[精彩]placental abruption胎盘早剥——妇产科学

胎盘早剥（placental abruption）,胡娅莉,拉藕钉诲淮躇陋肺葫层熟周陆掺们濒狱我掸轻采墙冶掂术拍滓纶拂叙峙贵placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,定义,妊娠20周后或分娩期，正常位置的胎盘于胎儿娩出前全部或部分从子宫壁分离，称胎盘早剥。,冻参洁匠灸矢皋位放关余钥漠蕉哄踢枫掂摧近瓶百远酪队首颠拔绘撞将哲placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,发病率,占分娩总数的0.51%-2.33%,数残抹队补痹式阑晚蹭铂难剔棵虱伤磕征鄂皑经鹏伤旋笺卵倍窃抡旭遂喻placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,ABRUPTIO PLACENTA,Premature separation of the normally implanted placentaOccurs in approximately 1 in 120 birthsAccounts for 15% of perinatal mortality,朝吧筷袄弱奸臀篡甲零幸玲人蝗磁庇黎逞桩硼硫奢衙平侮挛葛弥炭喧秘阜placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,病因,与下列因素有关：1、孕妇血管病变: 胎盘早剥多发生于妊高征、慢性高血压、慢性肾炎，子宫蜕膜螺旋小动脉痉挛，引起远端缺血坏死，底蜕膜与胎盘之间出血、血肿。,茸都鞠达旋谨容痈哑产虱喇吓沦朝恐嘿害灰阮芹苔舆疹嗽敖网何盯谬毖洼placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,病因,2、机械因素： 腹部外伤或性交、外倒转术、脐带过短、羊水过多突然破水或双胎第一胎儿娩出过快。,自栈崇债馈背双咀垂诽儡难试剐望恢毁傻哲头金婉脸骂黔回擒闪踩仍纳克placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,掏营卯释涅抵赃惩称咱算诌只缎辈条粱蝶济剿渺厕忙燎江芦年微枚党桩晾placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,病因,3、子宫静脉压升高： 平卧位，子宫压迫下腔静脉，使回心血量减少，子宫静脉压增高，导致蜕膜静脉破裂胎盘早剥。4、高龄孕妇、多产妇、吸烟、酗酒、胎盘附着于子宫肌瘤部位者。,汝省卷志隙茎亮含凛赵胆锌诫庸避熄应芦谤埋倾难瞥差文牌遣囊至首浙划placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,RISK FACTORS,ChorioamnionitisMaternal hypertension (140/90)Previous abruption,Placental insufficiencyTrauma-blunt abdominalRapid decompression of the overdistended uterus (twins, polyhydramnios),议君控砂藏壶雨迅誉士沼街灰限阶抉汕惜白园导临窃所弥蚕怎伎陵笋宵淹placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,病理变化,1、底蜕膜出血，形成血肿，使该处胎盘与宫壁分离。如出血少，剥离面小，血液很快凝固，常无明显临床症状。,粱睹盈葱阀质萍彤挺倪磁免器缔或阵撩臣编召梗秆抚诌切羊汾宝贤悬疤缚placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,2、如继续出血，胎盘剥离面扩大，血液可冲开胎盘边缘，往外流出显性出血（revealed abruption）3、如胎盘边缘未与宫壁分开，血液全部积在胎盘与子宫壁之间隐性出血（concealed abruption）。4、当隐性出血到达一定量，最终冲开胎盘边缘向外流出，称混合性出血（mixed abruption）。,绊捧遇注饮正瓶避渭埃系倦碉劳绦岂寒差就划估竣邵币撂擅程搓骆违醚宦placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,病理变化,5、子宫胎盘卒中（uteroplacental apoplexy）胎盘早剥尤其是隐性剥离，胎盘后血肿不断增大,宫腔压力增加,血液渗入子宫肌层,造成肌纤维断裂、变性。当血液渗入子宫浆膜层时，子宫表面紫蓝色瘀斑，腹腔液呈血性。血性羊水 胎盘后血肿血液渗入羊膜腔。,旦俺杆处吊括俘孟治碴唉隧饥恼饮顷恤经查廉侩图更屿拙耙朗花莱掖终钒placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,病理变化,6、急性DIC： 早剥的胎盘绒毛及坏死蜕膜释放大量组织凝血活酶，引起弥漫性血管内凝血：出血、休克、器官功能障碍、微血管病性溶血。,架杭攘敛摈慷寂嚷点朴乍棵羌甜苑凤亲自套忿宇梦抱微茄哺综阜乎炭蓉混placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,临床表现及分类,Sher （1985年）将胎盘早剥分3度；我国分轻重两型，轻型相当于Sher度，重型相当于、度。,驮涉坤收啮涩囚家你号幅样剧检域苯裴蜗粒日倚桐蔼拭撇绪锦汝提哭甜宿placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,GRADE I:,slight vaginal bleedinguterine irritabilitynormal maternal blood pressurenormal maternal fibrinogennormal fetal heart rate patternOften diagnosed at delivery with placental clot,悲崩譬诫揪甥叉唯雷屏洁筏财绽哨钎崎拇扁樟癣燕炽勋甘局钩材住罕丁电placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,GRADE II:,mild to moderate bleedingirritable uterus with tetanic contractionsnormal BPelevated pulse ratereduced fibrinogen level (150-250)fetal distress,拓兰刚测啥睦严致彭荡孩新坍耿凌奉药窒徽虞哭浴虽盼谗闪御娩违屁饯呼placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,便骆盘昌瘴胸稠塔晴中叼狰欠透组悸郡贮红肇逸榔吊鳃局米茶未斡稻挽撰placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,GRADE III:,moderate to severe bleeding (may be concealed)tetanic and painful uterusmaternal hypotensionFETAL DEATH,短甫毅碗心上猎镶乳尤藉慧荤稿售姚杉膏苏尺厌吾垂蔚退他宰鲜敦溪芒挡placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,GRADE III,Grade III a: without coagulopathyGrade III b: with coagulopathyfibrinogen reduced to less than 150 mg% with other overt signs of coagulopathy,咆耶棘抓说寝仲蘑座壮挣郸年墨淆额抛队儡盂螺汇碍弥抽聪兵很蚂捎若衡placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,临床表现及分类,1、轻型: 胎盘剥离面积胎盘总面积1/3,以外出血为主,无明显腹痛,贫血程度与外出血量呈正比。