Postpartum hemorrhage
Page 224
Definition
? Postpartum hemorrhage has been defined as
the loss of 500ml or more blood after the
delivery of the fetus (completion of the third
stage of labor).
? Hemorrhage after the first 24 hours is
designated late postpartum hemorrhage.
Sheehan syndrome
? Severe intrapartum or early postpartum
hemorrhage is on rare occasions followed
by sheehan syndrome,which in the classical
case is characterized by failure in laceration,
amenorrhea,atrophy of the breasts,loss of
pubic and axillary hair,superinvolution of
the uterus,hypothyroidism and adrenal
cortical insufficiency.
Sheehan syndrome
? In some but not all instances of sheehan
syndrome,varying degrees of anterior
pituitary necrosis with impaired secretion of
one or more trophic hormones account for
endocrine abnormalities,Some cases imply
impaired hypothalamic function.
Etiology
? Uterine atony(uterine inertia)
? Genital tract lacerations
? Placenta factors
? Impaired coagulation mechanism
Clinical manifestation and
diagnosis
? Bleeding
? shock.,infection
? uterine atony
? genital tract lacerations
? placenta factors
Placenta factors
? Retained placenta fragments
? placenta adherence
? placenta accreta,increta and percreta
– placenta accreta is used to describe any placental
implantation in which there is abnormally firm
adherence to the uterine wall.Placenta villi are attached
to the myometrium in placenta accreta; actually invade
the myometriumin placenta increta,or penetrate
through the myometrium in placenta percreta
副 胎 盘 手取胎盘
（三）产后出血的病因诊断
子宫收缩乏力
症状,间歇性阴道流血
体征,面色苍白、脉搏细弱、血压下降，
宫底高，轮廓不清
诊断,症状，体征，收集阴道出血
胎盘因素：
症状,胎盘娩出前阴道多量流
血, 多伴有宫缩乏力 。
诊断,检查娩出的胎盘胎膜 。
病因诊断（二）
病因诊断（三）
软产道裂伤：
症状,胎儿娩出后血持续不断，血色鲜红能自凝
诊断,检查软产道，会阴裂伤分三度：
Ⅰ 度：指会阴皮肤及阴道入口黏膜撕裂
Ⅱ 度：裂伤已达会阴肌层，累及阴道后
壁黏膜
Ⅲ 度：肛门外括约肌已断裂，甚至阴道
直肠隔及部分直肠前壁有裂伤。
病因诊断（四）
凝血功能障碍
症状,在孕前或妊娠期已有易于出血倾向，
表现为全身不同部位出血，最多见
子宫大量出血或少量持续不断出血。
血不凝不易止血。
诊断,病史，实验室检查
处理（ management ）
治疗 原则,
1.纠正病因
2.制止出血
3.补充血容量及纠正休克
4.预防感染
治疗方法：
（一） 补充血容量及纠正休克
保持静脉通路
补充新鲜血
补充晶体：平衡液、低分子右旋糖酐
根据中心静脉压进行补液
应用调节血管紧张度的药物：多巴胺
纠正酸中毒
（二）制止出血方法
针对出血原因,1.子宫收缩乏力：
2.胎盘因素：
3.软产道损伤：
4.凝血机制障碍：
1.子宫收缩乏力
按摩子宫
应用宫缩剂
压迫法,宫腔填塞纱布 \双手压迫
手术止血, 血管结扎术
介入栓塞
子宫切除
（ 1）手法按摩子宫
（ 2）宫缩剂
不同途径给缩宫素（ Oxytocin),iv、
ivdrop, 宫体 im
麦角新碱和缩宫素的联合应用：宫体 im
前列腺素的应用,PG05（肛塞、阴道、口含米
索前列醇
宫
腔
纱
布
填
塞
术
（ 3）
（ 4）血管结扎术
子宫动脉结扎术
子宫动脉上行支结扎术
子宫卵巢动脉吻合支结扎术
髂内动脉结扎术
盆
腔
血
管
结
扎
术
Ligation the uterine artery
髂
内
动
脉
结
扎
术
hysterectomy
subtotal~
total~
子宫次切
子宫全切
2.胎盘因素
若胎盘已剥离未排出，应导尿，按摩子宫，
轻拉脐带协助胎盘取出。
胎盘剥离不全或粘连应人工徒手剥离胎盘
胎盘胎膜残留，清宫
胎盘嵌顿，麻醉后取出胎盘
胎盘植入，切除子宫
3.软产道损伤
Repair the laceration
? 宫颈裂伤
? 阴道裂伤
? 会阴裂伤
Puerperal Infection
Page 257
definition
? Puerperium,is the postpartum period during
which the pelvic organs return to their
prepregnant conditions
? puerperium infection is a general term used
to describe any bacterial infection of the
genital tract after delivery
? puerperium morbidity,
Puerperium morbidity
? Temperature 38.0 or higher,the temperature
to occur on any 2 of the first 10days
postpartum,exclusive of the first 24 hours,
and to be taken by mouth by a standard
technique at least four times daily.
