产后出血定义PPT课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,产后出血定义PPT课件,Chief complain,amenorrhea for 8,+,months,itching for 2,+,months,vaginal bleeding for 5 hours,no fetal movement for,2,hours,Case,1,Current pregnant experience,Regular menstruation, unclear exact LMP . amenorrhea for about 8,+,M. ultrasound estimated early pregnancy 2 m after amenorrhea. No morning sickness during early pregnancy, without regular antenatal care during pregnancy.,Feel itching especially during night about 2,+,m on both legs, abdomen and chest , without complicating nausea, vomiting or uncomfortable upper abdomen.,5 hrs ago, vaginal bleeding about,5,0ml with slight abdominal pain,No dizziness, dim eyesight et al. transferred to our hospital,immediately by local hospital.,On,the,way,of,transport,no feeling of fetal movement anymore.,Deny abnormal previous medical history,Case,1,Situation at admission, P:64bpm, R:21/min, BP:150/104mmHg,No pale of face (skin), conscious and fluent speaking with doctors,Physical examination : (-),Obstetric examination:,tender,uterus,height of uterus:30cm, abdominal circumference:89cm, ROA, fetal heart beat: not to hear.,No obvious vaginal bleeding .,Blood test(,急诊,):,WBC 9.110,9,/L, N 69.4%,RBC 3.1910,12,/L,HB 98g/L,PLT 18610,9,/L, PT,18.3s, APTT,55.4s, Fg,103mg/L,Urine test (,急诊,),：,Glu (+),，,Pro (+),，,WBC (+),，,RBC(-),Case,1,Questions,?,What are the common causes of vaginal bleeding,during third trimester,?,What,s the possible cause of vaginal bleeding for this patient,?,What are the common causes of fetal deaths? What,s the most possible reason of fetal death for this patient,?,What are the diagnosis for this women,?,What are the assisted examinations that you suggest to do,?,Case,1,Diagnosis,?,Assisted examinations,Unltrasound,: BPD8.9cm,FL6.8cm,A 4.1cm.The placenta was located on the posterior wall of the uterus without signs of covering the inner os of the cervix and the thickness of placenta was 3.1cm without identified mass between the placenta and the uterus. No fetal heart or fetal movement was detected.,Liver function,mol/L,Repeated blood test,: Hb 98g/L, abnormal Coagulation function.,Blood type,: A, Rh(+),GDM screen test,: (-),TP,: (-),TORCH : (-),Make decisions,When to terminate the pregnancy?,How to terminate the pregnancy?,Vaginal delivery?,CS?,患者帅,XX,，女，,41,岁。既往体健。,生育史：,1998,年 人工流产,1999,年 因,“,难产,”,在双流某医院剖宫产，女儿，健在,1999,年 人工流产,2010,年 人工流产,2011,年 因,“,瘢痕子宫,”,在双流某医院剖宫产，儿子，健在,2013,年 人工流产,此次妊娠,Case,2,停经,12+,周来我院建卡,Case,2,妊娠,23+,周 彩超,胎盘,Case,2,胎盘,妊娠,31+,周 彩超,Case,2,胎盘,胎盘,MRI,结果（,34+2,周）,胎盘,Case,2,术中见：子宫前壁下段明显膨隆凸起，遍布迂曲增粗的血窦；膀胱表面遍布细蚯蚓状增生血管。胎盘覆盖子宫中下份各壁，完全覆盖宫颈内口，且有大量的胎盘组织凸向子宫前壁下段并深入宫颈管内；胎盘与宫壁粘连、植入。,剖宫产术中所见,Case,2,Hb,PLT,PT,APTT,Fg,术前,137,134,12,31.2,282,术中,52,95,17.8,150,65,术后,75,77,12.2,40.2,161,术中出血估计,4500ml,，共输入红细胞悬液，新鲜冰冻血浆,600ml,，冷沉淀,6U,，自体回收血,220ml,。术毕再输入新鲜冰冻血浆,500ml,术前,术中,术后患者血常规、凝血功能变化,Case,2,凶险性前置胎盘的定义是什么？,凶险性前置胎盘,为什么,“,凶险,”,？,凶险性前置胎盘的治疗原则？终止妊娠的方式？终止妊娠的时机？,围手术期可采取哪些,措施减少出血？,Case,2,患者，,33,岁，因“停经,37+4,周，要求待产”入院。,现病史,：患者平素月经规律，,LMP2016-11-26,，因双侧输卵管阻塞在我院于,2016-12-12,宫腔植入冻胚,2,枚。早孕期超声提示为双绒毛膜双胎。孕期定期产检无特殊。现停经,37+4,周，入院待产。,Case,3,既往史,：,2014,年因不孕在我院行腹腔镜下盆腔粘连松解术，,2016,年,1,月因异位妊娠在我院行腹腔镜下患侧输卵管切除术,+,对侧输卵管结扎术。余无特殊。,月经婚育史,：初潮,11,岁，经期,4,天，周期,30,天，。已婚，配偶体健，宫外孕,1,次，人工流产,1,次。,家族史,：无特殊。,Case,3,查体,：，,P95,次,/,分，,R21,次,/,分，,BP120/76mmHg,。心肺（,-,） ，腹部膨隆，张力较大，宫高,49cm,，腹围,113cm,，余（,-,）。,辅助检查,：,B,超（,2017-8-14,）：胎,1,：横位，胎心率,145,次,/,分，羊水。胎,2,：头位，胎心率,148,次,/,分，羊水。,Case,3,血常规,：,X10,9,/L,中性粒细胞百分比,78%,，,12,/L,HGB 125g/L,PLT 130X10,9,/L;,凝血功能,：秒；秒，,Fg 450mg/dl,。,肝肾功能正常。,Case,3,入院诊断,：,1.,双绒毛膜双羊膜囊双胎；术后；,3.,羊水过多；,4.G3P0+2 37+4,周宫内一横位一头位双活胎待产,入院后处理,：监测胎心胎动，完善相关检查，择期终止妊娠。,Case,3,患者入院后第三天行择期剖宫产，术中见：子宫明显大于孕周，取子宫下段横切口，娩出大婴，男，重,3260g,，身长,50cm,，羊水清亮，量约,2000ml,。小婴，女，重,2720g,，身长,49cm,，羊水清亮，量约,2200ml,。胎儿娩出后立即予缩宫素,10U,宫壁注射，,10U,静脉滴注，胎盘自然剥离，子宫收缩极差呈口袋状，出血多且迅速。,Case,3,干纱布,30,张,湿纱布,10,张,HR,：,156,次,/,分,BP,：,75/41mmHg,负压引流：血液,800ml,会阴垫，无菌单大面积血染，称重,1020g,病人目前情况,血常规：,HGB 68g/L PLT:140*10,9,/L,凝血功能：,PT,：秒（参考值：秒）,APTT,：秒（参考值：秒）,Fg,：,110mg/dL,Questions?,1.,目前估计出血量共计多少？产后出血的定义？,2.,该患者产后出血的主要原因？,3.,导致该患者产后大出血的高危因素？,4.,下一步处理？,Case,3,持续双合诊按摩子宫，捆绑子宫下段,术中行双侧子宫动脉上行支结扎。出血逐渐减少后迅速关腹，术毕检查子宫收缩差，仍有活动性出血，急诊行双侧子宫动脉介入术。出血明显减少。,估计出血,2700ml,。输血：去白红细胞悬液,6U,，新鲜冰冻血浆,800ml,，纤维蛋白原,2g,。,术后血常规：,RBC3.02*10,9,/L,，,HGB94g/L,，凝血功能正常。,病人转归,Case,3,谢谢！,