Postpartum Hemorrhage (PPH) refers to blood loss of >500ml within 24 hours after delivery of the fetus. if the postpartum hemorrhage is >1000ml and does not improve within 30-60 minutes after conventional treatment, or if the condition worsens, it is Intractable Postpartum Hemorrhage (IPH). If not treated in time, it can cause maternal death. The incidence of postpartum hemorrhage is 2%-3%, blood loss ≥500ml~1000ml is 4%-11%, blood loss >1000ml is <1%, and the incidence of intractable postpartum hemorrhage is about 1,8‰. Postpartum hemorrhage is a serious complication during labor and delivery, and is the first cause of maternal death in China. Emergency treatment is needed when postpartum hemorrhage is >1000ml. Rapid diagnosis and treatment can save the life of the mother.
Diagnostic criteria
1. Clinical manifestations
Vaginal bleeding >500ml after delivery; the cause of postpartum hemorrhage is mainly based on medical history (mode of delivery, presence of obstetric complications and medical and surgical comorbidities), symptoms, estimation of blood loss and examination (including vaginal and general examination). Internal bleeding (such as broad ligament hematoma) should be ruled out when there is an unexplained increase in heart rate and decrease in blood pressure after delivery.
2.Physical examination
It can help to find the cause of postpartum bleeding.
(1) Vaginal examination can reveal whether the depth of cervical laceration reaches the vaginal vault or whether there is a hematoma of the birth canal.
(2) Examination reveals a mass in the sciatic rectal fossa and whether there is skin discoloration and petechiae in the perineum.
(3) Abnormalities are found at the end of vaginal examination, and soft uterine body is considered as weak contraction; if the fundus is elevated, accumulation of blood in the uterine cavity is considered.
3.Auxiliary examination
(1) Routine blood count: hemoglobin, platelets, white blood cells, blood type and cross-matching.
(2) Coagulation routine; PT, APTT, TT, fibrinogen, ATIII, etc.
(3) Liver and kidney function, dielectric, blood gas analysis.
(4) Electrocardiogram, bedside chest X-ray.
4.Classification diagnosis
(1) Lack of uterine contraction (uterine atony), accounting for 70%-90%, is the most common cause of postpartum hemorrhage.
(2) placental factors (placental factors): commonly placental impaction, placental adhesions, placental implantation or partial placental residue, etc.
(3) soft birth canal laceration (birth canal laceration): common in vaginal surgical delivery, delivery of a huge baby, emergency delivery, poor elasticity of soft birth canal tissues and excessive labor force.
(4) coagulation defects: common in placental abruption, stillbirth, amniotic fluid embolism, severe pre-eclampsia and other obstetric complications.
5.Differential diagnosis
Differentiation is based on etiology.
(1) Uterine rupture: history of obstructive delivery, history of intravenous intravenous oxytocin or history of labor forceps, bleeding after the first vaginal delivery; internal bleeding is the main cause, early suspicion, early routine vaginal examination, early definitive diagnosis can be made.
(2) Amniotic fluid embolism: 80% occurs during or after delivery, with clinical signs of respiratory failure and cardiopulmonary circulatory disorders or allergic reactions, and the diagnosis can be confirmed if keratinized epithelium is found in peripheral blood. In case of delayed amniotic fluid embolism without expiration but with vaginal bleeding blood non-coagulation, DIC (+), treated as coagulation dysfunction.
【Treatment plan】.
Treatment principles: postpartum bleeding >1000ml according to second and third line emergency, for the cause of bleeding, continue anti-shock and etiological treatment, correct DIC, apply antimicrobial agents, and protect the function of critical organs.
1.Emergency treatment
(1) On the basis of emergency treatment, call for help, while rapidly establishing double venous channels, actively replenishing blood volume, rapidly rehydrating intravenous fluids, crystal first and then colloid; keeping airway unobstructed, administering oxygen by mask; monitoring bleeding volume and vital signs, dynamic monitoring of blood routine, liver and kidney function, coagulation function, cross-matching blood. Actively search for the cause and deal with it.
(2) Secondary emergency treatment: (blood loss > 1000ml)
Anti-shock treatment: blood and fresh frozen plasma transfusion, oxygen administration, monitoring of bleeding volume and vital signs, urine volume, oxygen saturation, dynamic monitoring of coagulation function, and central venous pressure monitoring if necessary. Also treat according to the following etiology.
2.Treatment of etiology
(1) Treatment of weak contractions.
Massage of the uterus, abdominal massage, vaginal massage method.
Uterine contractions 10u-20u added to 500ml crystalloid solution for maintenance by intravenous drip, misoprostol 400-600u contained or rectovaginal administration; carboprost aminotriol (Ximperia) 250ug uterine body, cervical or deep intramuscular injection, repeat if necessary. total amount not to exceed 2000ug in 24 hours.
Uterine hydrosac or sarafoil tamponade; Uterine hydrosac compression: for those bleeding after vaginal delivery, Uterine sarafoil tamponade for those bleeding during cesarean delivery (1,5 to 2m long and 7 to 8cm wide uterine tamponade, removed in 24 to 72 hours).
B-Lynch suture, which is simple, safe and preferred for contractile bleeding in cesarean delivery.
Transabdominal uterine vascular ligation.
(2) Injury to the birth canal
Local hematoma incision and suturing.
(3) Placental factors
Freehand stripping, immediate scraping if incomplete, do not pull hard if placenta implantation is suspected; 2 uterine involution, return the uterus first, then strip the placenta.
(4) Coagulation disorders
Replenish coagulation factors, fresh frozen plasma, fresh blood, cold precipitation, prothrombinogen complex, platelets, etc.
3.Tertiary emergency treatment (blood loss >1500ml)
(1) Embolization of the internal skeletal artery.
Indications.
Various kinds of refractory postpartum hemorrhage that have been invalidated by conservative treatment; postpartum hemorrhage ≥ 1000ml, those who still have bleeding tendency after conservative treatment; severe birth canal laceration, large hematoma in the birth canal.
Contraindications.
Patients with DIC combined with bleeding from other organs; patients with extremely unstable vital signs who should not be moved.
(2) Subtotal or total hysterectomy of the uterus.
Indications.
Various refractory postpartum hemorrhages that have failed conservative treatment (such as implanted placenta, weak contractions, uterine rupture, aggressive placenta praevia, uterine cavity infection); patients who are too late to be transferred or whose condition is not suitable for transfer; no conditions for intra-skeletal artery embolization.
(3) Intensive care: integrated treatment in ICU wards and multidisciplinary cooperation to protect vital organ functions.
4.Transfer in emergency
(1) Principle local resuscitation, not transfer, may seek help.
(2) postpartum hemorrhage ≥ 1000ml, after conservative treatment still have a tendency to bleeding, no local conditions of intra-skeletal artery embolization, in maintaining blood volume and respiratory ventilation, vital signs allow short distance transfer, have transportation, and contact with higher hospitals before transfer.
[Efficacy assessment
After secondary and tertiary emergency, maternal vaginal bleeding was stopped, vital signs were stable, and DIC was normal.