婦產(chǎn)科學(xué)--胎盤早剝placental abruption課件

1、胎盤早剝placental abruption胡婭莉1定義妊娠20周后或分娩期，正常位置的胎盤于胎兒娩出前全部或局部從子宮壁別離，稱胎盤早剝。2發(fā)病率占分娩總數(shù)的0.51%-2.33%3ABRUPTIO PLACENTAPremature separation of the normally implanted placentaOccurs in approximately 1 in 120 birthsAccounts for 15% of perinatal mortality4病因與以下因素有關(guān)：1、孕婦血管病變: 胎盤早剝多發(fā)生于妊高征、慢性高血壓、慢性腎炎，子宮蛻膜螺旋小動脈痙攣，引

2、起遠(yuǎn)端缺血壞死，底蛻膜與胎盤之間出血、血腫。5病因2、機(jī)械因素： 腹部外傷或性交、外倒轉(zhuǎn)術(shù)、臍帶過短、羊水過多突然破水或雙胎第一胎兒娩出過快。67病因3、子宮靜脈壓升高： 平臥位，子宮壓迫下腔靜脈，使回心血量減少，子宮靜脈壓增高，導(dǎo)致蛻膜靜脈破裂胎盤早剝。4、高齡孕婦、多產(chǎn)婦、吸煙、酗酒、胎盤附著于子宮肌瘤部位者。8RISK FACTORSChorioamnionitisMaternal hypertension (140/90)Previous abruptionPlacental insufficiencyTrauma-blunt abdominalRapid decompression

3、of the overdistended uterus (twins, polyhydramnios)9病理變化1、底蛻膜出血，形成血腫，使該處胎盤與宮壁別離。如出血少，剝離面小，血液很快凝固，常無明顯臨床病癥。102、如繼續(xù)出血，胎盤剝離面擴(kuò)大，血液可沖開胎盤邊緣，往外流出顯性出血revealed abruption3、如胎盤邊緣未與宮壁分開，血液全部積在胎盤與子宮壁之間隱性出血concealed abruption。4、當(dāng)隱性出血到達(dá)一定量，最終沖開胎盤邊緣向外流出，稱混合性出血mixed abruption。11病理變化5、子宮胎盤卒中uteroplacental apoplexy胎盤早

4、剝尤其是隱性剝離，胎盤后血腫不斷增大,宮腔壓力增加,血液滲入子宮肌層,造成肌纖維斷裂、變性。當(dāng)血液滲入子宮漿膜層時(shí)，子宮外表紫藍(lán)色瘀斑，腹腔液呈血性。血性羊水 胎盤后血腫血液滲入羊膜腔。12病理變化6、急性DIC： 早剝的胎盤絨毛及壞死蛻膜釋放大量組織凝血活酶，引起彌漫性血管內(nèi)凝血：出血、休克、器官功能障礙、微血管病性溶血。13臨床表現(xiàn)及分類Sher 1985年將胎盤早剝分3度；我國分輕重兩型，輕型相當(dāng)于Sher度，重型相當(dāng)于、度。14GRADE I:slight vaginal bleedinguterine irritabilitynormal maternal blood pressur

5、enormal maternal fibrinogennormal fetal heart rate patternOften diagnosed at delivery with placental clot15GRADE II:mild to moderate bleedingirritable uterus with tetanic contractionsnormal BPelevated pulse ratereduced fibrinogen level (150-250)fetal distress1617GRADE III:moderate to severe bleeding

6、 (may be concealed)tetanic and painful uterusmaternal hypotensionFETAL DEATH18GRADE IIIGrade III a: without coagulopathyGrade III b: with coagulopathyfibrinogen reduced to less than 150 mg% with other overt signs of coagulopathy19臨床表現(xiàn)及分類1、輕型: 胎盤剝離面積胎盤總面積1/3,以外出血為主,無明顯腹痛,貧血程度與外出血量呈正比。子宮軟，如臨產(chǎn)能分辨宮縮，胎位清

7、楚，胎心多正常。有時(shí)診斷依靠產(chǎn)后胎盤檢查胎盤后壓跡。20臨床表現(xiàn)及分類2、重型 胎盤剝離面積胎盤總面積1/3,多內(nèi)出血或混合出血。病癥：常突然腹痛、或腰背痛，惡心嘔吐、面色蒼白、大汗。體征：嚴(yán)重貧血貌但外出血量少。血壓下降、脈搏細(xì)速，子宮板狀、壓痛以胎盤剝離處為著，子宮大于妊娠月份，如臨產(chǎn)不能分辨宮縮，胎位不清，胎盤剝離面1/2，胎心常消失。21PATIENT HISTORYPainVaries from mild cramping to severe painBack painthink posterior abruptionBleedingMay not reflect true amou

8、nt of blood lossTraumaOther risk factors22PHYSICAL EXAMSigns of circulatory instabilityMild tachycardia normalMaternal hypotension never normal urine output ,Shock represents 30% blood lossMaternal abdomenFundal heightLocation of tendernessTetanic contrations23ULTRASOUNDDiagnostic for abruption in l

9、ess than 5 % of case-helpful in ruling-out other causesLocation: prognostic indicator of fetal outcomeSubchorionic: placenta-membranesRetroplacental: placenta-myometriumPreplacental: placenta-amniotic fluid24ULTRASOUND SIGNSRetroplacental echolucencyThickening of the placentaAbnormally round “torn e

10、dge2526輔助檢查B型超聲檢查 子宮壁與胎盤之間可能見血腫；胎盤絨毛板凸向羊膜腔；胎盤正常結(jié)構(gòu)消失。B超陰性不排除胎盤早剝！實(shí)驗(yàn)室檢查：RBC、HB、尿常規(guī)、肝腎功能DIC檢查27診斷1、病史：妊娠20周后有“誘因的陰道流血、腹痛。外傷史、妊高征史。2、體征：重型者典型的體征。3、對病情嚴(yán)重程度的估計(jì)。28鑒別診斷1、前置胎盤；2、先兆子宮破裂29并發(fā)癥1、DIC；2、產(chǎn)后大出血；3、休克；4、急性腎功能衰竭；5、胎兒宮內(nèi)死亡；6、羊水栓塞30處理1、糾正休克；2、降低宮內(nèi)壓3、迅速終止妊娠：剖宮產(chǎn)？陰道分娩？4、治療DIC：肝素？補(bǔ)充凝血因子抗纖溶31處理4、防腎功能衰竭：防DIC；防低

11、血容量休克；治腎功能衰竭:高血鉀處理尿毒癥處理酸中毒處理32CASE32 y.o. G2P1 at 36 weeks .with bright red vaginal bleeding. She is in town for a family reunion, and has no medical record available.33?34HISTORYPast OB HistoryPrior episodes of bleedingAbdominal painUterine ContractionsRecent intercourseTobacco/Substance AbusePast Medical History35EXAMINATIONBP、PAssessment of uterine contractions and tendernessGentle speculum examDigital cervical exam afte