指南速递 | 2019昆士兰临床指导：原发性产后出血(下)

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翻译：杨泓 何泽琳 邓诗蕾 黄启涛（南方医科大学南方医院妇产科 ）

审校：陈继明（南京医科大学常州临床医学院妇产科学教研室；南京医科大学附属常州第二人民医院妇产科）

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接上文：2019昆士兰临床指导：原发性产后出血(上)

3.治疗

在没有血流动力学改变的情况下，大出血可在分娩时可迅速发展。因此，对所有产妇的密切监护、早期诊断和迅速反应是至关重要的¹。

3.1 

失血量估计

3.3 

复苏

对PPH的最初应对需要多科室的共同参与^1,12来恢复产妇的血流动力学状态，同时确定出血的原因并进行治疗。一旦确认PPH，立即通知有经验的资深产科医生（并要求立即出席）。

3.3.1 氨甲环酸

在PPH发病后尽快给予氨甲环酸⁵⁶，最好在PPH后3小时内给予。

3.3.2 PPH期间的支持

3.4 

宫缩异常

必须清空子宫腔以促子宫收缩。最初的临床和机械措施包括：

按摩子宫底，刺激宫缩^4,11,12,29

评估是否需要双手加压^4,11

检查胎盘和胎膜是否完整

排出子宫内血块

插入留置尿管，排空膀胱^11,12

3.4.1 治疗宫缩乏力的一线药物

3.4.2 治疗宫缩乏力的二线药物

3.4.3 难治性产后出血

3.5 

创伤

创伤是PPH的第二大常见原因，可能涉及子宫，**，**或会阴。

3.5.1 **道创伤

3.5.2 子宫**创伤

3.5.3 子宫破裂

子宫破裂可以自行发生或与先前的产科手术有关，出血的严重程度取决于破裂的程度。

3.5.4子宫内翻

子宫内翻与即刻危及生命的出血和休克有关，延迟治疗将增加死亡风险。在尝试重新定位底部之前考虑麻醉。

3.6

 妊娠相关物残留

3.7

凝血功能障碍

晚期诊断或低估出血量可能与凝血病有关⁷²。如果怀疑是凝血病，请咨询血液学家或输血专家，以获得血液成分替换，实验室检测和结果解释方面的建议¹。

3.7.1目标结果

尽早和频繁地测量以下参数。治疗成功后，数值应趋于正常¹。

3.7.2凝血障碍处理原则

5.

产后出血后的护理

附录B：PPH药物和血液制品

有关适应症、注意事项、禁忌症和相互作用的详细信息，请参阅药典。

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审校专家

陈继明

陈继明，男，副主任医师，医学博士（博士后在站），硕士研究生导师。现任南京医科大学常州临床医学院妇产科学教研室主任，南京医科大学附属常州第二人民医院妇科病区主任，杏霖妇科内分泌研究院学术部部长/学术审核组组长。主要专业特长为妇科内分泌疾病、妇产科常见病诊治及妇科良恶性肿瘤的微创治疗，擅长单孔腹腔镜手术（LESS）及自然通道"无疤痕"腹腔镜手术（V-NOTES）。熟练掌握单孔腹腔镜下妇科良恶性肿瘤手术，并将5mm mini切口单孔腹腔镜手术广泛应用于妇科疾病的诊治。单孔腹腔镜技术曾获市卫计委医学新技术引进奖一等奖，第六届/第七届中国妇产科网手术视频大赛三等奖，第六届妇科肿瘤长江论坛青年医师优秀视频二等奖、2018江苏省抗癌协会妇科肿瘤专委会学术年会视频比赛二等奖，第六届/第七届SESGE优秀手术视频等。

现任“中国妇幼保健协会妇科内分泌专业委员会青年科研学组秘书”、“中国妇幼保健协会妇科内分泌专业委员会妇科内分泌与肿瘤青年学组委员”、“中国妇幼保健协会妇科内分泌专业委员会健康扶贫工作学组委员”、“中国妇幼保健协会妇幼微创分会腹腔镜学组委员”、“中国妇幼保健协会妇幼微创分会青年委员会全国青年委员”、“中国医师协会妇产科分会妇科单孔腹腔镜技术全国科研协作组成员”、“中国中药协会女性生殖健康药物研究专业委员会委员”、“中国性科学理事会专家委员会委员”、“中国老年医学学会妇科分会青年委员会委员”、“中国医疗保健国际交流促进会妇产科分会妇产科创新技术与临床转化学组委员”、“中国中医药研究促进会中西医结合妇产与妇幼保健分会委员”、“中国整形美容协会女性生殖整复分会生殖物理整复专业学组成员”、“中国医药教育协会毕业后与继续医学教育指导委员会委员”、“中国研究型医院学会妇科肿瘤专业委员会青年委员”、“中国成人教育协会医学继续教育专业委员会腔镜国际培训中心常务委员”、“江苏省医师协会妇产科医师分会委员”、“江苏省医师协会微无创医学专业委员会妇科学组委员”、“江苏省预防医学会妇女保健专业委员会妇科内分泌学组成员”、“江苏省预防医学会妇女保健专业委员会女性盆底学组成员”、“常州市医学会妇产科分会第五届委员会委员兼秘书”、“常州市医师协会妇产科医师分会第二届委员会委员兼秘书”、“美国妇科腹腔镜医师协会（AAGL）会员”、“杏霖妇科内分泌研究院优秀科普讲者”、“杏霖妇科内分泌研究院媒体宣传信息员”。

获评"江苏省333人才工程第三层次培养对象"、“江苏省卫生拔尖人才”、“常州青年医学创新人才工程培养对象”、“2018常州市引进优秀医学博士”、“2019《健康报》社首批青年医生全明星成长计划”、“院十佳青年医务工作者”、“院十佳党员创新人才”、“院十佳患者信赖的医务工作者”。

现为《中国计划生育与妇产科杂志》、《现代药物与临床杂志》、《国际妇产科前沿杂志》编委、《实用妇科内分泌杂志》中青年编委、《Life Research》editor；《World Journal of Gynecology & Women’s Health》associated editor；《重庆医学》、《中国性科学》、《中国肿瘤外科》、《安徽医药》等杂志特邀审稿专家。

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