妊娠晚期出血antepartum haemorrhage.ppt

妊娠晚期出血Antepartum HaemorrhageChapter 12Department of Obstetrics and GynecologyZhuJiang Hospital Southern Medical UniversityDr Fu Xiafei Antepartum haemorrhageW Placental abruption胎盘早剥W Placental previa 前置胎盘内 容F掌握： 胎盘早剥 的临床表现、诊断要点、常见并发症及处理原则F掌握： 前置胎盘 的临床表现、诊断要点及处理原则F熟悉： 前置胎盘的分类Placental AbruptionDefinition The separation of the placenta in normal site from the site of uterine implantation before delivery of the fetus after the 20th week or during delivery Placental abruption起病急，发展快，危害大需急诊处理Incidence: 1-2% (国外 )0.46-2.1% (国内 )CausesuMaternal vascular diseases: v hypertensive disorder in pregnancyv hypertensionv renal diseasesuMechanical factors: v abdominal trauma v abnormally short umbilical cordCausesusudden loss in uterine pressure:v rapid loss of amniotic fluidv the delivery of the first twinuSudden increase of uterus venous pressureuOthers: v maternal cocaine use or smokingv previous placental separationv tendency to embolismPathologyHemorrhage into decidual basalis(底蜕膜） -decidual hematomaHematoma（血肿） expands and disrupts more vessels to separate from placentaUterus unable to sufficiently contract to compress the torn vessels主要病理变化： 底蜕膜出血，形成血肿，使胎盘从附着处分离Classification Revealed abruption 显性剥离 /外出血血液冲开胎盘边缘，并沿胎膜与子宫壁间经宫颈管向外流出Classification Concealed abruption隐性剥离 /内出血胎盘边缘仍附着于子宫壁，或胎先露固定于骨盆入口，血液积聚于胎盘与子宫壁之间Classification Mixed bleeding混合型出血当内出血达到一定程度时，血液终会冲开胎盘边缘及胎膜而外流Uteroplacental apoplexy子宫胎盘卒中W胎盘后血肿压力增高，血流浸入子宫肌层，引起肌纤维断裂。当血液渗透至子宫浆膜层时，子宫表面呈紫蓝色瘀斑W收缩力差，产后出血Classification 子宫胎盘卒中Clinical Findings Symptoms W Vaginal bleedingW Abdominal painW Back pain Signs WPhysical examination: uterine tenderness and/or increased uterine tone; Fetal distressu degree: the separations are small, produce few or no symptoms, and usually are not noted until the placenta is inspected. Signs.u degree: 1/3 of the placenta separated from the uterine wall, patients will present with vaginal bleeding, uterine tenderness and abnormal contractions. Signs.Clinical Findingsu degree: more than 50% of the placenta separated from the uterine wall, patients will present with shock, high-frequency contractions and fetal demise（死亡）Clinical FindingsLaboratory FindingsuUltrasound: 胎盘与子宫壁之间出现边缘不清的液性低回声区；胎儿宫内状况maybe helpful but is not totally reliable. Negative findings with ultrasound do not exclude placental abruption.u Blood routine and Coagulation functionDiagnosissymptoms Signs ExaminationsPlacental Abruption Placental PreviaUterine Rupture Differential diagnosisuDifficult to recognize with certainty, diagnosis often made by exclusionuPainful vaginal bleedinguPlacenta previa painless vaginal bleedingComplicationsu DIC 重要病理生理改变W 大量组织凝血活酶释放，进入母体循环，激活凝血系统，产生大量的纤维蛋白原降解产物u Postpartum haemorrhage 产后出血u Acute renal failure 急性肾衰u Acute amniotic fluid embolism 羊水栓塞Complications-fetus 急性缺氧 新生儿窒息 早产 围产儿死亡ManagementEmergency measures：Antishock measures should be instituted as necessarynCesarean Delivery: Rapid delivery of the fetus who is alive but in distress practically always means cesarean delivery.Vaginal Delivery: the degree of separation appears to be limited and the fetus can be monitored for signs of fetal distress.Management Correct DIC： 尽快终止妊娠，补充凝血因子，肝素 Prevention of renal failure Postpartum hemorrhage： 宫缩剂 Management complicationsPreventionustrengthen the antenatal examination and prevent maternal hypertensionumanagement of high risk pregnancyuavoid trauma uavoid rapid decompression of uterusuavoid smokingConclusionuDefinitionuPathology: revealed, concealed, mixeduClinical findings: 3 degrees uComplicationsW DIC W Postpartum haemorrhageW Acute renal failure W Amniotic fluid embolismuTreatmentW Emergency me