산과적 출혈

1. 산과적 출혈

2. Obstetrical Hemorrhage • Antepartum Hemorrhage • Postpartum Hemorrhage • Postpartum Hemorrhage • Placental abruption • Placenta previa • Uterine atony • Retained placental fragments • Placenta accreta, increta, and percreta • Inversion of uterus • Genital tract lacerations • Puerperal hematoma • Rupture of uterus

3. Placental Abruption

4. Placental Abruption

5. Risk Factors • Increased age & parity • Preeclampsia • Chronic hypertension • Preterm ruptured membranes • Cigarette smoking • Cocaine abuse • Prior abruption • Uterine leiomyoma

6. Pathology • Hemorrhage into the decidua basalis • Decidual hematoma due to split • Separation, compression, destruction of the placentaadjacent to it • Rupture of decidual spiral artery • Retroplacental hematoma • Disrupt more vessels to separate more placenta

7. Pathology • Concealed hemorrhage • Effusion of blood behind the placenta but its margin still remain adherent • Completely separated placenta with attached membrane • Blood gains access to the amniotic cavity • Fetal head is so closely applied to the lower segment

8. Pathology • Chronic placental abruption • Hemorrhage with retroplacental hematoma arrested completely without delivery • Fetal-to-maternal hemorrhage • Bleeding is almost always maternal • Traumatic abruption may cause fetal bleeding

9. Pathology

10. Clinical Diagnosis • Classical sign • Pain, shock, uterine rigidity, absent fetal heart sounds • Ultrasonography • Negative findings do not exclude potentially life-threatening placental abruption

11. Clinical Diagnosis • Signs and symptoms • Vaginal bleeding • Uterine tenderness or back pain • Fetal distress • Hypertonus • Idiopathic preterm labor • Dead fetus

12. Complication • Consumptive coagulopathy • Mainly intravascular induction of coagulation • Overt hypofibrinogenemia (< 150 mg/dL) • Elevated fibrinogen-fibrin degradation product (> 100 ㎍/ml) • Thrombocytopenia after repeated transfusion

13. Complication • Renal failure • Acute tubular necrosis • Massive hemorrhage & coexisting acute or chronic HT • Decreased cardiac output • Intrarenal vasospasm • Impaired renal perfusion • Prompt fluid & electrolyte replacement • Prevent life threatening renal dysfunction

14. Complication • Uteroplacental apoplexy (Couvelaire Uterus) • Widespread extravasation of blood into the uterine musculature • Seldom interfere with uterine contraction • Not indicated for hysterectomy

15. Couvelaire Uterus

16. Management • Gestational age and status of the mother and fetus • Tocolytic therapy is contraindicated • Oxytocin • If no rhythmic contraction superimposed, standard dose of oxytocin is given • Fetus distressed -> cesarean section • Fetus dead -> vaginal delivery preferred

17. Management

18. Placenta Previa

19. Risk Factors • Advancing maternal age • Multiparity • Prior cesarean delivery • Smoking (placental hypertrophy) • Defective vascularization of the decidua • Associated with placenta accreta

20. Clinical Findings • Sudden painless hemorrhage near the end of the second trimester or after • Initial bleeding • Usually not profuse • Cease spontaneously, but recur • Coagulation defects : rare

21. Diagnosis • Sonography • MRI

22. Management • Placenta previa with preterm fetus • Active bleeding이 없는 한 계속 임신을 유지 • 일단 출혈이 멈추고 태아가 건강하면 퇴원 • Cesarean section • Lower segment transverse uterine incision • Poor contractile nature • Hemostasis • Oversewing • Gauze packing -> remove transvaginally

23. Management • Hysterectomy is needed occasionally • Especially in associated with placenta accreta • Perinatal morbidity & mortality • Prematurity is the major cause

24. Postpartum Hemorrhage • Definition • Loss of 500 ml or more • After completion of the third stage • Actual loss = two times of estimated loss

25. Predisposing Factors • Bleeding from placental implantation site • Hypotonic myometrium – uterine atony • Retained placental tissue • Succenturiate lobe • Accreta, etc. • Trauma to the genital tract • Coagulation defects • Intensify all of the above

26. Uterine Atony • Predisposing factors • Overdistended uterus • Large fetus • Multiple fetuses • Hydramnios • Distension with clots • Anesthesia • Halogenated agents

