3妇产科xiaodong-2013七年制择译

1、1Placenta previa前置胎盘 and Abruptio placenta胎盘早剥Xiaodong LuoDepartment of Obstetrics and Gynecology, the Second Affilate Hospital，ChongQing University of Medical Science2Placenta previaDefinition the placenta is implanted partially or completely over the lower uterine segment 子宫下段within the zone of ef

2、facement and dilatation of the cervix. After 28 weeks3Placenta previa is an obstetric complication 。 in the second and third trimesters of pregnancy. serious morbidity and mortality to both the fetus and the mother. causes of vaginal bleeding4Incidenceapproximately 1 in 200 deliveries and only 20% a

3、re total 90% of patient will be parous经产妇 the major reason of hemorrhage in the third trimester pregnancy 5EtiologyThe condition may be multifactorial 多因素的multiparity多产, multiple gestations多胎, advanced maternal age高龄产妇, previous cesarean delivery曾剖腹产, previous abortion, and possibly, smoking. 61.sca

4、rred or poorly vascularized endometrium in the uterine corpus宫体血供差Endometrial scarring in the upper segment of the uterus - initial trophoblastic nidation着床 - relatively unscarred lower uterine segment or growth toward the unscarred lower uterine segment. 72. large placenta twin pregnancy increased

5、placental surface area - a reduction in uteroplacental子宫胎盘的 oxygen or nutrient delivery.83.Abnormal forms of placenta异常胎盘4.The retardation of zygote 受精卵growth9ClassificationComplete or central placenta previa中央前置胎盘（或完全前置胎盘）Partial placenta previa部分前置胎盘Marginal placenta previa边缘前置胎盘10111213Clinical m

6、anifestation1.Vaginal bleeding阴道流血Characters: Painless, in the third trimester, sudden onset, causeless无诱因的, recurrent, Unrelated to activity, often occurs during sleep14(2)Reasons:Mechanical separation机械分离 Formation of the lower segment or effacement and dilatation of cervix15Note: placenta lies in

7、 the posterior portion of the lower uterine segment-difficult to ascertain子宫后壁的前置胎盘不易确诊. transvaginal ultrasonography transabdominal approach.16(3)The time of onset of bleeding, the amount , the frequency is related to type of placenta previatypeonsetamountFrequencyCentralEarlier, 28th weekSevere, s

8、hockmorePartial Between central and marginalbetween central and marginalMarginal Late, 3740 weeksslightless17note:A few nulliparous patients初产妇 even reach term without bleeding.182.Signs: Anemia and shock Abdominal examUterus ：soft ,relaxed ,and nontender无压痛.The infant will present in an oblique斜位 o

9、r transverse lie横位 in about 15% of cases. No evidence of fetal distress 胎儿窘迫193.Ultrasonographythe diagnosis of placenta previa is based upon results of ultrasound examination.A simple, precise, and safe method to visualize the placenta, accuracy rate is over 95%20Diagnosis1.Clinical symptoms and si

10、gns2.Sonography: rapid, simplest, precise, safest3.Diagnoses in parturition分娩(1)Cesarean section剖宫产(2)Vaginal delivery阴道分娩21Differential diagnosis1. Cord velamentous insertion脐带帆状附着2. Rupture of the marginal sinus边缘窦破裂223.Abruptio Placenta Abruptio Placenta is the other major cause of vaginal bleedi

11、ng in pregnancy4. Bleeding of cervix and vagina23ComplicationsMaternal:Postpartum hemorrhage, shock, death Puerperal infection产褥感染Placenta increta植入性胎盘Amniotic fluid embolism 羊水栓塞Fetus:Preterm delivery早产Perinatal mortality rate is increased24TreatmentPrinciple: Tocolysis保胎, hemostasis止血, correct ane

12、mia, prevent infectionblood transfusion, terminate the pregnancy in time适时终止妊娠,25amount of uterine bleeding the duration pregnancy and viability of the fetus the degree of placenta previa the presentation, and position of the fetus the gravidity and parity of the patientthe status of the cervix whet

13、her or not labor has begun. 261.Terminate the pregnancy(1)Cesarean sectioncomplete, partial previa delivery at 36 weeks, fetal lung maturity. Incision of the placenta should be avoided切口应避免胎盘27(2)Vaginal deliveryVaginal delivery may be attempted when the placenta is marginal because the risk of hemo

14、rrhage is much lower.Delivery ended soon after282.Expectant therapy期待疗法: hospitalizationThe initial hemorrhage of placenta previa may occur before pulmonary maturation is established. In such cases, fetal survival can often be enhanced by expectant therapy. 29Symptomatic women are often hospitalized

15、 from their initial bleeding episode until delivery.30The degree of bleeding and the maturity of the fetus must be constantly weighted in managing these patients.313.Prevent and treat postpartum hemorrhageManual removal of the placenta胎盘完全取出 Reinforce the uterine contraction加强宫缩Mattress suture 褥式缝合U

16、terine Packing 宫腔填塞Ligation of the uterine arterySelective arterial embolizationHysterectomy子宫切除4.Correct anemia and prevent infection32PreventionContraception and avoid prolificacy多产To avoid inflammation and trauma in curettage or suction evacuation真空吸引术Antenatal care and educationTo diagnose and t

