再谈产后出血患者出血量的计算

产后出血(postpartum hemorrhage)是产科最常见、最凶险的并发症之一,是导致全球孕产妇死亡的主要原因。准确地预估出血量,对临床上选择何种方法预防和治疗产后出血具有重要的指导意义。临床上常用的方法有：目测法、面积法、称重法、血红蛋白测定法以及休克指数等方法,近年又有学者研究发明了一种新型直观、较为精确的容量袋法。     

Increased postpartum blood loss in pregnancies associated with placental malaria.

OBJECTIVE: To determine the relationship of placental malaria and parity with postpartum blood loss in a malarious area of Tanzania. METHODS: A total of 706 uncomplicated vaginal deliveries were studied at Muhimbili University Hospital, Dar es Salaam, Tanzania. Maternal age, parity, date of delivery, birth weight, presence of placental malaria, stillbirths, and delivery complications were noted. Collection and measurement of vaginal blood loss commenced immediately following birth using a plastic vinyl sheet placed underneath the mother. The bed was divided in the middle to allow the blood to drain into a bucket. Blood loss was measured for a period of 2 h following delivery. RESULTS: In singleton births the mean postpartum blood loss was 170 mL in nulliparas and 187 mL in multiparas (p=0.017). Blood loss was 400 mL or greater in 23 women (3.4%) and 500 mL or greater in 10 women (1.5%). Mean postpartum bleeding tended to increase with maternal age, parity, and birth weight. In logistic regression the odds ratio for a blood loss of 400 mL or greater was significantly increased for women with placental malaria (3.2; 95% confidence interval, 1.1-9.0; p=0.028), after adjusting for a birth weight greater than 4000 g. Placental malaria showed a marked seasonal pattern, which corresponded to the months of peak prevalence for a postpartum blood loss of 400 mL or greater (p=0.007). CONCLUSION: A postpartum blood loss of 400 mL or greater should be considered a possible complication of placental malaria.     

Assessing blood loss in clinical practice

Postpartum haemorrhage is a major global cause of mortality and morbidity amongst childbearing women. Failure or delay in recognising the severity of bleeding is an important contributory factor in these outcomes. Earlier recognition of haemorrhage would facilitate earlier intervention and treatment, helping resolve the causes of bleeding sooner, and thereby improving outcomes for women. Ways to achieve earlier recognition have traditionally focussed on the clinical skill of assessing the volume of blood loss. However, despite extensive research, the optimum method of assessing blood loss and achieving earlier diagnosis remains unclear. Examination of the psychological literature suggests that clinical decision-making is more complex and highlights some of the reasons why traditional approaches have had a limited effect. Using psychological theories of decision-making to inform solutions may lead to more successful strategies to address the issues than the current focus on volume assessment of blood loss.     

如何准确评估出血量及产后出血的早期识别

早期识别产后出血以及准确估计出血量,对预防产后出血以及尽早做出决策有很大的帮助,产后出血的早期识别包括：识别产后出血的高危因素和发生产后出血后的早期识别。常见的估计出血量的方法有称重法、容积法、休克指数法等。     

阴道分娩产后出血发病率及影响因素的队列研究

目的探讨上海市孕产妇阴道分娩产后出血相关的影响因素。方法将2015年6月—2016年5月期间在上海市4家医院首次建卡产检的孕妇纳入队列,随访至分娩,收集其建卡、初次产检和分娩的资料。计算阴道分娩产后出血的发生率,并用独立样本t检验或方差分析进行单因素分析,用多元线性回归分析探讨阴道分娩产后出血量的影响因素。结果共收集到阴道分娩孕产妇资料3 495份,产后出血(500 mL)发生率为1.5%(53/3 495),产后出血量平均为(255.6±156.4)mL。多元线性回归分析显示,产次每增加1次,产后出血量下降13.3 mL;合并妊娠期高血压疾病和分娩巨大儿分别可使产后出血量升高42.3 mL和22.3 mL。结论上海市孕产妇阴道分娩产后出血发生率较低,提倡孕期的合理增重有利于控制产后出血量,对于初产妇和合并妊娠期高血压疾病的孕妇应积极防范产后出血的发生。     

Misoprostol versus oxytocin for the reduction of postpartum blood loss.

