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。     

Volume Replacement Following Severe Postpartum Hemorrhage

Severe postpartum hemorrhage (PPH) can be defined as a blood loss of more than 1500 mL to 2500 mL. While rare, severe PPH is a significant contributor to maternal mortality and morbidity in the United States and throughout the world. Due to the maternal hematologic adaptation to pregnancy, the hypovolemia resulting from hemorrhage can be asymptomatic until a large amount of blood is lost. Rapid replacement of lost fluids can mitigate effects of severe hemorrhage. Current evidence on postpartum volume replacement suggests that crystalloid fluids should be used only until the amount of blood loss becomes severe. Once a woman displays signs of hypovolemia, blood products including packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa should be used for volume replacement. Overuse of crystalloid fluids increases the risk for acute coagulopathy and third spacing of fluids. A massive transfusion protocol is one mechanism to provide a rapid, consistent, and evidence‐based team response to this life‐threatening condition.     

Postpartum hemorrhage--update on problems of definitions and diagnosis

Maternal mortality due to postpartum hemorrhage (PPH) continues to be one of the most important causes of maternal death worldwide. PPH is a significantly underestimated obstetric problem, primarily because a lack of definition and diagnosis. The 'traditional' definition of primary PPH based on quantification of blood loss has several limitations. Notoriously, blood loss is not measured or is significantly underestimated by visual estimation and there are no generally accepted cut-offs limits for estimated blood loss. A definition based on hematocrit change is not clinically useful in an emergency such as PPH, as a fall in hematocrit postpartum shows poor correlation with acute blood loss. The need for erythrocyte transfusion alone to define PPH is also of limited value, as the practice of blood transfusion varies widely. Definitions based on symptoms of hemodynamic instability are problematic, as they are late signs of depleted blood volume and commencing failure of compensatory mechanisms threatening the mother's life. There is thus currently no single, satisfactory definition of primary PPH. Proper and timely diagnosis of PPH should above all include accurate estimation of blood loss before vital signs change. Estimation of blood loss by calibrated bags has been shown to be significantly more accurate than visual estimation at vaginal delivery. Careful monitoring of the mother's vital signs, laboratory tests, in particular coagulation testing, and immediate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality.     

产后出血的研究进展

产后出血（PPH）是导致孕产妇患病及死亡的常见原因之一,目前多数定义为阴道分娩后24 h累计失血量≥500 mL,剖宫产术后累计失血量≥1 000 mL。但PPH的诊断不仅要以失血量为依据,也要重视血流动力学的改变。缩宫素作为预防和治疗PPH的一线药物已成为共识,卡贝缩宫素、卡前列素氨丁三醇和米索前列醇等亦可应用。具有PPH高危因素的孕妇,剖宫产术中除预防使用缩宫素之外,还可考虑静脉使用氨甲环酸以减少出血。尚无证据表明哪一种手术治疗方式更佳,常需根据实际情况进行选择。发生PPH时,凝血功能异常是大量输血和子宫切除的预测指标,当出血难以控制时,早期输注纤维蛋白原是安全和有效的。早期识别,综合处理,建立团队,总结和模拟演练都是PPH处置不可或缺的环节。     

Embryo transfer is a risk factor for severe postpartum hemorrhage and blood transfusion requirement

Purpose: This study aimed to investigate the risk factors for severe postpartum hemorrhage (PPH) and blood transfusion requirement that are recognizable during any period of pregnancy.

Materials and methods: We retrospectively reviewed the medical data of 4829 pregnant women who received care and delivered at our institution between July 2010 and March 2015. The cohort was divided into patients with and without severe PPH. Multivariate logistic regression analysis was performed to assess risk factors associated with severe PPH. The same analysis was repeated for blood transfusion requirement.

