4 Past History Underlying Disease No Current Medication Asthma ไม่มียาพ่นประจำ หอบล่าสุด 2 ปีก่อนThalassemia homozygous Hb EHb typing HbE 79.9% HbF48%MigraneNo Current MedicationNo Drug Food AllergyNo History of blood transfusionNo Smoking and alcohol drinking
5 Family History ปฏิเสธโรคประจำตัวในครอบครัว ปฏิเสธประวัติมะเร็งในครอบครัว
6 Ob-Gyn History G2P1A1, PARA 0-0-1-0, GA 32+2 week by date A1 : Abortion with D&C N3M0 ปี 2555 ที่รพ. ประเทศลาวLMP 28/01/56, EDC 1/11/56Menarche 12 ปีปฏิเสธประวัติโรคติดต่อทางเพศสัมพันธ์ปฏิเสธประวัติตกขาวผิดปกติและเลือดออกผิดปกติทางช่อง คลอดปฏิเสธประวัติก้อนผิดปกติในอุ้งเชิงกราน
7 Ob-Gyn HistoryPrevious Contraception: ยาคุมกำเนิดแบบแผงทานมา 1 ปีครึ่ง หยุด มา 6 เดือนANC HistoryFirst ANC ที่คลินิก 2 ครั้ง Second ANC ที่รพ. 4 ครั้งFirst ANC GA 17+1 week by date, First U/S 15/8/56 GA 29 week รวม 6 ครั้งANC ทั้งหมด 4 ครั้ง มาฝากครรภ์สม่ำเสมอ ระหว่างฝากครรภ์ไม่มี complication ใดๆTotal Weight Gain 5.7 kg height 150cm weight 54.7 BMI 24.1TT ครบ 2 เข็ม
9 ANC Laboratory Investigation Ultrasound at GA 28+2 weekNo fetal anomalyNormal amniotic fluidFetal heart sound positiveFetal movement positiveVertex presentationfemale
10 ANC Risk Preterm Anemia: Homozygous Hb E Couple risk for Thalassemia Previous Dilatation and Curettage
11 Physical ExaminationVital Signs BT 36.6, PR 96bpm, RR 20/min, BP 119/89mmHg, SpO2 100%GA: A Thai pregnant female, good consciousnessHEENT: no pale conjunctivae, anicteric scleraeCVS: normal S1S2, no murmurRS: normal breath sound, no adventitious sounds
12 Physical ExaminationABD: Fundal Height 3/4 > O, 31cm, no ballotmentLarge part at Left side, small part at Right sideno engagement, ballottement positive at inguinal regionVertex Presentation, longitudinal lineFetal position: OPFetal movement: positive FHR 140 bpm EBW 2300gUterine Contraction: Duration sec, Interval 5 min, Intensity ++
13 Physical Examination PV: Dilatation 6cm, Effacement 100%, Station 0, Consistency Firm, Position anterior, Fetal position OP, Membrane Intact, Amniotic fluid none, adequate PelvimetrySpeculum: no membrane leakageExtremity: no pitting edemaCNS: grossly intact
14 Problem List1. Preterm Labor2. Anemia3. Well controlled Asthma
15 Impression: G2P0A1, GA 32+2 week with preterm labor pain with anemia and well controlled asthma
16 CTG EFM Paper speed: 1cm/min FHR baseline 140bpm FHR variability: moderateAcceleration: 14 in 20 minNo decelerationImpression: CAT 1Uterine ContractionFrequency 1.5 – 2 minDuration 1 minIntensity mild to moderateRelaxation Time 1 -2 min
17 Ultrasound SVF: Vertex Fetal movement: postive, Fetal Heart Sound: positiveFacial Profile: no cleft lip, no cleft palateNuchal area: cannot be examinedNo spina bifida
18 Ultrasound 4 heart chamber seen LVOT/RVOT/3VS – seen Stomach seen at Left side2UA/1UV seenBladder seenAFI – normalPlacenta posterior, no acreata
25 Management หลักการที่สำคัญคือ 1.Antenatal glucocorticoids 2. Tocolytic drugs for up to 48hr3. Appropiate antibiotics for GBS prophylaxis
26 Glucocorticoids + Every case in preterm labor + Benefit in GA 24- GA 34 weeks+ Dexamethasone 6 mg IM every 12 hr X 4 Dose
27 Tocolytic agentsUse for inhibits Uterine contraction( but can inhibit in short terms)-wait for max effect of steroid- to transfer the mother- stop contraction uterine that result from correctable Exp. AppendicitisChoices of agent+ Beta agonist ( terbutaline, salbutamol )+ Calcium channel blocker ( Nifedipine )
28 Beta – adrenergic Receptor Agonists (Terbutaline, Salbutamol) ในไทยนิยมใช้ ยับยั้งการเจ็บครรภ์คลอดก่อนกำหนดมากที่สุด เป็น First line drugloading dose 0.25 mg IV stat + maintenance dose 2.5 mg ผสมใน 5% D/W 500 ml และให้ 5% D/NSS หรือ LRS 1,000 ml IV drip 10 d/min เริ่มให้ IV drip 10 ug/min (30 d/min) ปรับเพิ่มยาครั้งละ 5 ug/min (15 d/min) ทุก 10 นาที maximum dose คือ 25 ug/min (75 d/min) หรือเมื่อไม่มี uterine contraction Contraindicationstructural heart disease, cardiac ischemiaHyperthyroidismpoor control DMpoor control hypertentionSevere hypovolemia
32 Normal blood vs. Postpartum Hemorrhage Normal delivery-related blood loss- vaginal delivery 500 ml.- cesarean delivery 1000 ml.- cesarean hysterectomy 1500 mlPostpartum hemorrhageDefinitions10% decline in hematocrit, and the need for a blood transfusion.delivery-related blood loss that is excessive in nature and results in a symptomatic patient or signs of hypovolemia.
