妇产科学教学课件：Placental abruption

1、Placental abruption,Definition,Occurs after 20th weeks, premature separation of the normally situated placenta before delivery of fetus,Incidence: in abroad: 1%-2% in our country: 0.46%-2.1%. The fetal mortality is depending on the degree of separation. Placental abruption is a severe complication o

2、f late pregnancy. It is also a significant contributor to maternal mortality.,peels away from the inner wall of the uterus before delivery deprive of oxygen and nutrients of the fetus heavy bleeding in the mother. mother and baby in jeopardy.,Etiology,(1)vascular lesion：PIH, especial severe pre-ecla

3、mpsia, chronic hypertension, chronic renal disease-vascular sclerosis spasm -Local vascular injury-vascular rupture into decidual basalis -bleeding, hematoma formation-shears off adjacent denuded vessels, separation of the placenta from the uterine wall. producing further bleeding and enlarging the

4、separated area,Etiology,uterine venous congestion-sudden rise in uterine venous pressure to intervillous space-congestion or rupture of venous bed-hematoma formation-separation of placenta and uterine wall,Etiology,(2) Sudden uterine decompression： premature rupture of membrane (especially the prete

5、rm PROM) the first fetus is delivered rapidly in twin. amniotic fluid flowed rapidly in polyhydramnios, the uterine cavitys pressure decreased suddenly, uterus contracts, which cause the separation of the placenta and uterus.,Etiology,(3)Mechanical factors: trauma or injury to the abdomen short umbi

6、lical cord (absolute or relative) In amniocentesis, injure the vessel in the attachment of placenta-hematoma behind the placenta formation-separation of the placenta and uterine wall,Predisposing factors,Previous placental abruption. Advanced maternal age Multipara Smoking,Predisposing factors,Abnor

7、mal metabolism Predisposing thrombosis. Uterus myoma. drug abuse.,Pathological changes,bleeding to decidual basalis,hematoma of retroplacenta,Separation of the placenta and uterine wall,Revealed or external bleeding,the complications are fewer and less severe. Small amount bleeding and quickly cease

8、. No obvious symptoms.,concealed or internal placental abruption,The hemorrhage is confined within the uterine cavity, detachment of the placenta may be complete, and the complications are often severe.,Mixed bleeding,concealed or internal placental abruption The placenta marginal incomplete,Utero-p

9、lacental apoplexy ( Couvelaire uterus),the placental margins remain adherent, hemorrhage that infiltrates the uterine wall. Uterine tetany follows extensive intra myometrial bleeding -purplish and copper-colored, ecchymosis loses its contractile power because of disruption of the muscle bundles.,DIC

10、 (disseminated intravascular coagulation ),The mother may then develop a widespread petechiae, active bleeding，shock, and failure of the normal clotting mechanism. Acute renal failure：acute renal cortical and tubular necrosis.,thromboplastinfrom the villi and decidua of the stripping side,Mothers ci

11、rculation,Activate blood coagulation system,Micro-thrombosis in capillary of the lung, kidney.,Ischemia and dysfunction of the organs,agglutinant,Mothers circulation,Activate fibrinolytic system,FDP,Hyperfibrinolysis,DIC,Enter into,Enter into,form,secondary,Consume blood coagulation factor,Clinical

12、findings and diagnosis,patients report of her symptoms physical examination performed. tested to evaluate the possibility of life-threatening problems with the mothers clotting system.,Symptoms and signs,begin anytime after 20 weeks of pregnancy. Classic signs and symptoms of placental abruption dep

13、ending on the site and extent of bleeding, there are 3 grades.,clinical findings correspond to the degree of separation. About 30% of separations are small, produce few or no symptoms , and usually are not noted until the placenta is inspected.,Symptoms degree: External bleeding, often seen during l

14、abor Separated area is small No pain in the abdomen or back, no anemia Uterus：soft Fetus：normal,Symptoms degree: Separated area is about 1/3 of the placenta. No or small vaginal bleeding, anemia of the patient is not match to bleeding. Sudden occurred abdominal pain, sore waist or low back pain. Ute

15、rus：enlarged, uterine height increased, tenderness of the separated place, intermittence during uterine contraction. Fetus：survival,Symptoms degree: Separated area is 1/2 of the placenta. Nausea, vomitting, pale, blood pressure decrease, pulsation extenuate etc shock symptoms, which is correspond to

16、 the maternal blood loss. Uterus：hard like a board, no relaxation during uterine contraction intermittence. Fetal position is not so clear Fetus：fetal heart rate vanish, fetal death.,Concealed: no visible vaginal bleeding bleeding is trapped behind the placenta bleeding into the muscle of the uterus

17、. abnormal contractions of the uterus, particularly extremely hard, prolonged contractions.,mother symptoms of organ failure as her organs are deprived of oxygen. a drop in blood pressure,Laboratory findings Blood cell and coagulation test Peripheral blood smear Clot observation test,Laboratory test

18、ing is not useful in making the diagnosis of abruptio placentae, but sometimes supports a diagnosis of severe abruption. DIC occurs in 10 to 20 percent of cases of severe abruption with death of the fetus.,3.Ultrasound help identify possible reasons of vaginal bleeding. diagnose an abruption high ra

19、te of missed or incorrect diagnoses rule out placenta previa,Differential diagnosis,placenta previa and placental abruption,Placenta previa : beyond 28 weeks of gestation age who presents with painless vaginal bleeding.,Classically, the absence of abdominal pain and uterine contractions has been use

20、d to distinguish placenta previa from placental abruption.,some women with placenta previa have painful uterine contractions in addition to bleeding, thus the diagnosis of placenta previa must be determined by sonographic examination.,Complications,Fetal death Disseminated intravascular coagulation(

21、DIC) Postpartum hemorrhage Acute renal failure Amniotic fluid embolism,Affect to mother and fetus:,Mother: anemia, cesarean section rate, postpartum hemorrhage rate, the incidence of DIC. Fetus: acute distress, neonatal asphyxia, iatrogenic preterm labor, fetal mortality increasing and neonatal mort

22、ality increasing,Treatment,Emergency measures (antishock) Blood and fluid transfusion: fresh blood Antishock measures Prevention renal failure: supply blood volume (urine volume30ml/h) Detection and correction of coagulation disorders.(RBC, blood plasma, PLT, cryoprecipitate etc.),2. Terminate pregn

23、ancy in time (1)Cesarean section Indication Fetal distress in degree placental abruption Pregnancy with degree placental abruption can not be terminated in short term by vaginal delivery. Pregnancy with degree placental abruption can not be terminated immediately by vaginal delivery, whose condition

24、 get worse and the fetus is dead. Failed trial of labor,(2)Vaginal delivery Indication: Separation is limited, fetus is safe, cervix has dilated, pregnancy can be terminated in short term. Induction of labor Artificial rupture of membrane Carefully observe heart rate, blood pressure, uterine height, vaginal bleeding and the fetal condition.,3.Treatment the complications Postpartum hemorrhage: oxytocin, carboprost tromethamine injection, uterine massage; Coagulation disorders: promptly terminate pregnancy, correct the coagulation disorders (1) supplement blood v