OBJECTIVE: To compare the effect of 400 mug of oral misoprostol with 5 U of intravenous oxytocin in the reduction of postpartum blood loss and prevention of postpartum hemorrhage. METHODS: In a prospective, double-blind, randomized controlled trial conducted in a tertiary maternity hospital 622 women received either 400 mug of oral misoprostol or 5 U of intravenous oxytocin after delivery of the anterior shoulder or within 1 min of delivery. The primary outcome was a hematocrit drop of 10% or greater 24 h postpartum. The secondary outcomes were a hemoglobin drop of 30 mg/L or greater, the use of additional oxytocin, an estimated blood loss greater than 1000 mL, manual removal of the placenta, a blood transfusion, and shivering and fever (>or=38 degrees C) as adverse effects of misoprostol. RESULTS: There was no difference between the 2 groups regarding the primary outcome (a >or=10% hematocrit drop occurred in 3.4% and 3.7% of the participants in the oxytocin and misoprostol groups, P=0.98). The rate of use of additional oxytocin was higher in the misoprostol group (51% versus 40.5%, P=0.01). Shivering was confined to the misoprostol group (6.8%), and fever occurred in 12.5% of the women in the misoprostol group and 0.3% of the women in the oxytocin group. CONCLUSION: The routine use of 400 microg of oral misoprostol was no less effective than 5 U of intravenous oxytocin in reducing blood loss after delivery, as assessed by change in postpartum hematocrit. The adverse effects of misoprostol were mild and self-limiting.     

产后出血的保守性手术治疗

产后出血是分娩期常见而且严重的并发症,在药物和子宫按摩不能控制出血时,需采取手术干预。保守性手术是指保留子宫的手术方法,包括血管结扎、宫腔填塞压迫止血、子宫压迫缝合等。B-Lynch缝合技术在产后出血的保守性手术治疗中具有里程碑式的意义,并且由此改良出多种子宫压迫缝合方法。这些技术各有利弊和不同的适应证,根据产后出血的不同原因选择合适的保守性手术方式,才能达到良好止血和减少并发症的目的。     

Effect of postpartum oxygen inhalation on vaginal blood loss

Aim.?To assess the efficacy of oxygen inhalation immediately after normal delivery on blood loss.

Method.?A prospective randomised study conducted on 104 primiparas divided into two groups who underwent normal vaginal delivery. The study group (O₂ inhalation group), 52 women, received 8 l/min oxygen via a facemask for 2 h after the third stage of labour, whereas the control group, 52 women breathed room air in addition to conventional management. All women were evaluated hourly for vaginal blood loss. Blood loss volume was measured from the end of placenta delivery to 2 h postpartum and compared between the two groups.

Results.?The study and the control groups were similar in age, gestational age, body weight and induction rate. The mean vaginal blood loss 2 h postpartum was 27.7 ± 5.8 ml in O₂ inhalation group and 48.8 ± 8.4 ml in the controls (P < 0.05).

Conclusion.?Postpartum oxygen inhalation appears to reduce blood loss after normal vaginal delivery.     

Drape estimation vs. visual assessment for estimating postpartum hemorrhage.

OBJECTIVE: To compare (1) visual estimation of postpartum blood loss with estimation using a specifically designed blood collection drape and (2) the drape estimate with a measurement of blood loss by photospectrometry. METHODS: A randomized controlled study was performed with 123 women delivered at the District Hospital, Belgaum, India. The women were randomized to visual or drape estimation of blood loss. A subsample of 10 drape estimates was compared with photospectrometry results. RESULTS: The visual estimate of blood loss was 33% less than the drape estimate. The interclass correlation of the drape estimate to photospectrometry measurement was 0.92. CONCLUSION: Drape estimation of blood loss is more accurate than visual estimation and may have particular utility in the developing world. Prompt detection of postpartum hemorrhage may reduce maternal morbidity and mortality in low-resource settings.     

Use of the “obstetric shock index” as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage

Objective

To establish the normal range for the “obstetric shock index” (OSI) after birth and to determine its usefulness as an aid to estimate blood loss in postpartum hemorrhage (PPH).

Methods

A retrospective case–control analysis was conducted involving pregnant women admitted to St Georges Hospital for delivery: 50 with no PPH (control group) and 50 with massive PPH (> 30% loss of blood volume; case group). The OSI was calculated at 10 and 30 minutes from PPH onset.

Results

Mean OSI in the control group at 10 and 30 minutes was 0.74 (range, 0.4–1.1) and 0.76 (range, 0.5–1.1), respectively. In the case group, mean OSI at 10 and 30 minutes was 0.91 (range, 0.4–1.5) and 0.90 (range, 0.5–1.4), respectively, with 64% requiring blood products. In the case group, 89% of women with an OSI of 1.1 or more at 10 minutes required transfusion; 75% with an OSI of 1.1 or more at 30 minutes required transfusion.

Conclusion

We recommend that the normal OSI range should be 0.7–0.9. An OSI of more than 1 seems to be a useful adjunct in estimating blood loss in cases of massive PPH and in predicting the need for blood and blood products.     