Results: A total of 127 (2.7%) patients had severe PPH and 43 (0.87%) required blood transfusion. The multivariate logistic regression analysis demonstrated that embryo transfer (odds ratio [OR] 2.6; p?p?p?=?.03), prior cesarean section (OR 1.8; p?=?.01), and maternal age (OR 1.5; p?=?.03) were independent risk factors for severe PPH. Embryo transfer was an independent risk factor for blood transfusion requirement (OR 3.1, p?Conclusions: Embryo transfer is a risk factor for both severe postpartum hemorrhage and blood transfusion requirement.     

The more you lose the more you miss: accuracy of postpartum blood loss visual estimation. A systematic review of the literature

Midwives and nurses have a key role in monitoring postpartum period. They represent the first line professional figure in quantifying blood loss, initiating early diagnosis of obstetric hemorrhage, and mobilizing a team response, if needed. These actions are crucial in determining maternal outcome in postpartum hemorrhage (PPH). In our review we aimed to: (1) Provide a picture of PPH including its pathophysiology, epidemiology, and associated complications; (2) Discuss diagnosis of this dangerous postpartum event; and, (3) Especially evaluate the efficiency of the employment of visual blood loss estimation as a rapid way to suspect PPH and activate the patient assessment.     

Postpartum hemorrhage management in 2012: Predicting the future

Transfusion therapy in postpartum hemorrhage (PPH) traditionally has been modeled after precedents set in the Vietnam and Korean wars. However, data from recent military combat casualties suggest a different transfusion strategy. Transfusion of packed red blood cells, fresh frozen plasma, and platelets in a ratio of 1:1:1 improves dilutional coagulopathy and survival. Women who present with low fibrinogen at the time of diagnosis of PPH have poorer outcomes and might benefit from early fibrinogen replacement. The antifibrinolytic agent, tranexamic acid, decreases bleeding and progression to severe PPH, but its role in PPH management is evolving. Observational data suggest that the use of recombinant factor VIIa should be limited to bleeding that has not responded to an optimal transfusion strategy. Point-of-care testing using thromboelastography is helpful in guiding the selection of blood products to be transfused. Additionally, massive transfusion protocols can decrease the overall number of products transfused and improve outcomes.     

Nationwide survey of severe postpartum hemorrhage in Japan: an exploratory study using the national database of health insurance claims

Aim: The aim of this study was to investigate epidemiological and clinical aspects of severe postpartum hemorrhage (PPH) in Japan.

Methods: We used national health insurance claims from 2011 to 2014 provided by the Ministry of Health, Labour and Welfare. The data included randomly selected claims that covered 10% of all inpatients in October, a so-called sampling dataset (covering 1/120 inpatients per year). We extracted claims for transfused blood, and further narrowed down the claims by names of diseases linked to PPH. As most referral obstetric facilities have adopted the diagnosis procedure combination (DPC)-based payment system while small-scale obstetric facilities have not (non-DPC facilities), the claims were also analyzed separately for DPC and non-DPC facilities. We assessed the incidence and causes of PPH, transfusion volume of red blood cells (RBC) and fresh frozen plasma (FFP), and surgical hemostatic management.

Results: The number of PPH cases that required blood transfusion in the sampling dataset was 29, 29, 32, and 36 in 2011, 2012, 2013, and 2014, respectively. The leading cause of PPH was uterine atony followed by placental abruption. Although no specific trends were observed for the volume of transfused RBC (1467?±?234?ml in 2014), there was a steady increase in the rate of FFP utilization in non-DPC facilities from 37% to 79% over the 4-year sampling period. Intrauterine balloon tamponade emerged in 2014.

Conclusion: This nationwide survey indicates that the annual incidence of severe PPH is increasing. Furthermore, FFP has become more prevalent in small-scale obstetric facilities.     

