胎儿窘迫、子宫破裂、产后出血PPT课件

1、 教学内容教学内容n胎儿窘迫、子宫破裂、产后出血胎儿窘迫、子宫破裂、产后出血 约约2学时学时n脐带异常脐带异常 、羊水量异常、早产、羊水量异常、早产、胎膜早破、过期妊娠、多胎妊娠胎膜早破、过期妊娠、多胎妊娠 约约1学时自学学时自学n浙江大学医学院附属妇产科医院浙江大学医学院附属妇产科医院 产科产科 Tel：Post Partum Hemorrhage Uterine Rupture, Fetal DistressWomen Hospital , School of Medical, ZheJiang University Wang Zheng Ping Post partum hemorrha

2、ge Post partum hemorrhagenPast partum hemorrhage denotes excessive bleeding (500ml in vaginal delivery) during the first 24 hours after delivery Cesarean section 1000mlnCommon cause of death and diseases in pregnant women globallynLeading cause of death in pregnant women in ChinanIncidence 2%-3% of

3、total number of deliveriesEtiologynUterine atony: 70%nObstetric lacerations: 20%nRetained placental tissue: 10%nCoagulation:1% Uterine atonynGeneral factors: extreme nervousness, weak， severe anemianObstetric factors: prolonged labour, placenta previa, placenta abruptionUterine factors: uterine musc

4、ular fiber underdevelopment, such as uterine deformity or myoma; uterine overstretched, such as macrosomia, multiple pregnancy, polyhydramnios nDrug factors: sedative, anesthesia, tocolytics Placental factorsnRetained placenta nPlacental incarceration（嵌顿嵌顿 ）nIncomplete placental separationnPlacental

5、 adhesionnPlacental implantation (accreta, increta, percreta)nResidual placenta and amniotic membraneImplantation of placentaBirth canal injurynLaceration during labour are usually associated with:Poor vulval elasticityStrong labour force, emergency delivery, macrosomiaInadequate skills at assisted

6、vaginal deliveryInadequate cessation of bleeding during episiotomy repair, missing out tears at cervix or fornices Coagulation disordernComplications associated with obstetric: amniotic fluid embolism, pregnancy induced hypertensive diseases, placenta abruptio and intrauterine demisenPregnancy liver

7、 disease: acute fatty liver, severe hepatitisnHematology diseases: primary thrombocytopenic purpura, aplastic anemia etc Clinical presentationnVaginal bleeding:If bleeding occurs immediately after delivery of baby, consider birth canal injuryIf bleeding occurs minutes after delivery of baby, conside

8、r placenta factorsIf bleeding occurs minutes after delivery of placenta, main reasons are uterine atony or retained products of conceptionPersistent bleeding and blood do not coagulate, consider coagulation disorder Clinical presentationnRecessive bleeding：Vaginal hematoma, Hematocele of uterine cav

9、ity , etcnShock: dizziness, paleness, weak pulse, low blood pressure etc Diagnosis nEstimation of blood lossnAscertain cause of post partum hemorrhage Estimation of blood lossnVisual observation: only 50%-70% of blood lossnContainer: kidney dish, measuring cupnSurface area: blood stained 10cmx10cm =

10、 10mlnWeighing: 1.05g = 1mlnShock index = pulse rate/systolic pressurenHct1000mlnHourly urine output 2500ml Shock index (SI)nSI =0.5, normal blood volumenSI = 0.5-1, blood loss 160bpm; during severe hypoxia 110bpmCST shows late deceleration, severe variable decelerationfetal heart rate 100bpm, with

11、frequent late decelrations indicating severe fetal hypoxia, may die intrauterine any moment Late deceleration Variable deceleration Diagnosis of acute fetal distressnMeconium stained amniotic fluid: green color, dirty, thick and little volumeI degree: light green, II degree: yellowish green, dirty,

12、III degree:brownish yellow, thick Diagnosis of acute fetal distressnFetal movement: early stage frequent fetal movement, subsequently reduced to absentnFetal acidosis: fetal scalp blood analysispH 7.2 (normal 7.25 7.35)PO2 60mmHg (normal 35 55mmHg)Diagnosis of chronic fetal distressnReduced or absen

13、t fetal movementnAbnormal fetal monitoringnLow fetal biophysical profile scoringnAbnormal umbilical artery blood flow nMeconium stained amniotic fluidReduced or absent fetal movementnReduced fetal movement 6 times/2 hours, 50% drooprate nHeart beat disappears：usually 24 hours after absent of fetal m

14、ovement fetal nNormal fetal movement count: 30-100 times/12hours Abnormal fetal electronic monitoringnNST is known as non-reactive type, during 20 minutes continuous fetal movement fetal heart rate acceleration15bpm, sustaining15s, baseline variability 5bpmnOCT frequent severe variable decelerations

15、 or late decelerations are seen Low biophysical profile scoringnBased on ultrasound assessment of fetal body movement, breathing movement, flexor tone, amniotic fluid volume, couple with fetal electronic monitoring NST results combined scoring (each variable score 2, total score is 10) nScore 3 indi

16、cates fetal distress, score 4-7 suspicious fetal hypoxiaAbnormal umbilical artery blood flownumbilical artery diastolic blood flowreducing absence inversion Meconium stained amniotic fluidnAmnioscopy examination shows dirty amniotic fluid in light green or brownish yellow color Management nAcute fet

17、al distress: emergent treatmentnChronic fetal distress: management plan depends on severity of the pregnancy complications, gestational age, fetal maturity, fetal distress condition Management of acute fetal distressnGive oxygen: face mask or nasal prong continuous oxygen at 10L/min flownSearch for

18、cause, active managementsupine hypotensive syndrome：lie the patient on left lateral positionexcessive oxytocin leading to uterine hyperstimulation：stop oxytocin immediatelyuse tocolytics when necessary Management of acute fetal distressTerminate pregnancy soonest possible:qCervix not fully dilated w

19、ith the following conditions, immediate caesarean section:(1)fetal heart rate 180bpm, accompanied by II degree meconium stained amniotic fluid(2) CST or OCT shows frequent late decelerations or severe variable decelerations, sine wave (3) fetal scalp blood pH 7.20(4) III degree meconium stained amni

20、otic fluid, with low amniotic fluid amount Management of acute fetal distressqFully dilated cervix: fetal biparietal diameter, has descend below ischial spines, perform assisted vaginal deliverynPrepare for newborn resuscitation Management of chronic fetal distressnRoutine management: left lateral position, give oxygen regularly (30mins, 2-3times/day)nActive treatment of pregnancy complications nTerminate pregnancy: pregnancy nearing term with less fetal movement or OCT shows late decelerations, s