妇产科学教学课件：13 Placental Abruption

PlacentalAbruptionGeneralConsiderationDefinition

separationofthenormallylocatedplacentaafterthe20thgestationalweekandpriortobirth.Incidence

0.51%-2.33%(ourcountry)0.5%(othercountries)Incidenceoffetaldeath

200‰-350‰ThemostimportantcauseofvaginalbleedinginlatepregnancyCauseofbleedingproportionPlacentalAbruption31.7%Placentaprevia12%Lesionofcervix7%FactorsofCord1%Nocause40%SeverecomplicationofpregnancyCausesofhemorrhageNumber(%)PlacentalAbruption141(19)Laceration/uterinerupture125(16)Uterineatony115(15)Coagulopathies108(14)Placentaprevia50(7)Placentaaccreta/increta/percreta44(6)Uterinebleeding47(6)Retainedplacenta32(4)Causesof763pregnancy-relateddeathsduetohemorrhage1999EtiologyUncertain(primarycause)RiskfactorsVasculardiseases:preeclampsia,chronichypertension,renaldisease.Mechanicalfactors:abdomenstrick,intercourse,extremeshortnessofumbilicalcord（脐带过短）amniocentesis（羊膜穿刺术）

uterinevolumesuddenlynarrowanduterinecavitypressuredrop：ruptureofmembranewhenpolyhydramnios（羊水过多）IncreasedageandparitySuddenincreaseinuterinevenouspressure：Supinehypotensivesyndrome（仰卧位低血压）other：Smoking,cocaineuse,uterinemyoma，RacePathologyMainchange

hemorrhageintothedeciduabasalis→deciduasplits→decidualhematoma→separation,compression,destructionoftheplacentaadjacenttoitTypesrevealedabruptionconcealedabruption,mixedtypeUteroplacentalapoplexy子宫胎盘卒中TypesrevealedabruptionconcealedabruptionmixedtypeUteroplacentalapoplexy

Bleedingintothemyometriumoftheuterusgivingadiscoloredappearancetotheuterinesurface.AdjunctiveExaminationUltrasonographyPositionofplacenta,severityofabruption,survivaloffetusSigns:retroplacentalhematomaNegativefindingsdonotexcludeplacentalabruptionLaboratoryexaminationconsumptivecoagulopathy:Rt,DICFunctionofliverandkidney.Manifestation

VaginalbleedingalongwithabdominalpainMildtypeabruption≤1/3,apparentvaginalbleedingSeveretypeabruption>1/3,largeretroplacentalhematoma,vaginalbleedingcompaniedbypersistentabdominalpain,tendernessontheuterus,changeoffetalheartrate.shockandrenalfailure.0IIIIIIdefinedbypostpartumcheckplacentaabruptionarea<1/3

abruptionarea1/3

abruptionarea>1/2NoorlitterbleedingnoabdominalpainNo→moderatevaginalbleedingabdominalpainNo→severevaginalbleedingSeverepainuterine=gestationweeksuterine>gestationweeksuterine>gestationweeksuterinesoft，noorlittertenderness

moderate→severeuterinetenderness,maybeassociatedwithankylosingcontractionsseverepainwithankylosinguterusMaternalbloodpressureandheartrateisnormalMaternaltachycardia,bloodpressureandheartratechangesMaternalshockNocoagulationdisordersLowfibrinogenemia(150-250mg/dL)Hypofibrinogenemia

