胎盘早剥与前置胎盘

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•熟识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GeneralConsiderationDefinitionTheseparationoftheplacentafromitssiteofimplantationafter20weeksofgestationorduringthecourseofdelivery.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）•子宫静脉压突然上升•子宫体积突然缩小【病因】未明EtiologyUncertain(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）PathologyMainchangehemorrhageintothedeciduabasalis→deciduasplits→deciduralhematoma→separation,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DICHypovolemicshockAmnionicfluidembolismAcuterenalfailureComplication【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、猛烈子宫软，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，胎心音特别腹部检查【常用帮助检查】•B超•实验室检查——贫血程度、凝血功能、肝肾功能等DiagnosissignandsymptomVaginalbleedingUterinetendernessorbackpainFetaldistressHighfrequencycontractionsHypertonusIdiopathicpretermlaborDeadfetusDiagnosisUltrasonographyDifferentialdiagnosisPlacentapreviaPainlessbleedingPre-ruptureofuterusdystocia【处理原则】•补充血容量，防治休克；准时终止妊娠，防治并发症•终止妊娠方法——剖宫产——阴道分娩TreatmentTreatmentwillvarydependingupongestationalageandthestatusofmotherandfetusTreatmentofhypovolemicshock:intensivetransfusionwithbloodAssessmentoffetusTerminationofpregnancy:CSorVaginaldeliveryTreatmentTreatmentofconsumptivecoagulopathySupplementofcoagulationfactors:freshblood,frozenbloodplasma,fibrinogen,bloodplatelet.Heparin:highcoagulationAnti-fibrinolysisPreventionofrenalfailureThankyou!!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,询问?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掩盖宫颈内口，其位置低于胎儿先露部，称为前置胎盘

定义(Definition)

DefinitionPlacentaprevia:Abnormallocationoftheplacentaover,orincloseproximitytotheinternalos.(after28weeks)Incidence:

approximately1/250pregnancy

EtiologyMechanism:

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ClassificationComplete(total)placentaprevia:

entirecervicalosiscoveredPartialplacentaprevia:themarginoftheplacentaextendsacrossbutnotalloftheinternalos.Marginal:edgeoftheplacentaliesadjacenttotheinternalosLowlyingplacenta:placentaislocatednearbutnotdirectlyadjacenttotheinternalos.ClassificationdiagnosisPainlessvaginalbleed:

firstbleedingepisodeis29~30weeksUltrasonography: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缘由引起的产前出血CautionDoublesetupvaginalexaminationNodigitalvaginalorrectalexaminationispreformedincaseofplacentaprevia.Onlyasafinalanddefinitiveeventandonlyunderconditionsofdoublesetup.Thisprocedureinvolvescarefulevaluationofthecervixintheoperationroomwithfullpreparationsforrapidcesareansection.处理Treatment

原则：止血补血，预防感染方法；期盼疗法

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.ManagementBasicmanagementInitialhospitalizationwithhemodynamicstabilizationEnforcedbedrestRestrictionsofactivityExpectantmanagement

(allowforfurtherfetalgrowthandmaturation)BloodtransfusionisgivenasnecessaryAmniocentesisforfetallungmaturitytestingCesareanbirthiffetusisthoughttobematureIndicationofvaginaldeliveryDeliverycanbeaccomplishedwithminimalbloodlossFetusisdeadMa