placental abruption胎盘早剥——妇产科学

1,胎盘早剥（placental abruption）,胡娅莉,2,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。,3,发病率,占分娩总数的0.51%-2.33%,4,ABRUPTIO PLACENTA,Premature separation of the normally implanted placentaOccurs in approximately 1 in 120 birthsAccounts for 15% of perinatal mortality,5,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。,6,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。,7,8,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。,9,RISK FACTORS,ChorioamnionitisMaternal hypertension (140/90)Previous abruption,Placental insufficiencyTrauma-blunt abdominalRapid decompression of the overdistended uterus (twins, polyhydramnios),10,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。,11,2、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）。,12,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。,13,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。,14,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。,15,GRADE I:,slight vaginal bleedinguterine irritabilitynormal maternal blood pressurenormal maternal fibrinogennormal fetal heart rate patternOften diagnosed at delivery with placental clot,16,GRADE II:,mild to moderate bleedingirritable uterus with tetanic contractionsnormal BPelevated pulse ratereduced fibrinogen level (150-250)fetal distress,17,18,GRADE III:,moderate to severe bleeding (may be concealed)tetanic and painful uterusmaternal hypotensionFETAL DEATH,19,GRADE III,Grade III a: without coagulopathyGrade III b: with coagulopathyfibrinogen reduced to less than 150 mg% with other overt signs of coagulopathy,20,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。,21,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。,22,PATIENT HISTORY,PainVaries from mild cramping to severe painBack painthink posterior abruptionBleedingMay not reflect true amount of blood lossTraumaOther risk factors,23,PHYSICAL EXAM,Signs of circulatory instabilityMild tachycardia normalMaternal hypotension never normal urine output ,Shock represents 30% blood lossMaternal abdomenFundal heightLocation of tendernessTetanic contrations,24,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,25,ULTRASOUND SIGNS,Retroplacental echolucencyThickening of the placentaAbnormally round “torn edge”,26,27,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,28,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。,29,鉴别诊断,1、前置胎盘；2、先兆子宫破裂,30,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,31,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,32,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,33,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.,34,?,35,HISTORY,Past OB HistoryPrior episodes of bleedingAbdominal painUterine ContractionsRecent intercourseTobacco/Substance AbusePast Medical History,36,EXAMINATION,BP、PAssessment of uterine contractions and tendernessGentle speculum examDigital cervical exam