<150mg/dLCoagulationdisordersNoFetaldistressFetaldistress，fetusaliveFetaldeathDiagnosissignandsymptomVaginalbleedingUterinetendernessorbackpainFetaldistressHighfrequencycontractionsHypertonus(高张力)IdiopathicpretermlaborFetaldeathDiagnosisUltrasonographyDifferentialdiagnosisPlacentaprevia：Painlessbleedingthreatenedruptureofuterus：dystociaComplicationDICandcoagulationdisordersHypovolemicshockAmnionicfluidembolism（羊水栓塞）AcuterenalfailureFetaldeathTreatmentTreatmentwillvarydependingupongestationalageandthestatusofmotherandfetusTreatmentofhypovolemicshock:intensivetransfusionwithbloodAssessmentoffetusTerminationofpregnancy:CSorVaginaldeliveryTreatmentofhypovolemicshockGeneraltreatmentoxygenuptakewithoxygenmaskQuicklymakeupthevolume:

bloodloss,estimatedphysiologicalneedTherehydrationselect:freshwholebloodorplasmaCorrectiveshockindicators

thehematocrit≥30%urinevolume≥30ml/h,bloodpressureandheartratestableTerminationofpregnancyMaternalconditionisgood,estimatedaquicklychildbirthImmediateruptureofmembraneShortenthesecondstageoflaborManualremovaloftheplacentaPreventionofpostpartumhemorrhage:

massagetheuterus,contractionagentVaginaldeliveryCesareansectionSeveretype，impossiblydeliveryinashorttimeMildtypebutwithfetaldistress;Thelaborprogression:noPreventionofbleedingUteroplacentalapoplexytreatmentTerminationofpregnancyTreatmentofDIC

Timely,adequateinputoffreshblood.Infusionoffreshplateletconcentrates.Givefibrinogen:Averageamountof3-6gInfusionoffreshplasma:theadditionoffibrinogen,VIIIfactorTheapplicationofheparin:TheantifibrinolyticdrugapplicationMakeupthevolumeDrug:

20%mannitolof250m1rapidintravenousfurosemide40mgintravenousDialysistherapyTreatmentofAcuteRenalFailureWhenurine

<

17mlornourine,renalfailuremayoccured.CaseDiscussion病史患者，女，45岁，2001年12月4日12:10入院因“停经8月余，抽搐2次，神志不清3小时”入院。平素月经不详，LMP：2001年4月？。孕期未行产前检查。3小时前突然倒地，口吐白沫，神志不清，四肢抽搐（持续5分钟）。即刻送当地中心医院，查体发现血压176/90mmHg，双侧瞳孔增大，对光放射存在，皮肤黄染，心肺正常，双下肢水肿（＋＋）。拟诊“重度妊高征，子痫”而给予硫酸镁、降压药等治疗。在诊治过程中又抽搐一次，持续10分钟。因病情危重，治疗效果不佳，转入我院。26岁时曾患甲肝，生育史：1-0-0-1，顺产。体检T:37℃;BP:200/110mmHg;P:108;R:28神志不清，面色萎黄，全身皮肤中度黄染，浅表淋巴结无肿大。双侧瞳孔轻度扩大，对光反射存在，心率108次/分，律齐，未及杂音。呼吸有鼾声，肺部听诊无异常。妊娠腹，腹壁软，肝脾未及。宫高29.5cm，腹围93cm，FHR:150-157次/分，子宫壁张力较高，胎位不清，宫缩20秒/5-10分钟。双下肢水肿（＋＋），膝反射亢进，病理性反射未引出。阴道检查：阴道有暗红色血液流出，量100ml，宫口3cm，胎膜未破，先露头－2。留置导尿见尿量约100ml，淡酱油色。辅助检查血常规：WBC:18.4×109/L;N:84.7%;RBC:4.2×1012/L;Hb:137g/L;PLT:59×109/L;HCT:39.4%;尿蛋白4+。电解质：K3.45mmol/L;Na134mmol/L;Cl80mmol/L肝肾功能:LDH:2185U/L;sGPT:310U/L;sGOT:751U/L;AKP:237U/L;总胆红素:179.3umol/L;直接胆红素:120.9umol/L;血氨:169umol/L;血糖:6.7mmol/L;肌酐:55umol/L;尿酸:577umol/L;尿素氮:5.9umol/L。D二聚体弱阳性;FDP(+)产科B超：宫内见一活胎，双顶径8.1cm，胎盘II级，位于前壁，羊水指数13.7cm，胎盘与子宫壁之间见一液性暗区，大小