产后大出血集束化管理策略

doi:10.3877/cma.j.issn.2096-1537.2021.04.002

产后出血（PPH）是产科最常见的急危重症，是全球范围内导致孕产妇死亡的最常见原因。早期诊断和治疗是改善孕产后出血产妇预后的关键。一旦高度怀疑或明确诊断为PPH，应立即建立多学科组成的诊疗小组，分析出血原因，评估严重程度，在针对病因治疗的同时重视并发症的处理。本文基于国内外重要临床研究、权威指南和共识，参照循证医学证据，就PPH的识别、评估和应急救治流程提供诊疗意见，助力提高相关医务人员对PPH的认识和救治成功率。

关键词: 产后出血, 集束化管理, 产科急症

Postpartum hemorrhage (PPH) is a leading cause of severe maternal morbidity and mortality worldwide. Early diagnosis and treatment are the key to improve the outcome for patients with PPH. Once PPH is highly suspected or diagnosed, the bundle implementation process, including careful assessment the causes of bleeding, evaluation of the severity, treatment for the causes and complications should be performed by a relevant multidisciplinary team immediately. This study has provided early recognition, assessment and treatment advice concerning PPH identification, evaluation and relevant treatment procedures based on the clinical studies, authoritative guidelines, and consensus all over the world with evidence-based medical evidence as reference, so as improve our understanding of PPH and increase relevant treatment success rate.

Key words: Postpartum hemorrhage, Standardized bundles, Obstetric emergency

表1 PPH预防性和治疗性药物剂量、用法和不良反应

药物名称	剂量和用法		不良反应
药物名称	预防	治疗	不良反应
缩宫素	起始剂量为5~10 IU（溶于250 ml 0.9 %氯化钠溶液）iv，持续30 min；维持速度为1~3 U/h；或起始剂量为20 IU（溶于500 ml 0.9 %氯化钠溶液）iv，持续1 h；维持剂量为20 IU（溶于1000 ml 0.9 %氯化钠溶液）iv，速度2.5 IU/h，输注时间＞8 h	初始剂量为5 IU iv，持续时间＞2 min，必要时每5分钟重复给药，不超过10 IU；维持剂量为20~40 IU（溶于500~1000 ml 0.9 %氯化钠溶液），以125 ml/h速度持续4 h	快速给药可引起低血压、低钠、心动过速和心律失常
米索前列醇	无法给予缩宫素时，600 μg顿服、舌下含服或经直肠给药	600~1000 mg顿服、舌下含服或直肠给药	恶心、呕吐、发热、腹泻
卡前列素氨丁三醇	100 μg iv，持续1 min，或im	250 μg im或imm，必要时每15~90 分钟重复给药，总累计剂量＜2 mg	恶心、呕吐、腹泻
TXA	1 g或10~15 mg/kg iv，持续10~20 min	在诊断后3 h内用药。1 g iv，持续时间＞10 min，如果30 min后仍持续出血，可再次给药	头痛、肌肉酸痛、恶心、腹泻
马来酸麦角新碱	-	0.2 mg im或imm，必要时2~3 h重复给药	血压升高、恶心、呕吐、急性心肌梗死
rFⅦa	-	50~100 μg/kg iv	血栓、脑梗死、急性心肌梗死

表1 PPH预防性和治疗性药物剂量、用法和不良反应

药物名称	剂量和用法		不良反应
药物名称	预防	治疗	不良反应
缩宫素	起始剂量为5~10 IU（溶于250 ml 0.9 %氯化钠溶液）iv，持续30 min；维持速度为1~3 U/h；或起始剂量为20 IU（溶于500 ml 0.9 %氯化钠溶液）iv，持续1 h；维持剂量为20 IU（溶于1000 ml 0.9 %氯化钠溶液）iv，速度2.5 IU/h，输注时间＞8 h	初始剂量为5 IU iv，持续时间＞2 min，必要时每5分钟重复给药，不超过10 IU；维持剂量为20~40 IU（溶于500~1000 ml 0.9 %氯化钠溶液），以125 ml/h速度持续4 h	快速给药可引起低血压、低钠、心动过速和心律失常
米索前列醇	无法给予缩宫素时，600 μg顿服、舌下含服或经直肠给药	600~1000 mg顿服、舌下含服或直肠给药	恶心、呕吐、发热、腹泻
卡前列素氨丁三醇	100 μg iv，持续1 min，或im	250 μg im或imm，必要时每15~90 分钟重复给药，总累计剂量＜2 mg	恶心、呕吐、腹泻
TXA	1 g或10~15 mg/kg iv，持续10~20 min	在诊断后3 h内用药。1 g iv，持续时间＞10 min，如果30 min后仍持续出血，可再次给药	头痛、肌肉酸痛、恶心、腹泻
马来酸麦角新碱	-	0.2 mg im或imm，必要时2~3 h重复给药	血压升高、恶心、呕吐、急性心肌梗死
rFⅦa	-	50~100 μg/kg iv	血栓、脑梗死、急性心肌梗死

图1 PPH的预防和管理流程注：PPH为产后出血；MDT为多学科协作；TEG为血栓弹力图；ROTEM为旋转式血栓弹力测定；UBT为子宫内球囊填塞；NASG为非充气防休克服；RBC为红细胞；FFP为新鲜冰冻血浆；PLT为血小板；TXA为氨甲环酸；rFⅦa为重组活化人凝血因子Ⅶ；PCC为凝血酶原复合物浓缩剂

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Standardized bundles on postpartum hemorrhage

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