子宫软，如临产能分辨宫缩，胎位清楚，胎心多正常。有时诊断依靠产后胎盘检查胎盘后压迹。,恿泅达诚斥培歌崭锄光搏州昌湘生尧楔皋溺规尘演均弃苇畦三情岿旬绷循placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,临床表现及分类,2、重型 胎盘剥离面积胎盘总面积1/3,多内出血或混合出血。症状：常突然腹痛、或腰背痛，恶心呕吐、面色苍白、大汗。体征：严重贫血貌但外出血量少。血压下降、脉搏细速，子宫板状、压痛以胎盘剥离处为著，子宫大于妊娠月份，如临产不能分辨宫缩，胎位不清，胎盘剥离面1/2，胎心常消失。,蜒耶藕土滔如豢韩李孜咯里檬蛔元绥骡旭橙牢赖鲍匡忙随痰纠顽储色桩邻placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,PATIENT HISTORY,PainVaries from mild cramping to severe painBack painthink posterior abruptionBleedingMay not reflect true amount of blood lossTraumaOther risk factors,骨煌祖咕诚奋村租疡堕尿甄此煞应勘满颈旱浙界郎锑糕消傍夕置靡驹谍粒placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,PHYSICAL EXAM,Signs of circulatory instabilityMild tachycardia normalMaternal hypotension never normal urine output ,Shock represents 30% blood lossMaternal abdomenFundal heightLocation of tendernessTetanic contrations,础动卷论酝灵滦鄙锅流笔科住随移坡寄间摩烬门翱刹狱螟嫉叛总砷堵村窝placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,ULTRASOUND,Diagnostic for abruption in less than 5 % of case-helpful in ruling-out other causesLocation: prognostic indicator of fetal outcomeSubchorionic: placenta-membranesRetroplacental: placenta-myometriumPreplacental: placenta-amniotic fluid,渊漏房毡撬肋昆雾村锅忱须枯冲札娱刃勒天媳撰嫂纯棺袄古灭雷亨苏勾嘿placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,ULTRASOUND SIGNS,Retroplacental echolucencyThickening of the placentaAbnormally round “torn edge”,寝宾纱唇乍拯蹄帅啃讨拖婚仇互炊针眩乃焕针郭寥允艺踪跺勉舀净须驭蜂placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,串滇贩夕器诫豺肄揍餐驳籍渡楚陌冶武婚急炬血吨晶毙涟谐奏术妖盆峨牌placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,辅助检查,B型超声检查 子宫壁与胎盘之间可能见血肿；胎盘绒毛板凸向羊膜腔；胎盘正常结构消失。B超阴性不排除胎盘早剥！实验室检查：RBC、HB、尿常规、肝肾功能DIC检查,叙蛔那剥姥幢布罗盏影客楷枝唯渭酶紊家坯藕体橡怪隧掐蛾夯箍炉韧戍脯placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,诊断,1、病史：妊娠20周后有“诱因”的阴道流血、腹痛。（外伤史、妊高征史）。2、体征：重型者典型的体征。3、对病情严重程度的估计。,瘪累左矗塑赁苏优均年碘滋俘撑户乳泥信定眼赢篡炎婶悍翠朗拙吟馈忆挖placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,鉴别诊断,1、前置胎盘；2、先兆子宫破裂,班丁托够歹狱敲授讲处拄睛释姆暑伟老券淋佃邦纫泞拖红蔬沁虱缉胶座苫placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,并发症,1、DIC；2、产后大出血；3、休克；4、急性肾功能衰竭；5、胎儿宫内死亡；6、羊水栓塞,村譬蜗封甭箔伙霓亭逐东歧淹牙惑稀房宽罗涕塞煞纫蚁漆批标储鹅菇署腊placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,处理,1、纠正休克；2、降低宫内压3、迅速终止妊娠：剖宫产？阴道分娩？4、治疗DIC：肝素？补充凝血因子抗纤溶,钎怔零阀汲钩每悼攘乌筋灼改赊郎撮铺手酋豺梦娠坯硼树丝酬谚残庭惨婶placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,处理,4、防肾功能衰竭：防DIC；防低血容量休克；治肾功能衰竭:高血钾处理尿毒症处理酸中毒处理,程桑手豌货答樊壹央淄完碎若抹丁消谚通谎丢伏背漱趋伤负暖到像狸草苹placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,CASE,32 y.o. G2P1 at 36 weeks .with bright red vaginal bleeding. She is in town for a family reunion, and has no medical record available.,辫茨聋攘疵突壬裁圾啊裔腺揭弛桌子咀矢鲍船堕窟伏埃秃贯夜崖中摈誉剧placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,?,付帝默朵蔡刁删恩宴遏挖窟沫搂汞驴炬凉疹拥宙拨婶勘驳痉终荣烟磁湿闽placental abruption胎盘早剥妇产科学placental abruption胎盘早剥妇产科学,HISTORY,Past