Blood and blood component therapy

Significant hemorrhage may be defined as that degree of bleeding that either produces signs and symptoms of hemodynamic instability or that is likely to produce such if left untreated. Signs and symptoms of hemodynamic instability include dizziness, tachycardia, hypotension, and oliguria. Although the most useful laboratory indicator of significant blood loss is a marked drop in hemoglobin and hematocrit, initial measurements may not be indicative of actual blood loss because equilibration of volume may take several hours to occur. Hemorrhage severe enough to require transfusion may result following the loss of 750–1000 mL in nonpregnant women. Most gravidas with uncomplicated term pregnancies, however, will expand their blood volume an average of 50%, and thus, greater blood loss is required to produce symptomatic anemia. Although whole blood is ideal for blood replacement in a woman with ongoing hemorrhage, crystalloids and packed red blood cells are generally utilized for volume expansion and improvement in oxygen-carrying capacity because of the limited availability of whole blood. Packed red blood cells may be expected to raise the hematocrit by approximately 3% per unit. Fresh frozen plasma contains all major clotting factors and is utilized for the treatment of coagulopathy. Various other components are available for specific coagulation defects.The major risks of blood component therapy are fatal transfusion reaction (approximately 1:100,000 units) and transfusion of various infections such as hepatitis B (1:63,000 U), hepatitis C (1:103,000 U), and human immunodeficiency virus (1:450,000–1:660,000 U). Thus, it is understandable that a woman and her health care provider may have significant apprehension when blood component therapy is indicated. However, it is of paramount importance not to delay such therapy when indicated because procrastination may place the woman's life at significant risk.     

阴道分娩产后出血原因识别及防治

产后出血是产妇死亡的主要原因,阴道分娩时软产道撕裂是导致产后出血的重要环节,应当及时识别,认真处理,积极防控。应当记住:失血量评估要到位;重视高危产妇,重视团队协作;正确按摩子宫,正确使用药物,正确选择手术。     

Uterine tamponade using condom catheter balloon in the management of non-traumatic postpartum hemorrhage

Aim: To study the efficacy and complications of uterine tamponade using condom catheter balloon in non-traumatic postpartum hemorrhage (PPH). Material and Methods: This prospective study was conducted in a tertiary care teaching hospital in India. Eighteen patients with non-traumatic PPH not responding to medical management were included in the study. Uterine tamponade was achieved by a condom catheter balloon filled with saline and kept in situ for 8-48?h. The main outcome measures were success rate in controlling hemorrhage, time required to stop bleeding, subsequent morbidity and technical difficulties. Data was analyzed using appropriate statistical methods. Results: The success rate of condom catheter balloon in controlling hemorrhage was 94%. The mean amount of fluid filled in the condom catheter balloon was 409?mL. The average time taken to control bleeding was 6.2?min. The mean duration for which condom catheter balloon was left in situ was 27.5?h. The average amount of blood loss was 1330?mL. Five patients (28%) had infective morbidity. Conclusion: Condom catheter balloon is effective in controlling non-traumatic PPH in 94% cases. It is effective, simple to use, easily available and is a cheap modality to manage non-traumatic postpartum hemorrhage, especially in limited 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.     

New insights into fatigue and health-related quality of life after delivery

BACKGROUND: A delivery has a major impact on the health-related quality of life (HRQoL) of the new mother, especially on fatigue. A common complication during delivery that might have a relationship with maternal morbidity is blood loss. The objectives were to investigate fatigue and HRQoL in women after vaginal delivery (VD), elective caesarean section (CS) and emergency CS, and its relationship with postpartum hemoglobin (Hb) levels during the first 6 weeks postpartum. METHODS: Some 141 patients (71 after VD, 36 after elective CS and 34 after emergency CS) completed the HRQoL questionnaires MFI and EQ-5D between 12 and 24 h after VD and 24-48 h after CS (t=0). At 1, 3 and 6 weeks postpartum these questionnaires were repeated, together with the SF36. RESULTS: Patients after VD had higher mean physical HRQoL scores than after CS. The average period to reach full physical recovery was 3 weeks after VD, 6 weeks after elective CS, and >6 weeks after emergency CS. Mean mental HRQoL scores of the study groups were similar or even better compared to reference values. The significant correlation between Hb level and mean physical HRQoL scores found at t=0 had disappeared at 1 week postpartum. CONCLUSIONS: Results of this study provided insights into the natural course of fatigue and HRQoL postpartum. Important differences in fatigue and HRQoL scores were observed between the 3 modes of delivery. These HRQoL measures can be used in future clinical trials to assess the effects of interventions postpartum.     