17、reat the hemorrhage in pregnancy in timeTo diagnose early and treat rightly33Major Clinical manifestation bleeding Painless, in the third trimester, sudden onset, causeless, profuse, recurrent34Reasondevelopment of the lower uterine segment increasing presence of uterine contractions, which dilate a

18、nd efface the cervix宫颈消失. Changes in the cervix and lower uterine segment resulting in placental detachment分离. 35Placenta abruptionDefinitionOccurs after 20th weeks, premature separation of the normally situated placenta正常位置胎盘 before delivery of fetus36 occurs in about one out of every 500-750 deliv

19、eries. The fetal mortality rate depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality.37peels away from the inner wall of the uterus before delivery deprive the baby of oxygen and nutrients heavy bleeding in the mother. mother and baby in

20、jeopardy危险.38Etiology vascular lesion：PIH eclampsia妊娠子痫 vascular sclerosis spasm血管硬化痉挛 Local vascular injury vascular rupture into decidual basalis bleeding, hematoma formation shears off adjacent denuded vessels相邻血管继而剥离 producing further bleeding and enlargement of separated area trauma or injury t

21、o the abdomen an unusually short umbilical cord Sudden uterine pression突然的子宫降压：rapid loss of the fluid in the uterus (amniotic fluid39 Abrupt rise in uterine venous pressure to intervillous space绒毛间隙 congestion of venous bed separation of placenta4041Predisposing factorsPrevious placental abruption.

22、 High blood pressure. Blood-clotting disorders凝血障碍. Multiple pregnancy. Substance abuse药物滥用. 42Advanced maternal ageUterine distention Vascular deficiency or deterioration Multiparity Uterine anomalies or tumors43Pathological changesbleeding to decidual basalishematoma of separationretroplacenta 44R

23、evealed or external bleeding显性出血： the complications are fewer and less severe.45concealed or internal placental abruption隐形剥离 The hemorrhage is confined within the uterine cavity, detachment 分离of the placenta may be complete,and the complications are often severe.Mixed type concealed or internal pla

24、cental abruption The placenta marginal plete 4647A Utero-placental apoplexy子宫胎盘卒中 ( Couvelaire uterus) the placental margins remain adherent, hemorrhage that infiltrates the uterine wall. Uterine tetany follows extensive intra myometrial bleeding子宫肌层大量出血 -purplish and copper-colored, ecchymosis蓝紫色或赤

25、褐色瘀斑loses its contractile power because of disruption of the muscle bundles.48DIC：disseminated intravascular coagulation . The mother may then develop a widespread petechiae出血点, active bleeding，shock, and failure of the normal clotting mechanism. Acute renal failure：acute renal cortical and tubular

26、necrosis The likelihood of fetal hypoxia and fetal death depends on the amount and duration of placenta separation and, in severe cases, the loss of a significant amount of fetal blood.4950Clinical findings and diagnosispatients report of her symptoms physical examination performed.tested to evaluat

27、e the possibility of life-threatening problems with the mothers clotting system.511. Symptoms and signsbegin anytime after 20 weeks of pregnancy. Classic signs and symptoms of placental abruption depending on the site and extent of bleeding, there are 2 grades: mild, severe clinical findings corresp

28、ond 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.52Symptoms mildbleeding from the vaginaNo pain in the abdomen or backUterus：softFetal：normal5354severebleeding from the vagina or no bleeding se

29、vere pain in the abdomen or backtenderness of the uterusAbdominal and back pain often begin suddenly. The amount of vaginal bleeding can very greatly. The amount of blood doesnt necessarily correspond to how much of the placenta has separated from the inner wall of the uterus.55Concealed隐形剥离: no vis

30、ible vaginal bleedingbleeding is trapped behind the placentableeding into the muscle of the uterus. abnormal contractions of the uterus, particularly extremely hard, prolonged contractions. 56mother symptoms of organ failure as her organs are deprived of oxygen.a drop in blood pressure57Laboratory f

31、indingsBlood cell and coagulation testPeripheral blood smear外周血涂片Clot observation test58Laboratory testing 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 th

32、e fetus.593.Ultrasoundhelp identify possible sources of vaginal bleeding. diagnose an abruption high rate of missed or incorrect diagnoses rule out placenta praevia60Complication Hemorrhagic shock Consumptive coagulopathy消耗性凝血病Uterine apoplexy子宫卒中Ischemic necrosis of distant organsPreterm laborFetal

33、 distress and fetal mortality increasingAmniotic fluid embolism61Treatment Emergency measuresBlood and fluid transfusion: fresh bloodAntishock measuresPrevention renal failure: supply blood volumeDetection and correction of coagulation failure622. Cesarean sectionIndicationFetal distress without imp

34、ending delivery未临产 Severe and moderate abruption, threatening the life of motherUterine apoplexyFailed trial of labor63Vaginal deliveryIndication:Separation is limited, fetus is safeSeparation is extensive but fetus is deadInduction of labor Artificial rupture of membrane人工破膜64Differential diagnosisAbruptio placenta(severe)Placenta previaHistory Hypertension, renal disease, traumaNo any c