产科急症的辨识和处置之产前出血PPT课件

1,.,产前出血,前置胎盘胎盘早剥帆状胎盘血管前置宫颈息肉宫颈糜烂外伤疤痕子宫破裂肿瘤,2,.,前置胎盘,定义：胎盘部分或全部覆盖宫内口。完全性totalis部分性partialis边缘性marginalis发生率：0.5%-1%ofallbirths.高危因素：剖宫产史(x6)-多产(x2.6)先前宫腔操作史-吸烟,3,.,完全性,4,.,完全性（圆盘型）,5,.,部分性,6,.,9.1.1采购绩效评估的目的,确保采购目标之实现提供改进绩效之依据作为个人或部门奖惩之参考协助人员甑选与训练促进部门关系提高人员的士气,7,.,9.1.2采购绩效评估小组的组成,采购部门主管财务部门销售部门生产主管部门或工程部门供应商专家顾问,8,.,9.1.3采购绩效评估标准,历史绩效标准预算或标准绩效行业平均绩效标准目标绩效标准小思考:何种情况下选择何种绩效标准？,9,.,边缘性MARGINALIS,10,.,前置胎盘,临床特点:母源性无痛性阴道流血painlessbleedingofmaternalorigin诊断:1.超声Sonography2.阴窥Ifcervicalosdilatedcautiousinspection合并症:胎盘早剥,胎位异常,产后出血处理：卧床、防栓塞等Bedrest,Thrombosisprophylaxis,11,.,分娩方式DELIVERYMODUS,剖宫产Practicallyallwomendoneedcesareansection.注意点:1.胎儿早产又无分娩指征（观察）Thefetusispretermandthereisnoindicationfordelivery.(observe)2.胎儿成熟母出血不止（c.s)Thefetusismatureandthebleedingdoesnotstop.(cesareanS)3.孕妇临产Thepatientisinlabor(cesareanS)4.出血严重胎儿不成熟（c.s)Thebleedingsevere,andthefetusimmature(cesareanS),12,.,疤痕子宫、前置胎盘、胎盘植入,13,.,前置胎盘、胎盘植入,14,.,前置胎盘产前出血,15,.,胎盘早剥PLACENTALABRUPTION,孕产妇死亡的主因Oneoftheleadingcausesoftheperinatalmortality发生率:0.5%-1%ofalldeliveries病生Pathophysiology:因腹部外伤、母缺氧或缺血以及感染，绒毛从蜕膜板分离。,16,.,出血类型,17,.,临床分级CLINICALSTAGING,Grade0:无症状，仅从超声和产后检查诊断。asymptomatic;diagnosisoftenpostnatalorbysonographyGrade1:有外、内出血迹象，母循环系统无变化，无胎儿窘迫。scantexternalNofetaldistress.,18,.,Grade2:严重出血和胎儿窘迫heavybleeding(externalinternal)Fetaldistress(CTG)Grade3:严重出血、子宫剧痛和休克伴有DIC和胎儿濒死。severeexternalmaternalshockin30%ofcasesassociatedwithcoagulationdisorders.,19,.,高危因素:,先前有胎盘早剥Previousabruption(x10)宫肌瘤Myoms子宫纵膈Uterusseptum母亲疾病：高血压、栓塞性疾病、Maternaldiseases:Hypertension,Thrombophilia,Hyperhomocysteinemia胎盘异常：环状AbnormalPlacentation:forexample:Plac.Circumvallata滥用尼古丁和可卡因Nicotine&CocaineAbuse腹部外伤BluntAbdominalTrauma,20,.,诊断DIAGNOSIS,疼痛性阴道出血Painfullvaginalbleeding板状腹Tetaniccontractionsofuterus胎心监护异常PathologicalCTG超声图像Sonography:(敏感性Sensitivity:50%),21,.,22,.,处理,无症状Nosymptoms(nobleeding):观察母胎情况observethemotherandthefetus.严重出血胎儿存活：C.S。Severebleeding+thefetusisalive:Cesareansection.出血胎儿死亡：人工破膜成份输血阴道分娩引产，但若出血太严重则剖宫产。Clinicalsymptoms(bleeding)+thefetusisdead:Amniotomy+packedredcells+coagulationfactors+laborinduction(vaginalbirth),butifthebleedingtooseverethencesareansection,23,.,子宫内部出血BLEEDINGINTRAPARTAL,见红BLOODYSHOW血管前置VASAPRAEVIA帆状胎盘前置INSERTIOVELAMENTOSA胎盘早剥ABRUPTIOPLACENTAE子宫破裂UTERINERUPTURE,24,.,血管