2002年南京市10家医院剖宫产后出血的病因分析

目的:调查分析与剖宫产后出血的相关因素,为制定合理防治剖宫产后出血措施提供依据。方法:就2002年3月1日至2002年12月31日在南京市10家医院行剖宫产术分娩者有关剖宫产指征、产后出血相关因素进行问卷调查。结果: 1146例剖宫产分娩者产后24h平均出血量528 0ml;出血量≥500ml者447例,占39 .01%,其中宫缩乏力性出血为81 .3%。多因素分析显示,前置胎盘、双胎、新生儿高体重与剖宫产后出血有关。结论:剖宫产后出血发生率高,前置胎盘、双胎和新生儿高体重孕妇是剖宫产后出血的高风险人群。     

1999年南京市剖宫产术产后出血情况分析

目的了解南京市妇女剖宫产术后24 h内的失血量及出血情况.方法对南京市城、郊、县的一、二、三级医院,按东、西、南、北、中的地理位置进行分层抽样调查,各调查单位按连续病案号的方法纳入观察对象.出血量测量方法为容积法+称重法+面积法.结果抽样的4 171例产妇中,1 125例为剖宫产分娩,其剖宫产指征依次为头盆不称、胎儿窘迫、臀位;剖宫产指征不明确者占10.4%.剖宫产术产后出血量中位数为520 ml,明显高于阴道分娩者(3 046例)的397 ml(P<0.01).若以出血量≥500 ml为产后出血的诊断标准,则剖宫产术产后出血发生率高达53.7%,无出血高危因素的剖宫产者,第80百分位数产后出血量为678 ml;若以出血量≥700 ml为诊断标准,则剖宫产术产后出血发生率为19.8%.结论 (1)剖宫产术本身就是产后出血的原因,为母亲健康,应努力降低剖宫产率;(2)剖宫产术产后出血的诊断标准以出血量≥700 ml为宜.     

Retrospective Review of Time to Uterotonic Administration and Maternal Outcomes After Postpartum Hemorrhage

ObjectiveDespite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion.MethodsWe reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH.ResultsOf 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively.ConclusionIn this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.     

Postpartum haemorrhage and haematological management

Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Recent report of the Centre for Maternal and Child Enquiries (CMACE) in the United Kingdom, which was previously called Confidential Enquiries into Maternal and Child Health (CEMACH), confirmed a reduction in maternal deaths during the last Triennium (2006–2008). This is attributed to improvements in timely diagnosis and prompt and aggressive treatment. PPH is now the sixth most common direct cause of maternal deaths in the U.K. World Health Organization (WHO) estimates that postpartum haemorrhage accounts for 25% of maternal deaths worldwide. Substandard care and ‘too little being done too late’ remain a significant contributor of maternal deaths.Primary PPH refers to a blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks after birth. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and is associated with increased maternal morbidity and mortality. A timely, multi-disciplinary and systematic approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding, is essential to save life.Primary postpartum haemorrhage is caused by uterine atony, genital tract trauma, retained placental tissue and membranes after birth or coagulopathy. The latter may not only be a cause of PPH, but also could be an effect of massive haemorrhage due to a ‘washout phenomenon’. Rapid and profuse bleeding results in loss of platelets and clotting factors, that get ‘washed out’. This may lead to a depletion of coagulation factors and resultant bleeding.     

New WHO recommendations on prevention and treatment of postpartum hemorrhage

Improving health care for women during childbirth in order to prevent and treat postpartum hemorrhage (PPH) is an essential step toward achieving Millennium Development Goal 5. In March 2012, WHO held a Technical Consultation on the Prevention and Treatment of Postpartum Haemorrhage to review current evidence and to update previously published PPH guidelines. The present paper provides an overview of the most recent WHO guidelines for both prevention and treatment of PPH, with an emphasis on the key messages and changes.