第12章 胎盘早剥 与 前置胎盘.ppt

胎盘早期剥离与前置胎盘placentalabruptionPlacentapervia,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,GeneralConsideration,DefinitionTheseparationoftheplacentafromitssiteofimplantationafter20weeksofgestationorduringthecourseofdelivery.Frequency0.46%-2.1%(ourcountry)1%-2%(othercountries)Incidenceoffetaldeath200-350,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(primarycause)RiskfactorsIncreasedageandparityVasculardiseases:preeclampsia,chronichypertension,renaldisease.Mechanicalfactors:trauma,intercourse,polyhydramnios,SupinehypotensivesyndromeSmoking,cocaineuse,uterinemyoma,【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,Mainchangehemorrhageintothedeciduabasalisdeciduasplitsdeciduralhematomaseparation,compression,destructionoftheplacentaadjacenttoitTypesrevealedabruption,concealedabruption,mixedtypeUteroplacentalapoplexy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,DICHypovolemicshockAmnionicfluidembolismAcuterenalfailure,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,signandsymptomVaginalbleedingUterinetendernessorbackpainFetaldistressHighfrequencycontractionsHypertonusIdiopathicpretermlaborDeadfetus,Diagnosis,UltrasonographyDifferentialdiagnosisPlacentapreviaPainlessbleedingPre-ruptureofuterusdystocia,【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,TreatmentwillvarydependingupongestationalageandthestatusofmotherandfetusTreatmentofhypovolemicshock:intensivetransfusionwithbloodAssessmentoffetusTerminationofpregnancy:CSorVaginaldelivery,Treatment,TreatmentofconsumptivecoagulopathySupplementofcoagulationfactors:freshblood,frozenbloodplasma,fibrinogen,bloodplatelet.Heparin:highcoagulationAnti-fibrinolysisPreventionofrenalfailure,Thankyou!,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?,PLACENTAPREVIA,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,Placentaprevia:Abnormallocationoftheplacentaover,orincloseproximitytotheinternalos.(after28weeks)Incidence:approximately1/250pregnancy,Etiology,Mechanism:abnormalvascularizationPredisposingfactors:TwinpregnancyIncreasingmaternalageIncreasingparityPreviouscesareansection,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)placentaprevia:entirecervicalosiscoveredPartialplacentaprevia:themarginoftheplacentaextendsacrossbutnotalloftheinternalos.Marginal:edgeoftheplacentaliesadjacenttotheinternalosLowlyingplacenta:placentaislocatednearbutnotdirectlyadjacenttotheinternalos.,Classification,diagnosis,Painlessvaginalbleed:firstbleedingepisodeis2930weeksUltrasonography:benefitinlocalizingtheplacentaanddiagnosisplacentaprevia,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,DoublesetupvaginalexaminationNodigitalvaginalorrectalexaminationispreformedincaseofplacentaprevia.Onlyasafinalanddefinitiveeventandonlyunderconditionsofdoublesetup.Thisprocedureinvolvescarefulevaluationofthecervixintheoperationroomwithfullpreparationsforrapidcesareansection.,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.,ManagementBasicmanagementInitialhospitalizationwithhemodynamicstabilizationEnforcedbedrestRestrictionsofactivity,Expectantmanagement(allowforfurtherfetalgrowthandmaturation)BloodtransfusionisgivenasnecessaryAmniocentesisforfetallungmaturitytestingCesareanbirthiffetusisthoughttobemature,IndicationofvaginaldeliveryDeliverycanbeaccomplishedwithminimalbloodlossFetusisdeadMajorfetalmalform