27. Uterine Atony • Predisposing factors • Exhausted myometrium • Rapid labor • Prolonged labor • Oxytocin stimulation • Chorioamnionitis • Previous uterine atony

28. Diagnosis • Laceration에 의한 출혈과 감별하여야 한다 • Atony와 laceration이 동시에 있을 수 있다

29. Complications • 신부전, 간염, 수혈에 따른 부작용 • Sheehan 증후군 • 발생기전은 불명확하지만 뇌하수체 전엽의 괴사가 있는 경우가 있다. • 증상 • 수유불능, 무월경, 유방위축 • 액와모 및 치모 감소 • 갑상선기능저하, 부신피질기능저하 등

30. Management • 분만 3기의 출혈 • 자궁저를 문질러 자궁을 수축시킨다 (vigorous fundal massage). • 태반분리의 징후가 보이면 자궁저를 압박하면서 태반을 만출시킨다. • 태반분리가 안되고 계속 출혈이 있으면 자궁내에 손을 넣어 태반을 분리시킨다.

31. 태반만출

32. Manual Removal of Placenta

33. Management • 태반만출후 출혈 • Fundal Massage • OxytocinMethylergonovine 0.2mg IM or IV • Prostaglandin • Bimanual compression • Obtain help ! • Transfusion • Exploration • Inspect cervix & vagina

34. Bimanual Compression

35. 태반부착 이상 • 분류 • 유착태반 (accreta) • 감입태반 (increta) • 관통태반 (percreta)

36. 태반부착 이상 • 원인 • Ddecidua basalis의 전부 혹은 일부 소실 • 섬유화층 (Nitabuch layer) 미발달 • Subplacental sonolucent or "hypoechoic retroplacental zone" • 전치태반 • 이전의 제왕절개 • 이전의 소파수술 • 다산부

37. Placenta Percreta

38. Inversion of Uterus • 원인 • 태반만출시 제대를 과도한 힘으로 당길 때 • 이완된 자궁의 저부를 과도하게 압박할 때 • 유착태반 • 처치 • 정맥로 확보 및 수혈 • 자궁이완후 도수정복(manual reduction) • 안되면 자궁 절제

39. Uterine Inversion

40. Inverted Uterus

41. Manual Reduction

42. 질 및 자궁경부 열상 • 2 cm 정도의 경부열상 • 분만시 불가피하고 후유증도 없다. • 자궁수축이 잘 되면서 계속 출혈이 있을 때 • 질상부 및 경부열상 또는 잔류태반 확인 • 경부열상이 있을 때 • 후복막 혹은 복강내 출혈이 의심되면 개복 • 지나친 경부열상 봉합 • 경부협착이 생길 수 있다.

43. Repair of Cervical Laceration

44. Vulvar Hematoma

45. Rupture of Uterus • 파열 (rupture) • 자궁강과 복강의 완전히 통하여 태아가 복강내로 탈출된다. • 대량출혈이 있어 치명적이다. • 개열 (dehiscence) • 증상이 없는 수가 있고 자궁벽이 서서히 벌어지고 자궁강과 복강이 통하지는 않는다.

46. Cause of Uterine Rupture • Uterine injury or anomaly sustained before current pregnancy • Surgery involving the myometrium • Cesarean section or hysterotomy • Previously repaired uterine rupture • Myomectomy incision • Deep cornual resection • Metroplasty

47. Cause of Uterine Rupture • Uterine injury or anomaly sustained before current pregnancy • Coincidental uterine trauma • Abortion with instrumentation • Sharp or blunt trauma (accident, bullet, knife) • Silent rupture of previous pregnancy • Congenital anomaly

48. Cause of Uterine Rupture • Uterine injury or abnormality during current pregnancy • Before delivery • Persistent, intense contraction • Labor stimulation • Intraamniotic instillation • Perforation by internal pressure catheter • External trauma • External version • Uterine overdistension

49. Cause of Uterine Rupture • Uterine injury or abnormality during current pregnancy • During delivery • Internal version • Difficult forceps delivery • Breech extraction • Fetal anomaly distending lower segment • Vigorous uterine pressure • Difficult manual removal of placenta

50. Cause of Uterine Rupture • Uterine injury or abnormality during current pregnancy • Acquired • Placenta increta or percreta • Gestational trophoblastic neoplasm • Adenomyosis • Sacculation of entrapped retroverted uterus