RhD阴性产后出血的处理策略

产后出血常常需要输血治疗,RhD阴性血型孕产妇由于血源不足及同种免疫等问题,处理更为棘手。因此,RhD阴性孕妇应该在分娩前充分备血,自体血液储存是值得推荐的方法。剖宫产术中大量出血可以考虑回收式自体输血,在非常紧急情况下可以输注Rh阳性血液以挽救生命。     

Sublingual misoprostol versus oxytocin infusion to reduce blood loss at cesarean section.

OBJECTIVE: To compare the effectiveness of sublingual misoprostol administered immediately after delivery of the neonate at cesarean section, with intravenous oxytocin infusion in prevention of uterine atony and thereby reducing blood loss at cesarean section. METHODS: One hundred women with singleton term pregnancy undergoing elective or emergency lower segment cesarean section under spinal anesthesia were included in this study. They were randomly allocated to receive either misoprostol 400 mug sublingually or intravenous infusion of 20 units of oxytocin soon after delivery of the neonate. The main outcome measures were blood loss at cesarean section, change in hemoglobin levels, need for additional oxytocics and drug related side effects. RESULTS: The mean blood loss estimated was significantly lower in misoprostol group compared to oxytocin group (819 ml versus 974 ml; p = 0.004). The number of women who had blood loss exceeding 500 ml and the change in hemoglobin, however, was comparable between the two groups. There was a need for additional oxytocic therapy in 16% and 18% after use of misoprostol and oxytocin respectively (p = 0.673). The incidence of side effects such as pyrexia, shivering and metallic taste was significantly higher in misoprostol group compared to oxytocin group. CONCLUSION: Sublingual misoprostol appears to be as effective as intravenous infusion of oxytocin in reducing blood loss at cesarean section. However, occurrence of transient side effects such as shivering and pyrexia were noted more frequently with the use of misoprostol.     

Cesarean section intraoperative blood loss and mode of placental separation.

OBJECTIVE: To investigate whether manual removal of the placenta is associated with significant blood loss compared with spontaneous separation of the placenta during cesarean delivery. DESIGN: A randomized prospective study of 400 women with normal pregnancies undergoing cesarean delivery at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients were randomly assigned to the study group, (manual placental removal, n=200) or the control group (spontaneous placental separation, n=200). Operative blood loss was assessed by the volumetric and gravimetric methods. Hemoglobin levels were evaluated the third postoperative day and patient's postoperative complications were recorded. RESULTS: The mean+/-S.D. amount of blood loss associated with manual and spontaneous removal of the placenta was 713+/-240 and 669+/-253 ml, respectively. This difference was statistically significant (P=0.04). There was a postoperative decrease in hemoglobin levels in both groups. Preoperative hemoglobin levels were 11.6+/-3 g/dl in the study group and 11.2+/-1.1 g/dl in the control group, and the difference was statistically significant (P=0.006). The postoperative hemoglobin levels at day 3 were 9.0+/-1.2 g/dl in the study group and 9.9+/-1.2 g/dl in the control group (P=0.003), also a statistically significant difference. The incidence of endometritis, wound infection, and need for blood transfusion was similar in the two groups. CONCLUSION: Manual delivery of the placenta was significantly associated with greater operative blood loss and greater decrease in postoperative hemoglobin levels, but with shorter operative time compared with spontaneous placental separation. No difference in postoperative complications was noted between the groups.     

氨甲环酸用于减少产后出血量的临床研究

目的：探讨抗纤溶药物氨甲环酸注射液用于减少产后出血量的效果和安全性,方法：选择足月妊娠、阴道分娩的单胎、头位妇产妇400例,在分娩第二产程胎肩娩出后常规静脉注射缩宫素10U,随后随机分为4组,第1组（94例）静脉滴注氨甲环酸1．0g;第2组（92例）静脉滴注氨甲环酸0．5g;第3组（92例）静脉滴注国产止血芳酸0．5g;第4组（87例）为未作任何处理的对照组,另35例产妇因分娩巨大儿会影响产后出血量的计算而剔除。用容积法和称重法分别测量4组产妇胎盘娩出即时出血量和产后2h内出血量,两部分相加和总出血量。结果：（1）胎盘娩出即时出血量4组之间比较,差异无显著性（P＞0．05）。（2）产后2h出血量和总出血量4例之间比较;第1组分别为129．7ml和243．3ml;第2组分别为133．9ml和242．9ml;第3组分别为168．5ml和308．1ml;第4组分别为178．2ml和314．8ml。第1、2组与第3、4组相比,差异有极显著性（P＜0．01）;第1组产妇产后出血量少于第2组,但差异无显著性（P＞0．05）。（3）产后出血（≥400ml）发生率,第1组6．4％;第2组13．0％,第3组20．7％;第4组25．3％。（4）4组产妇均未出现明显的副作用。结论：氨甲环酸用于产后出血的治疗是安全有效的,其中1．0g剂量对减少产后出血量的效果最好,0．5g剂量的效果次之。