胎盘早剥与前置胎盘

胎盘早期剥离 与 前置胎盘 placental abruption Placenta pervia,李爱斌, 概述 病因 病理变化 临床表现 处理原则,内容提要, 解释胎盘早剥定义 了解病因及病理变化 掌握临床表现 熟悉处理原则,学习目的与要求,【概述】, 胎盘早剥指妊娠20周以后或分娩期，正常位置的胎盘在胎儿娩出前，部分或全部从子宫壁剥离 是严重威胁产妇及胎儿生命的并发症 围生儿死亡率高,General Consideration,Definition The separation of the placenta from its site of implantation after 20 weeks of gestation or during the course of delivery.Frequency 0.46%-2.1% (our country) 1%-2% (other countries) Incidence of fetal death 200-350, 血管病变 机械性因素(外伤、脐带过短） 子宫静脉压突然升高 子宫体积突然缩小,【病因】未明,Etiology,Uncertain (primary cause)Risk factorsIncreased age and parityVascular diseases: preeclampsia, chronic hypertension, renal disease.Mechanical factors: trauma, intercourse, polyhydramnios, Supine hypotensive syndromeSmoking, cocaine use, uterine myoma,【病理变化】,主要病理变化是底蜕膜出血 形成血肿 胎盘自附着处剥离 出血 腹痛（持续性）,Pathology,Main change hemorrhage into the decidua basalis decidua splits decidural hematoma separation, compression, destruction of the placenta adjacent to itTypes revealed abruption, concealed abruption, mixed typeUteroplacental apoplexy 子宫胎盘卒中, 出血形式,显性出血,混合性出血,隐性出血,母体贫血、失血性休克、DIC、子宫卒中、产后出血、感染、多脏器功能衰竭围生儿胎儿窘迫、新生儿窒息、RDS、新生儿死亡, 并发症,DICHypovolemic shockAmnionic fluid embolismAcute renal failure,Complication,【临床表现】,轻型 重型出血 外出血为主 ， 内出血为主，阴道出 量较多 血少或无 腹痛 轻或无 持续性、剧烈 子宫软，轻压痛， 子宫硬，压痛明显， 大小与孕月相符， 子宫大于孕月，胎位 胎位、胎心清楚 不清，胎心音异常,腹部检查,【常用辅助检查】, B超实验室检查贫血程度、凝血 功能、肝肾功能等,Diagnosis,sign and symptomVaginal bleedingUterine tenderness or back painFetal distressHigh frequency contractionsHypertonusIdiopathic preterm laborDead fetus,Diagnosis,UltrasonographyDifferential diagnosisPlacenta previa Painless bleedingPre-rupture of uterus dystocia,【处理原则】, 补充血容量，防治休克；及时终止妊娠，防治并发症 终止妊娠方法剖宫产 阴道分娩,Treatment,Treatment will vary depending upon gestational age and the status of mother and fetusTreatment of hypovolemic shock: intensive transfusion with bloodAssessment of fetusTermination of pregnancy: CS or Vaginal delivery,Treatment,Treatment of consumptive coagulopathySupplement of coagulation factors: fresh blood, frozen blood plasma, fibrinogen, blood platelet.Heparin: high coagulationAnti-fibrinolysisPrevention of renal failure,Thank you!,假如你是大夫.,例:孕37周阴道三次较多量无痛性出血,来诊?例:孕30周+4天 ,曾阴道无痛出血两次,咨询?,PLACENTA PREVIA,前 置 胎 盘,李爱斌,正常胎盘附着位置,妊娠28周后，胎盘附着于子宫下段，甚至胎盘下缘达到或覆盖宫颈内口，其位置低于胎儿先露部，称为前置胎盘,定义 (Definition),Definition,Placenta previa: Abnormal location of the placenta over ,or in close proximity to the internal os.(after 28 weeks )Incidence: approximately 1 /250 pregnancy,Etiology,Mechanism: abnormal vascularizationPredisposing factors:Twin pregnancyIncreasing maternal ageIncreasing parityPrevious cesarean section,分类 (Classification),完全性前置胎盘 部分性前置胎盘 边缘性前置胎盘,Classification,Complete (total) placenta previa: entire cervical os is coveredPartial placenta previa:the margin of the placenta extends across but not all of the internal os.Marginal:edge of the placenta lies adjacent to the internal osLow lying placenta:placenta is located near but not directly adjacent to the internal os.,Classification,diagnosis,Painless vaginal bleed: first bleeding episode is 2930 weeksUltrasonography: benefit in localizing the placenta and diagnosis placenta previa,病史与症状查体与体征关于阴道检查超声检查产后检查胎盘及胎膜注意：妊娠中期不宜过早作出诊断鉴别诊断 胎盘早剥 其他原因引起的产前 出血,Caution,Double setup vaginal examination No digital vaginal or rectal examination is preformed in case of placenta previa . Only as a final and definitive event and only under conditions of double set up. This procedure involves careful evaluation of the cervix in the operation room with full preparations for rapid cesarean section.,处理 Treatment,原则：止血补血，预防感染 方法；期待疗法 终止妊娠,孕37周以前或胎儿体重2300g .患者状态良好，胎儿存活。卧床休息.间断吸氧,静脉高能营养促胎儿成熟.抑制宫缩.,ManagementBasic managementInitial hospitalization with hemodynamic stabilizationEnforced bed restRestrictions of activity,Expectant management (allow for further fetal growth and maturation)Blood transfusion is given as necessaryAmniocentesis for fetal lung maturity testingCesarean birth if fetus is thought to be mature,Indication of vaginal deliveryDelivery can be accomplished with minimal blood lossFetus is deadMajor fe