placentalabruption胎盤早剝――婦產(chǎn)科學(xué)課件

,單擊此處編輯母版標(biāo)題樣式,*,單擊此處編輯母版文本樣式,第二級,第三級,第四級,第五級,單擊此處編輯母版標(biāo)題樣式,單擊此處編輯母版文本樣式,第二級,第三級,第四級,第五級,*,單擊此處編輯母版標(biāo)題樣式,單擊此處編輯母版文本樣式,第二級,第三級,第四級,第五級,*,*,胎盤早剝（,placental abruption）,胡婭莉,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部分從子宮壁分離，稱胎盤早剝。,發(fā)病率,占分娩總數(shù)的0.51%-2.33%,ABRUPTIO PLACENTA,Premature separation of the normally implanted placenta,Occurs in approximately 1 in 120 births,Accounts for 15%of perinatal mortality,病因,與下列因素有關(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，引起遠端缺血壞死，底蛻膜與胎盤之間出血、血腫。,病因,2、,機械因素：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。,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。,RISK FACTORS,Chorioamnionitis,Maternal hypertension(140/90),Previous abruption,Placental insufficiency,Trauma-blunt abdominal,Rapid decompression of the overdistended uterus(twins,polyhydramnios),病理變化,1、底蛻膜出血，形成血腫，使該處胎盤與宮壁分離。如出血少，剝離面小，血液很快凝固，常無明顯臨床癥狀。,2、,如繼續(xù)出血，胎盤剝離面擴大，血液可沖開胎盤邊緣，往外流出,顯性出血,（,revealed abruption）,3、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)隱性出血到達一定量，最終沖開胎盤邊緣向外流出，稱,混合性出血,（,mixed abruption）。,病理變化,5、子宮胎盤卒中（,uteroplacental apoplexy）,胎盤早剝尤其是隱性剝離，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，子宮表面紫藍色瘀斑，腹腔液呈血性。,血性羊水 胎盤后血腫血液滲入羊膜腔。,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。,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。,GRADE I,:,slight vaginal bleeding,uterine irritability,normal maternal blood pressure,normal maternal fibrinogen,normal fetal heart rate pattern,Often diagnosed at delivery with placental clot,GRADE II:,mild to moderate bleeding,irritable uterus with tetanic contractions,normal BP,elevated pulse rate,reduced fibrinogen level(150-250),fetal distress,GRADE III,:,moderate to severe bleeding(may be concealed),tetanic and painful uterus,maternal hypotension,FETAL DEATH,GRADE III,Grade III a:without coagulopathy,Grade III b:with coagulopathy,fibrinogen reduced to less than 150 mg%with other overt signs of coagulopathy,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，胎位清楚，胎心多正常。,有時診斷依靠產(chǎn)后胎盤檢查胎盤后壓跡。,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。,癥狀：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。,PATIENT HISTORY,Pain,Varies from mild cramping to severe pain,Back pain,think posterior abruption,Bleeding,May not reflect true amount of blood loss,Trauma,Other risk factors,PHYSICAL EXAM,Signs of circulatory instability,Mild tachycardia normal,Maternal hypotension,never,normal,urine output,Shock represents 30%blood loss,Maternal abdomen,Fundal height,Location of tenderness,Tetanic contrations,ULTRASOUND,Diagnostic for abruption in,less than 5%of case,-helpful in,ruling-out,other causes,Location:prognostic indicator of fetal outcome,Subchorionic:placenta-membranes,Retroplacental:placenta-myometrium,Preplacental:placenta-amniotic fluid,ULTRASOUND SIGNS,Retroplacental echolucency,Thickening of the placenta,Abnormally round“torn edge”,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,！,實驗室檢查：,RBC、HB、,尿常規(guī)、肝腎功能,DIC,檢查,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。,鑒別診斷,1、前置胎盤；,2、先兆子宮破裂,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,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？,補充凝血因子,抗纖溶,處理,4、,防腎功能衰竭：,防,DIC；,防低血容量休克；,治腎功能衰竭:,高血鉀處理,尿毒癥處理,酸中毒處理,?,HISTORY,Past OB History,Prior episodes of bleeding,Abdominal pain,Uterine Contractions,Recent intercourse,Tobacco/Substance Abuse,Past Medical History,結(jié)束語,當(dāng)你盡了自己的最大努力時，失敗也是偉大的，所以不要放棄，堅持就是正確的。,When You Do Your Best,Failure Is Great,So DonT Give Up,Stick To The End,謝謝大家,榮幸這一路，與你同行,ItS An Honor To Walk With You All The Way,演講人：,XXXXXX,時 間：,XX,年,XX,月,XX,日,