34 Risk Factor Previous postpartum hemorrhage Prolonged third stage of laborAugmented or stimulated laborMultiple gestationMultiparityCoagulation abnormalitiesCervical, vaginal, or perineal lacerationsPreeclampsiaArrest of descent of the fetusMediolateral episiotomyNulliparityPolyhydramniosMaternal hypotensionAsian or Hispanic ethnicity
35 Presentation Excessive flow of blood from vagina Hypovolemic shock if left untreatedtachycardia, tachypnea, hypotensionRelate with amount of blood lossอาจเจอในรูปแบบ occult bleeding or occult hemorrhagePresentationPPH often manifests as brisk and excessive flow of blood from the vagina. This finding is easily observed on physical examination. If the placenta has been delivered, blood can be seen at the vaginal entrance. Maternal hemodynamics may be unaltered initially. If the bleeding is left untreated, typical presenting signs of hypovolemic shock (i.e., tachycardia, tachypnea, and hypotension) become apparent. Bonnar described the symptoms related to PPH in relation to the amount of blood loss ( Table 161-1 ). 4 However, the signs and symptoms of hemorrhagic shock may not occur immediately and may extend over a longer period of time if shed blood is sequestered in the uterus. ******Occult bleeding occurs most frequently with retained placental fragments, uterine atony, and concealed hematomas in the pelvis, perineum, or retroperitoneal space. ******Occult hemorrhage in the uterus or hematomas should be suspected in patients who are in the third stage of labor with hemodynamic instability but little or no evidence of external bleeding. Signs and symptoms of excessive bleeding also may be delayed because of the relative hypervolemic state of the patient and by the position of the patient after delivery with the legs elevated in stirrups
36 Investigationในกรณีคนไข้ยางคนอาจจะไม่ได้มี immediate bleeding เพราะมี hematoma formation or accumulations ใน uterusใช้ U/S หา clot, hematoma, retained placental productsบางกรณีอาจทำ angiography with selective arterial embolization เพื่อ diagnosis and therapeutic treatmentในการประเมิณคนไข้ ส่ง CBC with platelet count, coagulation studies, PT, PTT, fibrinogen, D-dimer แต่ในกรณี acute hemorrhage อาจทำได้เฉพาะ Hct และ HbDiagnostic StudiesAlthough the diagnosis is obvious with significant and excessive bleeding after delivery, not all patients present with immediate bleeding, because of hematoma formation or accumulations in the interior of the uterus. Bedside ultrasonography can be used for the detection of clots, hematomas, and retained placental products. For patients who are at high for risk for development of PPH, periodic ultrasound examinations during pregnancy can offer invaluable information concerning the extent and progression of placental disease. Angiography with selective arterial embolization can be used both diagnostically and therapeutically. Bleeding sites can be visualized and embolized simultaneously. For evaluation of a proven or suspected case of PPH, the following laboratory studies are almost always indicated: complete blood count with platelet count, coagulation studies with prothrombin and activated partial thromboplastin times, fibrinogen, and D-dimer level. With acute hemorrhage, the measurements of hemoglobin concentration and hematocrit may be of limited use
37 Uterine Atony Blood flow ออกตรง placental site ประมาณ 600 ml/min. Uterine atony, or the inability of the uterine myometrium to contract effectively, is the most common cause of primary postpartum hemorrhage. Blood flow ออกตรง placental site ประมาณ 600 ml/min.หลัง delivery มดลูกจะ contract myometrial fibers รอบๆ spiral arterioles เมื่อการ contract ไม่ดีพอ จะเกิด rapid blood lossBimanual palpation ของ uterus ใช้ confirm diagnosisAt term, blood flow through the placental site averages 600 mL/minute.After placental delivery, the uterus controls bleeding by contracting its myometrial fibers in a tourniquet fashion around the spiral arterioles. If inadequate uterine contraction occurs, rapid blood loss can ensue.Clinical Manifestations and DiagnosisUterine atony is diagnosed clinically by rapid uterine bleeding associated with a lack of myometrial tone and an absence of other etiologies for postpartum hemorrhage. Typically, bimanual palpation of the uterus confirms the diagnosis.
