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1、胎盘早期剥离胎盘早期剥离 与与 前置胎盘前置胎盘placental abruptionplacental abruptionPlacenta pervia Placenta pervia 李爱斌 概述概述 病因病因 病理变化病理变化 临床表现临床表现 处理原则处理原则内容提要内容提要 解释解释胎盘早剥定义胎盘早剥定义 了解病因及病理变化了解病因及病理变化 掌握掌握临床表现临床表现 熟悉熟悉处理原则处理原则学习目的与要求学习目的与要求【概述概述】 胎盘早剥胎盘早剥指妊娠指妊娠2020周以后或分娩周以后或分娩 期，正常位置的胎盘在胎儿娩出前，部期，正常位置的胎盘在胎儿娩出前，部 分或全部从子宫壁剥
2、离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是严重威胁产妇及胎儿生命的并发症 围生儿死亡率高围生儿死亡率高General ConsiderationnDefinitionThe separation of the placenta from its site of implantation after 20 weeks of gestation or during the course of delivery.nFrequency0.46%-2.1% (our country)1%-2% (other countries) nIncidence of fetal death200-
3、350 血管病变血管病变 机械性因素机械性因素( (外伤、脐带过短）外伤、脐带过短） 子宫静脉压突然升高子宫静脉压突然升高 子宫体积突然缩小子宫体积突然缩小【病因病因】未明未明EtiologynUncertain (primary cause)nRisk factors1.Increased age and parity2.Vascular diseases: preeclampsia, chronic hypertension, renal disease.3.Mechanical factors: trauma, intercourse, polyhydramnios, 4.Supine
4、hypotensive syndrome5.Smoking, cocaine use, uterine myoma【病理变化病理变化】 主要病理变化是主要病理变化是底蜕膜出血底蜕膜出血 形成血肿形成血肿 胎盘自附着处剥离胎盘自附着处剥离 出血出血腹痛（持续性）腹痛（持续性）PathologynMain changen hemorrhage into the decidua basalis decidua splits decidural hematoma separation, compression, destruction of the placenta adjacent to itnTy
5、pesn revealed abruption, concealed abruption, mixed typenUteroplacental apoplexy 子宫胎盘卒中 出血形式出血形式显性出血显性出血混合性出血混合性出血隐性出血隐性出血母体母体贫血、失血性休克、贫血、失血性休克、 DICDIC、子宫卒中、产后出血、感、子宫卒中、产后出血、感 染、多脏器功能衰竭染、多脏器功能衰竭围生儿围生儿胎儿窘迫、新生儿窒胎儿窘迫、新生儿窒 息、息、RDSRDS、新生儿死亡、新生儿死亡 并发症并发症nDICnHypovolemic shocknAmnionic fluid embolismnAcute
6、 renal failureComplication【临床表现临床表现】轻型轻型 重型重型出血出血 外出血为主外出血为主 ， 内出血为主，阴道出内出血为主，阴道出量较多量较多 血少或无血少或无 腹痛腹痛 轻或无轻或无 持续性、剧烈持续性、剧烈 子宫软，轻压痛，子宫软，轻压痛， 子宫硬，压痛明显，子宫硬，压痛明显，大小与孕月相符，大小与孕月相符， 子宫大于孕月，胎位子宫大于孕月，胎位胎位、胎心清楚胎位、胎心清楚 不清，胎心音异常不清，胎心音异常腹部检查腹部检查【常用辅助检查常用辅助检查】 B B超超 实验室检查实验室检查贫血程度、凝血贫血程度、凝血 功能、肝肾功能等功能、肝肾功能等Diagnos
7、isnsign and symptomnVaginal bleedingnUterine tenderness or back painnFetal distressnHigh frequency contractionsnHypertonusnIdiopathic preterm labornDead fetusDiagnosisnUltrasonographynDifferential diagnosisnPlacenta previan Painless bleedingnPre-rupture of uterusn dystocia【处理原则处理原则】 补充血容量，防治休克；及时终补充
8、血容量，防治休克；及时终 止妊娠，防治并发症止妊娠，防治并发症 终止妊娠方法终止妊娠方法剖宫产剖宫产阴道分娩阴道分娩TreatmentnTreatment will vary depending upon gestational age and the status of mother and fetusnTreatment of hypovolemic shock: intensive transfusion with bloodnAssessment of fetusnTermination of pregnancy: CS or Vaginal deliveryTreatmentnTre
9、atment of consumptive coagulopathynSupplement of coagulation factors: fresh blood, frozen blood plasma, fibrinogen, blood platelet.nHeparin: high coagulationnAnti-fibrinolysisnPrevention of renal failureThank you!Thank you!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,咨询?PLACENTA PREVIA前 置 胎 盘
10、李爱斌正常胎盘附着位置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覆盖宫 颈内口，其位置低于胎儿先露部， 称为前置胎盘定义 (Definition) DefinitionPlacenta previa: Abnormal location of the placenta over ,or in close proximity to the internal os.(after 28 weeks )Incidence: approximately 1 /250 pregnancyEtiologyMechanism: abnormal vascularizationPre
11、disposing factors:Twin pregnancyIncreasing maternal ageIncreasing parityPrevious cesarean section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) placenta previa: entire cervical os is coveredPartial placenta previa:the margin of the placenta extends across but not all of the
12、internal os.Marginal:edge of the placenta lies adjacent to the internal osLow lying placenta:placenta is located near but not directly adjacent to the internal os.ClassificationdiagnosisPainless vaginal bleed:first bleeding episode is 2930 weeksUltrasonography:benefit in localizing the placenta and
13、diagnosis placenta previa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 其他原因引起的产前 出血CautionDouble setup vaginal examinationNo digital vaginal or rectal examination is preformed in case of placenta previa . Only as a final and definitive event and only under conditions of double set up.T
14、his procedure involves careful evaluation of the cervix in the operation room with full preparations for rapid cesarean section.处理 Treatment 原则：止血补血，预防感染，预防感染 方法；期待疗法 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.ManagementBasic managementInitial hospitalization with hemodynamic
15、stabilizationEnforced bed restRestrictions of activityExpectant management (allow for further fetal growth and maturation)Blood transfusion is given as necessaryAmniocentesis for fetal lung maturity testingCesarean birth if fetus is thought to be matureIndication of vaginal deliveryDelivery can be accomplished with minimal blood lossFe