– Although it is suggests that all puerperal fevers
are the consequence of pelvic infection,
temperature elevations may be the results of
other causes.
Extragenital causes of puerperal fever
? Respiratory complications
? pyelonephritis
? intense breast engorgement
? bacterial mastitis
? thrombophlebitis
? incisional wound abscess
Bacteria commonly responsible for
female genital infections
? Aerobes
– Group A,B and D streptococci
– Enterococcus
– Gram-negative bacteria---E,Coli,Klebsiella
– staphylococcus aureus
? Anaerobes
– peptococcus species
– peptostreptococcus species
– bacteroides bivius,B,Fragilis,B,Disiens
– clostridium species
– fusobacterium species
? others------mycoplasma hominis
– chlamydia trochomatis
Clinical manifestation
? Acute episiotis,vulvovaginitis and cervitis
? metritis(postpartum uterine infection)
– endometritis,endomyometritis,
endoparametritis
– subinvoluted,tenderness,rebound tenderness
– lochia
? adnexal infections,acute salpingitis
? parametrial phlegmen and pelvic abscess
? acute pelvic peritonitis or general peroitonitis
? septic pelvic thrombophlebitis:femoral,saphena
? pyemia and sepsis
Page 224
Definition
? Postpartum hemorrhage has been defined as
the loss of 500ml or more blood after the
delivery of the fetus (completion of the third
stage of labor).
? Hemorrhage after the first 24 hours is
designated late postpartum hemorrhage.
Sheehan syndrome
? Severe intrapartum or early postpartum
hemorrhage is on rare occasions followed
by sheehan syndrome,which in the classical
case is characterized by failure in laceration,
amenorrhea,atrophy of the breasts,loss of
pubic and axillary hair,superinvolution of
the uterus,hypothyroidism and adrenal
cortical insufficiency.
Sheehan syndrome
? In some but not all instances of sheehan
syndrome,varying degrees of anterior
pituitary necrosis with impaired secretion of
one or more trophic hormones account for
endocrine abnormalities,Some cases imply
impaired hypothalamic function.
