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1、妊娠晚期出血 Antepartum Haemorrhage,Chapter 12,Department of Obstetrics and Gynecology ZhuJiang Hospital Southern Medical University Dr Fu Xiafei,Antepartum haemorrhage,Placental abruption胎盘早剥Placental previa 前置胎盘,内 容,掌握：胎盘早剥的临床表现、诊断要点、常见并发症及处理原则 掌握：前置胎盘的临床表现、诊断要点及处理原则 熟悉：前置胎盘的分类,Placental Abruption,Defin
2、ition,The separation of the placenta in normal site from the site of uterine implantation before delivery of the fetus after the 20th week or during delivery,Placental abruption,起病急，发展快，危害大需急诊处理Incidence: 1-2% (国外)0.46-2.1% (国内),Causes,Maternal vascular diseases: hypertensive disorder in pregnancyhy
3、pertensionrenal diseases Mechanical factors: abdominal trauma abnormally short umbilical cord,Causes,sudden loss in uterine pressure:rapid loss of amniotic fluidthe delivery of the first twin Sudden increase of uterus venous pressure Others: maternal cocaine use or smokingprevious placental separati
4、ontendency to embolism,Pathology,Hemorrhage into decidual basalis(底蜕膜） -decidual hematoma Hematoma（血肿）expands and disrupts more vessels to separate from placenta Uterus unable to sufficiently contract to compress the torn vessels,主要病理变化：底蜕膜出血，形成血肿，使胎盘从附着处分离,Classification,Revealed abruption 显性剥离/外出血
5、血液冲开胎盘边缘，并沿胎膜与子宫壁间经宫颈管向外流出,Classification,Concealed abruption 隐性剥离/内出血胎盘边缘仍附着于子宫壁，或胎先露固定于骨盆入口，血液积聚于胎盘与子宫壁之间,Classification,Mixed bleeding 混合型出血当内出血达到一定程度时，血液终会冲开胎盘边缘及胎膜而外流,Uteroplacental apoplexy 子宫胎盘卒中胎盘后血肿压力增高，血流浸入子宫肌层，引起肌纤维断裂。当血液渗透至子宫浆膜层时，子宫表面呈紫蓝色瘀斑 收缩力差，产后出血,Classification,子宫胎盘卒中,Clinical Findin
6、gs,Symptoms Vaginal bleedingAbdominal painBack pain Signs Physical examination: uterine tenderness and/or increased uterine tone; Fetal distress,degree: the separations are small, produce few or no symptoms, and usually are not noted until the placenta is inspected. Signs. degree: 1/3 of the placent
7、a separated from the uterine wall, patients will present with vaginal bleeding, uterine tenderness and abnormal contractions. Signs.,Clinical Findings, degree: more than 50% of the placenta separated from the uterine wall, patients will present with shock, high-frequency contractions and fetal demis
8、e（死亡）,Clinical Findings,Laboratory Findings,Ultrasound: 胎盘与子宫壁之间出现边缘不清的液性低回声区；胎儿宫内状况maybe helpful but is not totally reliable. Negative findings with ultrasound do not exclude placental abruption.Blood routine and Coagulation function,Diagnosis,symptoms Signs Examinations,Placental Abruption,Placent
9、al Previa Uterine Rupture,Differential diagnosis,Difficult to recognize with certainty, diagnosis often made by exclusion Painful vaginal bleeding Placenta previa painless vaginal bleeding,Complications,DIC 重要病理生理改变大量组织凝血活酶释放，进入母体循环，激活凝血系统，产生大量的纤维蛋白原降解产物Postpartum haemorrhage 产后出血Acute renal failure
10、 急性肾衰Acute amniotic fluid embolism 羊水栓塞,Complications-fetus,急性缺氧新生儿窒息早产围产儿死亡,Management,Emergency measures：Antishock measures should be instituted as necessary,Cesarean Delivery: Rapid delivery of the fetus who is alive but in distress practically always means cesarean delivery.,Vaginal Delivery: th
11、e degree of separation appears to be limited and the fetus can be monitored for signs of fetal distress.,Management,Correct DIC：尽快终止妊娠，补充凝血因子，肝素Prevention of renal failurePostpartum hemorrhage：宫缩剂,Management complications,Prevention,strengthen the antenatal examination and prevent maternal hypertens
12、ion management of high risk pregnancy avoid trauma avoid rapid decompression of uterus avoid smoking,Conclusion,Definition Pathology: revealed, concealed, mixed Clinical findings: 3 degrees ComplicationsDIC Postpartum haemorrhageAcute renal failure Amniotic fluid embolism Treatment Emergency measure
13、s Cesarean Delivery Vaginal Delivery,Placental Previa,Definition,The placenta implants in the lower part of the uterus, over or very near the internal os after the 28th gestational week,Placenta previa,妊娠晚期常见并发症 妊娠晚期阴道流血最常见原因,Causes,Endometrium factors:A scarred endometrium Curretage for several tim
14、es An abnormal uterusPlacental factorsLargeAbnormal formation of the placenta Development retardation of trophoblast,Classification,Complete Partial Marginal,Classification,胎盘组织下缘与宫颈内口的关系，随诊断时期不同而有变化，分类也可随之改变 临产前的完全性前置胎盘，于临产后因宫口扩张可变为部分性前置胎盘 目前均以处理前的最后一次检查来决定其分类,Clinical Findings,Typical symptomPainl
15、ess vaginal bleedingSignsSoft uterusFetal malpresentationFetal distress,Examination,Ultrasound: Postpartum examination of placenta and membrane: 7cm,Differential diagnosis,Placental abruptionVelamentous placenta胎盘边缘血窦破裂宫颈病变,Differential diagnosis,帆状胎盘 velamentous placenta,Complications,Maternal comp
16、licationsPostpartum hemorrhageImplanted placentaPuerperal infection Fetal complicationsFetal distressPremature delivery Fetal blood loss or hemorrhage,Management,Principle: 抑制宫缩，止血，纠正贫血，预防感染The course of treatment depends on the amount of abnormal uterine bleeding, gestational week, whether the fetus is developed enough to survive outside the uterus, the type of placenta previa, the position of the fetus, the parity (number of previous births) for the mother, and the presence or absence of labor.,