41 Bimanual Uterine Massage To provide effective massage, the uterus should be compressed between the external fundally placed hand and the internal intravaginal hand. Care must be taken to avoid aggressive massage that can injure the large vessels of the broad ligament.
43 Uterotonic Therapy AGENT DOSE ROUTE DOSING INTERVAL SIDE EFFECTS CONTRAINDICATIONSOxytocin (Pitocin)10-80 U in 1000 mL crystalloid solutionFirst line: IV Second line: IM or IUContinuousNausea, emesis, water intoxicationNoneMisoprostol (Cytotec) mcgFirst line: PR Second line: PO or SLSingle doseNausea, emesis, diarrhea, fever, chillsMethylergonovine (Methergine)0.2 mgFirst line: IM Second line: IU or POEvery 2 to 4 hrHypertension, hypotension, nausea, emesisHypertension, preeclampsiaProstaglandin F 2α(Hemabate)0.25 mgFirst line: IM Second line: IUEvery 15 to 90 min (maximum of 8 doses)Nausea, emesis, diarrhea, flushing, chillsActive cardiac, pulmonary, renal, or hepatic diseaseProstaglandin E 2(Dinoprostone)20 mgPREvery 2 hrNausea, emesis, diarrhea, fever, chills, headacheHypotensionUterotonic medications represent the mainstay of drug therapy for postpartum hemorrhage secondary to uterine atony. Table 19-7 lists available uterotonic agents with their dosages, side effects, and contraindications. Oxytocin (Pitocin) is usually given as a first-line agent. Intravenous therapy is the preferred route of administration, but intramuscular and intrauterine dosing is possible. Initial treatment starts with 10 to 20 U of oxytocin in 1000 mL of crystalloid solution. Higher doses (80 units in 1000 mL) have proved safe and efficacious, with a 20% reduction in the need for additional uterotonic therapy compared with standard dosing.When oxytocin fails to produce adequate uterine tone, second-line therapy must be initiated. Currently, a variety of other uterotonic agents are available for use. The choice of a second-line agent depends on its side-effect profile as well as its contraindications. Misoprostol (Cytotec), a synthetic prostaglandin E 1 analog, is a safe, inexpensive, and efficacious uterotonic medication. It has been used for both the prevention and treatment of postpartum hemorrhage. 82 Misoprostol is attractive as a second-line agent in that it has multiple administration routes that can be combined. Although higher doses (600 to 1000 mcg) have traditionally been used rectally, the sublingual route allows for lower dosing (400 mcg) with higher bioavailability. 82 Although helpful in some settings, methylergonovine (Methergine) has limited usefulness in the acute postpartum hemorrhage because of its relatively long half-life and its potential for worsening hypertension in patients with preexisting disease. Prostaglandins are highly effective uterotonic agents. Both natural and synthetic prostaglandin formulations are available. Intramuscular and intrauterine administration of prostaglandin F 2α (Hemabate) can be used for control of atony. Recurrent doses (0.25 mg) may be administered as often as every 15 minutes to a maximum of eight doses (2 mg). It is important to note that asthma is a strong contraindication to its use because of its bronchoconstrictive properties. Finally, prostaglandin E 2 (dinoprostone) is a naturally occurring oxytocic that can dramatically improve uterine tone; however, it has an unfavorable side-effect profile (fever, chills, nausea, emesis, diarrhea, headaches) that often precludes its use.When atony is due to tocolytic drugs that have impaired calcium entry into the cell (magnesium sulfate, nifedipine), calcium gluconate should be considered as an adjuvant therapy. Given as an intravenous push, one ampule (1 g) of calcium gluconate can effectively improve uterine tone and resolve bleeding due to atony.If pharmacologic methods fail to control atony-related hemorrhage, alternative measures must be undertaken. These include uterine tamponade, selective arterial embolization, and surgical intervention.
50 4. เลือดไม่หยุดหลังตัดมดลูก Abdominal packing/umbrella packingArterial embolization/ recombinant factor VIIa
51 ReferrenceSteven G. (2012) 'Antepartum and Postpartum Hemorrhage', in (ed.) Obstetrics: Normal and Problem Pregnancies , Sixth Edition. : Saunders, an imprint of Elsevier Inc., ppJean-Louis Vincent (2011) 'Postpartum Hemorrhage', in (ed.) Textbook of Critical Care , Sixth Edition. : Saunders, an imprint of Elsevier Inc, pp