Etiology
? Uterine atony(uterine inertia)
? Genital tract lacerations
? Placenta factors
? Impaired coagulation mechanism
Clinical manifestation and
diagnosis
? Bleeding
? shock.,infection
? uterine atony
? genital tract lacerations
? placenta factors
Placenta factors
? Retained placenta fragments
? placenta adherence
? placenta accreta,increta and percreta
– placenta accreta is used to describe any placental
implantation in which there is abnormally firm
adherence to the uterine wall.Placenta villi are attached
to the myometrium in placenta accreta; actually invade
the myometriumin placenta increta,or penetrate
through the myometrium in placenta percreta
副 胎 盘 手取胎盘
（三）产后出血的病因诊断
子宫收缩乏力
症状,间歇性阴道流血
体征,面色苍白、脉搏细弱、血压下降，
宫底高，轮廓不清
诊断,症状，体征，收集阴道出血
胎盘因素：
症状,胎盘娩出前阴道多量流
血, 多伴有宫缩乏力 。
诊断,检查娩出的胎盘胎膜 。
病因诊断（二）
病因诊断（三）
软产道裂伤：
症状,胎儿娩出后血持续不断，血色鲜红能自凝
诊断,检查软产道，会阴裂伤分三度：
Ⅰ 度：指会阴皮肤及阴道入口黏膜撕裂
Ⅱ 度：裂伤已达会阴肌层，累及阴道后
壁黏膜
Ⅲ 度：肛门外括约肌已断裂，甚至阴道
直肠隔及部分直肠前壁有裂伤。
病因诊断（四）
凝血功能障碍
症状,在孕前或妊娠期已有易于出血倾向，
表现为全身不同部位出血，最多见
子宫大量出血或少量持续不断出血。
血不凝不易止血。
诊断,病史，实验室检查
处理（ management ）
治疗 原则,
1.纠正病因
2.制止出血
3.补充血容量及纠正休克
4.预防感染
治疗方法：
（一） 补充血容量及纠正休克
保持静脉通路
补充新鲜血
补充晶体：平衡液、低分子右旋糖酐
根据中心静脉压进行补液
应用调节血管紧张度的药物：多巴胺
纠正酸中毒
（二）制止出血方法
针对出血原因,1.子宫收缩乏力：
2.胎盘因素：
3.软产道损伤：
4.凝血机制障碍：
1.子宫收缩乏力
按摩子宫
应用宫缩剂
压迫法,宫腔填塞纱布 \双手压迫
手术止血, 血管结扎术
介入栓塞
子宫切除
（ 1）手法按摩子宫
（ 2）宫缩剂
不同途径给缩宫素（ Oxytocin),iv、
ivdrop, 宫体 im
麦角新碱和缩宫素的联合应用：宫体 im
前列腺素的应用,PG05（肛塞、阴道、口含米
索前列醇
宫
腔
纱
布
填
塞
术
（ 3）
（ 4）血管结扎术
子宫动脉结扎术
子宫动脉上行支结扎术
子宫卵巢动脉吻合支结扎术
髂内动脉结扎术
盆
腔
血
管
结
扎
术
Ligation the uterine artery
髂
内
动
脉
结
扎
术
hysterectomy
subtotal~
total~
子宫次切
子宫全切
2.胎盘因素
若胎盘已剥离未排出，应导尿，按摩子宫，
轻拉脐带协助胎盘取出。
胎盘剥离不全或粘连应人工徒手剥离胎盘
胎盘胎膜残留，清宫
胎盘嵌顿，麻醉后取出胎盘
胎盘植入，切除子宫
3.软产道损伤
Repair the laceration
? 宫颈裂伤
? 阴道裂伤
? 会阴裂伤
Puerperal Infection
Page 257
definition
? Puerperium,is the postpartum period during
which the pelvic organs return to their
prepregnant conditions
? puerperium infection is a general term used
to describe any bacterial infection of the
genital tract after delivery
? puerperium morbidity,
Puerperium morbidity
? Temperature 38.0 or higher,the temperature
to occur on any 2 of the first 10days
postpartum,exclusive of the first 24 hours,
and to be taken by mouth by a standard
technique at least four times daily.
– Although it is suggests that all puerperal fevers
are the consequence of pelvic infection,
temperature elevations may be the results of
other causes.
Extragenital causes of puerperal fever
? Respiratory complications
? pyelonephritis
? intense breast engorgement
? bacterial mastitis
? thrombophlebitis
? incisional wound abscess
Bacteria commonly responsible for
female genital infections
? Aerobes
– Group A,B and D streptococci
– Enterococcus
– Gram-negative bacteria---E,Coli,Klebsiella
– staphylococcus aureus
? Anaerobes
– peptococcus species
– peptostreptococcus species
– bacteroides bivius,B,Fragilis,B,Disiens
– clostridium species
– fusobacterium species
? others------mycoplasma hominis
– chlamydia trochomatis
Clinical manifestation
? Acute episiotis,vulvovaginitis and cervitis
? metritis(postpartum uterine infection)
– endometritis,endomyometritis,
endoparametritis
– subinvoluted,tenderness,rebound tenderness
– lochia
? adnexal infections,acute salpingitis
? parametrial phlegmen and pelvic abscess
? acute pelvic peritonitis or general peroitonitis
? septic pelvic thrombophlebitis:femoral,saphena
? pyemia and sepsis
