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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,胎盘早剥,汪希鹏,Obstetrics is “bloody business,Even though the maternal mortality rate has been reduced dramatically by hospitalization for delivery and the availability of blood for transfusion, death from hemorrhage remains prominent in the majority reports.,From willams obstetrics,Causes of hemorrhage,percent,胎盘早剥,子宫破裂或撕裂,宫缩乏力,凝血异常,前置胎盘,胎盘植入,产后出血,胎盘残留,141(19%),125(16%),115(15%),108(14%),50(7%),44(6%),47(6%),32(4%),763,例产科出血患者死亡分析,产科出血分类,产前出血,胎盘早剥,前置胎盘,血管前置,子宫破裂,产后出血,宫缩乏力,胎盘残留,产道损伤,凝血异常,定义,妊娠20周以后或分娩期，正常位置的胎盘在胎儿娩出前，局部或全部从子宫壁剥离，成为胎盘早剥,发生率,发生率是,1 in 200,deliveries.,发生率随孕妇年龄和产次增加,.,围产儿病率和死亡率,其他因素造成围产儿病率和死亡率因素已下降，但是胎盘早剥仍然是主要因素,胎盘早剥患者围产儿死亡率是,25%,.,新生儿即使存活，还有其他严重并发症,病因,风险因素,Risk factor,Relative risk(%),孕妇年龄和产次,先兆子痫,慢性高血压,胎膜早破,吸烟,凝血异常,吸毒,胎盘早剥史,子宫肌瘤,NA,2.1-4.0,1.8-3.0,2.4-3.0,1.4-1.9,NA,NA,10-25,NA,Etiology,外伤,腹部钝性外伤是造成胎盘早剥主要因素之一,车祸和殴斗是常见因素,Etiology-,胎盘早剥史,再次胎盘早剥发生率增加至,5% to 17%.,如果患者已发生2次胎盘早剥，再次早剥机率增加至,25%.,胎盘早剥出血类型,外出血,出血突破胎盘和子宫壁附着处,内出血,血液隐匿在胎盘和子宫肌壁中，未突破周围胎膜附着处,对大多患者，隐匿的血液迟早会突破胎盘周围胎膜，表现为外出血型,胎盘病理,胎盘部位血管畸形常见vascular abnormalities.,未完成胎盘部位血管动脉转化 (60%).,肌层内血管畸形，包括血管阻塞、肌层内血管出血 33%.,Sher分级 (international),Grade I,:,Slignt,vaginal bleeding and some uterine irritability are usually present. Maternal blood pressure is unaffected, and the maternal fibrinogen level is normal. The fetal heart rate pattern is normal.,Grade II,: External uterine bleeding is mild to moderate. The uterus is irritable, and,tetanic,or very frequent contractions may be present. Maternal blood pressure is maintained, but the pulse rate rate may be elevated and postural blood volume deficits may be present. The fibrinogen level may be decreased. The fetal heart rate often shows signs of fetal compromise.,Grade III,: bleeding is moderate to severe but may be concealed. The uterus is,tetanic,and painful. Maternal,hypotension,is frequently present and fetal death has occurred. Fibrinogen levels are often reduced to less than 150 mg/dl; other coagulation abnormalities (,thrombocytopenia, factor depletion) are present.,胎盘早剥分级中国,轻型,重型,出血,外出血为主，剥离面积不超过胎盘面积1/3，发生在产程中,隐匿型或混合型出血为主，剥离面积超过1/3，发生于先兆子痫和慢性高血压患者,症状,阴道出血，轻微腹痛、腹胀，无贫血,腹痛、伴随休克症状,体征,子宫软，正常收缩，宫体压痛，正常胎心率,子宫硬和宫体压痛，,宫底逐渐增高，宫缩频，胎心率过快或过慢，以及胎儿宫内死亡,诊断,病症和体征,B超检查,试验室检查,病症和体征,阴道出血,宫体压痛或腰背部痛,胎窘,宫缩较频,子宫张力较高,早产,死胎,阴道出血,晚期妊娠阴道出血，应考虑胎盘早剥可能，应立即进行检查,约 80%,胎盘早剥患者会有阴道出血临床表现,.,临床特点,胎盘早剥病症和体征变化较大，灵活掌握，认真判断,外出血型可能出血较多，但胎盘剥离面积不大，故有时尚未危及宫内胎儿,内出血型，虽然阴道出血少，但胎盘剥离面积大甚至完全剥离，直接造成胎儿宫内死亡,B超检查,判定胎盘位置和剥离程度,还能判定胎盘剥离处血液淤积的主要部位,Subchorionic,(between the placenta and the membranes),Retroplacental,(between the placenta and the,myometrium,),Preplacental,(between the placenta and the amniotic fluid),实验室检查,血红蛋白和血球压积,凝血试验: 纤维蛋白原，血小板计数纤维蛋白降解产物，PT， PTT,血块试验Clot test: a “poor mansfibrinogen assay,试管内血液6分钟内未凝，或凝血后30分钟内再溶解，提示存在凝血障碍，纤维蛋白原 150 mg/dl,胎儿监护,持续胎心监护记录胎心情况和宫缩活动性.,并发症,消耗性凝血障碍Consumptive coagulopathyDIC,急性肾功能衰竭,产后出血,低学容量休克,胎儿死亡,并发症-,纤维蛋白原,150mg/,dL,FDP, D-,dimer,升高,血小板,1000ml,重视隐匿出血患者，易低估,治疗目标：恢复有效血容量,失血性休克,(2),血浆扩容剂：白蛋白和血液替代品,成分血和全血,纠正凝血障碍,休克监测,blood pressure, heart rate,assessing the patients general state,urinay,output at least 30ml/h,central venous,pressue,(CVP), EKG,注意输血并发症,DIC,处理 (1),约,10%,胎盘早剥发生,DIC,常合并胎儿死亡和严重大出血,疑,DIC,者应检查：,BT,和,CT,纤维蛋白原和纤维蛋白降解产物(,FDP),血小板计数,优球蛋白溶解时间，,prothrombin,time(PT), partial,thromboplastin,time(PTT) and thrombin time.,DIC,处理 (2),最终目标是迅速娩出胎儿和胎盘，阻止凝血物质进入血管内，发生消耗性凝血,尽量用新鲜全血和新鲜血浆,在治疗,DIC,同时，应及时终止妊娠,肾衰处理,肾小管坏死，可恢复，但是肾皮质坏死，取决于坏死范围,肾功能检测,尿量，血肌酐和肌酐去除率,电解质,注意尿毒症,产后出血处理,25,胎盘早剥患者发生产后出血,处理：,快速恢复血容量,催产素、麦角和前列腺素加强宫缩,髂内动脉结扎或切除子宫,
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