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Postpartum bleeding (PPH)

chromextension://efaidnbmnnnibpcajpcglclefindmkaj/https://synapse.koreamed.org/upload/synapsedata/pdfdata/0119jkma/jkma-50-1096.pdf
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Primary PPH - ์ž์—ฐ๋ถ„๋งŒ ์‹œ 500 cc ์ด์ƒ - C/sec ์‹œ 1,000 cc ์ด์ƒ ์ถœํ˜ˆ
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Secondary PPH - ๋ถ„๋งŒ 24์‹œ๊ฐ„์—์„œ 6์ฃผ ๋‚ด์— ์ƒ๋‹นํ•œ ์–‘์˜ ์ถœํ˜ˆ์ด ์žˆ๋Š” ๊ฒƒ.

A. General Consideration

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ํ˜ˆ์•ก 500cc ๋งˆ๋‹ค Hct 3% ์”ฉ ๊ฐ์†Œ

A1. ์ถœํ˜ˆ๋Ÿ‰ ์ถ”์ •

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4*8 ๊ฑฐ์ฆˆ ํ•œ ์žฅ : ์•ฝ 10 mL
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ํŒจ๋“œ ํ•œ ๋ผ˜ * ํ•œ ๋ผ˜ : ์•ฝ 200 mL
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๋ฌด๊ฒŒ 1g = 1mL
A2. ์›์ธ
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Uterine atony
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Genital tract laceration
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Vulvar, vaginal hematoma

B. Uterine Atony

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๋ถ„๋งŒ ํ›„ ์ž๊ถ์ด ์ ์ ˆํ•œ ์ˆ˜์ค€์œผ๋กœ ์ˆ˜์ถ•ํ•˜์ง€ ๋ชปํ•ด ํƒœ๋ฐ˜์ด ๋ถ€์ฐฉ๋œ ๋ถ€๋ถ„์˜ ํ˜ˆ๊ด€์—์„œ๋ถ€ํ„ฐ ์ถœํ˜ˆ์ด ๋ฐœ์ƒ

B1. Risk factor

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Primiparity and high parity
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Oversitended uterus woth a large fetus, multiple fetus, hydramnios
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Labor abnormalities
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Labor induction with PG or oxytocin
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Prior postpartum hemorrhage

(1) ์˜ˆ๋ฐฉ์  ์˜ฅ์‹œํ† ์‹  ํˆฌ์—ฌ โ‡’ ์œ„ํ—˜๋„ 60% ์ •๋„ ๊ฐ์†Œ

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Oxytocin 10 U IM
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5 U IV bolus
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10~20 U/L N/S IV at 100~150 mL/hr

B2. Evaluation and management

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Laceration๊ณผ ๋งŒ์ถœ๋œ ํƒœ๋ฐ˜ ํ™•์ธ
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์ง€์†์ ์ธ fundal massage and uterotonic agent
(1) A & B
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10~15 L/mmin O2 by face mask
(2) C
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2 large bore IV access
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Sampling for Lab, Crossmatch 4 PRBC
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2L of crystalloid rapidly
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Transfusion ASAP

(3) Uterotonic agent

: ๋ถ„๋งŒ ํ›„ ์ถœํ˜ˆ์˜ ์˜ˆ๋ฐฉ ๋ฐ ์น˜๋ฃŒ
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Oxytocin (IV, IM ์‚ฌ์ด์— ์šฐ์œ„๋Š” ์—†๋‹ค)
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Ergot alkaloid : 2nd line (Methergine, ergonovine 0.2 mg IM) : oxytocin๊ณผ ๋ณ‘์šฉํˆฌ์—ฌ ๊ฐ€๋Šฅ
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Prostaglandin E & F

(4) Uterotonic agent์— ๋ฐ˜์‘ํ•˜์ง€ ์•Š๋Š” ์ถœํ˜ˆ

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Bimanual uterine compression
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2 IV line - oxytocin, transfusion
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Uine output check
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Crystalloid rapid infusion
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๋งˆ์ทจ ํ›„ remnant placenta๋‚˜ uterine rupture, laceration ์—ฌ๋ถ€๋ฅผ ์†์œผ๋กœ ํ™•์ธ
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Cervix์™€ vagina์— laceration์ด ์ƒ๊ฒผ๋Š”์ง€ ์œก์•ˆ ํ™•์ธ
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์—ฌ์ „ํžˆ ๋ถˆ์•ˆ์ •ํ•  ๊ฒฝ์šฐ Transfusion

(5) Bakri

(6) Surgical procedure
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uterine compression suture
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pelvic vessel ligation
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angiographic embolization
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hysterectomy
C. Uterine Inversion
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์ฆ‰์‹œ ์ •๋ณตํ•˜์ง€ ์•Š์œผ๋ฉด ์‹ฌํ•œ ์ถœํ˜ˆ ๋ฐ pain shock ๊ฐ€๋Šฅํ•จ.
C1. Risk factor
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Fundal placental implantation
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Uterine atony
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Cord traction before placental seperation
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Abnormaly adhered placentation with accrete syndrome
C2. Recognition and management
: ๋น ๋ฅธ ์ง„๋‹จ์ด ๋งค์šฐ ์ค‘์š”ํ•จ
(1) ํƒœ๋ฐ˜์ด ์ด๋ฏธ ๋ถ„๋ฆฌ๋˜์—ˆ๋‹ค๋ฉด - ์ž๊ถ์„ push upํ•˜๋ฉด ์ข…์ข… ์ •๋ณต์ด ๋œ๋‹ค.
(2) ํƒœ๋ฐ˜์ด ๋ถ„๋ฆฌ๋˜์ง€ ์•Š์•˜๋‹ค๋ฉด
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์ž๊ถ์˜ relaxation ๋ฐ repositioning์„ ์œ„ํ•ด tocolytics์ฒ˜๋ฐฉ์ด ๊ถŒ์žฅ.
(3) Surgical intervention

D. Genital Laceration

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