美國(guó)ACOG產(chǎn)后大出血治療策略PostPartumHemorrhagePPT學(xué)習(xí)教案

1、會(huì)計(jì)學(xué)1美國(guó)美國(guó)ACOG產(chǎn)后大出血治療策略產(chǎn)后大出血治療策略PostPartumHemorrhage第1頁/共33頁第2頁/共33頁第3頁/共33頁第4頁/共33頁第5頁/共33頁第6頁/共33頁Zymogens of Serine ProteasesActivitiesFactor XIIbinds to exposed collagen at site of vessel wall injury, activated by high-MW kininogen and kallikreinFactor XIactivated by factor XIIaFactor IXactivated

2、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 of activated platelets by prothrombinase complexCofactorsAct

3、ivitiesFactor 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 subendothelial cell-surface glycoprotein that acts as a cofac

4、tor 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 proteinsActivitiesvon Willebrand factorassociated with subendothelial

5、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 proteins contain gla residuesThrombomodulinprotein on the sur

6、face 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第7頁/共33頁第8頁/共33頁第9頁/共33頁第10頁/共33頁第11頁/共33頁第12頁/共33頁第13頁/共33頁第14頁/共33頁第15頁/共33頁Etiology ProcessClinical Risk

7、 FactorsToneOverdistended UterusPolyhydramnios, Multiple GestationMacrosomiaUterine Muscle Fatigue Rapid Labor, Prolonged LaborHigh ParityIntra Amniotic InfectionFever, Prolonged ROMFunctional/Anatomic Distortion of the UterusFibroid UterusPlacenta PreviaUterine AnomaliesTissueRetained ProductsAbnor

8、mal PlacentaIncomplete Placenta at DeliveryPrevious Uterine ScarHigh ParityRetained Blood ClotsAtonic UterusTraumaLacerationsPrecipitous or Operative DeliveryExtensions at C/SMalposition, Deep EngagementUterine RupturePrevious Uterine SurgeryUterine InversionHigh Parity, Fundal PlacentaThrombinPre-e

9、xistingCoagulopaties, Liver DiseaseAcquired in PregnancyITP, DICTherapeutic Anti-coagHistory of clots第16頁/共33頁第17頁/共33頁第18頁/共33頁第19頁/共33頁第20頁/共33頁Blood Loss (%)Blood PressureSigns & Symptoms500-1000ml (10-15)normalPalpitations, dizziness, tachycardia1000-1500ml (15-25)Slightly lowWeakness, sweat

10、ing, tachycardia1500-2000ml (25-35)70-80Restlessness, pallor, oliguria2000-3000ml (35-45)50-70Collapse, air hunger, anuria 2500cc blood loss 50% mortality if not managed urgently & appropriately第21頁/共33頁第22頁/共33頁第23頁/共33頁DrugDoseSide EffectsContraindicationsOxytocin10 IU IM/IMM5 IU iv bolus10-40

11、 IU/L-Usually none-ctx-N&V-water intoxication-hypersensitivityErgot0.25mg IM0.125 mg IVQ5mins 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-hy

12、persensitivity-asthma-active cardiac, pulmonary, renal, or hepatic diseaseMisoprostol(PGE1)400-1000mcg PR/PV/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-an

13、gina-death if iv-coronary artery disease-hypersensitivity第24頁/共33頁第25頁/共33頁第26頁/共33頁第27頁/共33頁第28頁/共33頁第29頁/共33頁第30頁/共33頁Step 1 Initial AssessmentResuscitation-Large bore ivs-O2-Vitals-foley catheterDx Etiology-explore uterus (tone/tissue)-explore genital tract (trauma)-review history (thrombin)-obse

14、rve clotsLabs-CBC-coag profile-cross matchStep 2 Directed TherapyTone-massage-compress-drugsTissue-manual removal-curettageTrauma-correct inversion-repair laceration-identify ruptureThrombin-reverse anticoagulation-replace factorsStep 3 Intractable PPHGet Help-OB/Surgery-Anesthesia-Lab/Blood Bank-ICULocal Control-manual compression-pack uterus-vasopressi