generally refers to GA 20wks Other Definitions Hematocrit Change – defined as change 10% but not useful in acute setting Need for Transfusion – variable practice Hemodynamic stability Timing – early or late Symptomatic Relevance One of top five causes of maternal mortality anywhere #1 cause maternal mortality worldwide Developed countries 1/100 000 births compared to 1/1000 births in developing countries Incidence 5% - 10% deliveries (depends on defn) Physiologic Adaptations of Pregnancy ? plasma volume 40-50% ? RBC 20-30% *in severe PIH - hemoconcentration Normal Mechanism of Hemostasis ‘Living ligatures’ – Baskett 2000 Intrinsic vasospasm Local decidual hemostatic factors including tissue fac