医学精品课件：3胎儿窘迫等.ppt

1、 教学内容教学内容n胎儿窘迫、子宫破裂、产后出血胎儿窘迫、子宫破裂、产后出血 约约2学时学时n脐带异常脐带异常、羊水量异常、早产、羊水量异常、早产、胎膜早破、过期妊娠、多胎妊娠胎膜早破、过期妊娠、多胎妊娠 约约1学时自学学时自学n王正平王正平 浙江大学医学院附属妇产科医院浙江大学医学院附属妇产科医院 产科产科 Tel：870615012211Post Partum Hemorrhage Uterine Rupture,Fetal DistressWomen Hospital,School of Medical,ZheJiang University Wang Zheng Ping Post p

2、artum hemorrhage Post partum hemorrhagenPast partum hemorrhage denotes excessive bleeding(500ml in vaginal delivery)during the first 24 hours after delivery；Cesarean section 1000mlnCommon cause of death and diseases in pregnant women globallynLeading cause of death in pregnant women in ChinanInciden

3、ce 2%-3%of total number of deliveries19.3219.324.014.0153.0 53.0 26.126.101020304050602000200120022003200420052006200720082009201020112012浙江浙江MMRMMR全国全国MMRMMR2000-20122000-2012年浙江省和全国孕产妇死亡率比较（年浙江省和全国孕产妇死亡率比较（1/101/10万）万）EtiologynUterine atony:70%nObstetric lacerations:20%nRetained placental tissue:1

4、0%nCoagulation:1%Uterine atonynGeneral factors:extreme nervousness,weak，severe anemianObstetric factors:prolonged labour,placenta previa,placenta abruptionUterine factors:uterine muscular fiber underdevelopment,such as uterine deformity or myoma;uterine overstretched,such as macrosomia,multiple preg

5、nancy,polyhydramnios nDrug factors:sedative,anesthesia,tocolytics Placental factorsnRetained placenta nPlacental incarceration（嵌顿嵌顿）nIncomplete placental separationnPlacental adhesionnPlacental implantation(accreta,increta,percreta)nResidual placenta and amniotic membraneImplantation of placentaBirt

6、h canal injurynLaceration during labour are usually associated with:Poor vulval elasticityStrong labour force,emergency delivery,macrosomiaInadequate skills at assisted vaginal deliveryInadequate cessation of bleeding during episiotomy repair,missing out tears at cervix or fornices Coagulation disor

7、dernComplications associated with obstetric:amniotic fluid embolism,pregnancy induced hypertensive diseases,placenta abruptio and intrauterine demisenPregnancy liver disease:acute fatty liver,severe hepatitisnHematology diseases:primary thrombocytopenic purpura,aplastic anemia etc Clinical presentat

8、ionnVaginal bleeding:If bleeding occurs immediately after delivery of baby,consider birth canal injuryIf bleeding occurs minutes after delivery of baby,consider placenta factorsIf bleeding occurs minutes after delivery of placenta,main reasons are uterine atony or retained products of conceptionPers

9、istent bleeding and blood do not coagulate,consider coagulation disorder Clinical presentationnVaginal hematomanShock:dizziness,paleness,weak pulse,low blood pressure etc Diagnosis nEstimation of blood lossnAscertain cause of post partum hemorrhage Estimation of blood lossnVisual observation:only 50

10、%-70%of blood lossnContainer:kidney dish,measuring cupnSurface area:blood stained 10cmx10cm=10mlnWeighing:1.05g=1mlnHct1000mlnHourly urine output 2500mlnShock index=pulse rate/systolic pressure Shock index(SI)nSI=0.5,normal blood volumenSI=0.5-1,blood loss 160bpm;during severe hypoxia 110bpmCST show

11、s late deceleration,severe variable decelerationfetal heart rate 100bpm,with frequent late decelrations indicating severe fetal hypoxia,may die intrauterine any moment Late deceleration Variable deceleration Diagnosis of acute fetal distressnMeconium stained amniotic fluid:green color,dirty,thick an

12、d little volumeI degree:light green,II degree:yellowish green,dirty,III degree:brownish yellow,thick Diagnosis of acute fetal distressnFetal movement:early stage frequent fetal movement,subsequently reduced to absentnFetal acidosis:fetal scalp blood analysispH 7.2 (normal 7.25 7.35)PO2 60mmHg (norma

13、l 35 55mmHg)Diagnosis of chronic fetal distressnReduced or absent fetal movementnAbnormal fetal monitoringnLow fetal biophysical profile scoringnAbnormal umbilical artery blood flow nMeconium stained amniotic fluidReduced or absent fetal movementnReduced fetal movement 6 times/2 hours,50%drooprate n

14、Heart beat disappears：usually 24 hours after absent of fetal movement fetal nNormal fetal movement count:30-100 times/12hours Abnormal fetal electronic monitoringnNST is known as non-reactive type,during 20 minutes continuous fetal movement fetal heart rate acceleration15bpm,sustaining15s,baseline v

15、ariability 5bpmnOCT frequent severe variable decelerations or late decelerations are seen Low biophysical profile scoringnBased on ultrasound assessment of fetal body movement,breathing movement,flexor tone,amniotic fluid volume,couple with fetal electronic monitoring NST results combined scoring(ea

16、ch variable score 2,total score is 10)nScore 3 indicates fetal distress,score 4-7 suspicious fetal hypoxiaAbnormal umbilical artery blood flownumbilical artery diastolic blood flowreducing absence inversion Meconium stained amniotic fluidnAmnioscopy examination shows dirty amniotic fluid in light gr

17、een or brownish yellow color Management nAcute fetal distress:emergent treatmentnChronic fetal distress:management plan depends on severity of the pregnancy complications,gestational age,fetal maturity,fetal distress condition Management of acute fetal distressnGive oxygen:face mask or nasal prong c

18、ontinuous oxygen at 10L/min flownSearch for cause,active managementsupine hypotensive syndrome：lie the patient on left lateral positionexcessive oxytocin leading to uterine hyperstimulation：stop oxytocin immediatelyuse tocolytics when necessary Management of acute fetal distressTerminate pregnancy s

19、oonest possible:qCervix not fully dilated with the following conditions,immediate caesarean section:(1)fetal heart rate 180bpm,accompanied by II degree meconium stained amniotic fluid(2)CST or OCT shows frequent late decelerations or severe variable decelerations,sine wave(3)fetal scalp blood pH 7.2

20、0(4)III degree meconium stained amniotic fluid,with low amniotic fluid amount Management of acute fetal distressqFully dilated cervix:fetal biparietal diameter,has descend below ischial spines,perform assisted vaginal deliverynPrepare for newborn resuscitation Management of chronic fetal distressnRo

21、utine management:left lateral position,give oxygen regularly(30mins,2-3times/day)nActive treatment of pregnancy complications nTerminate pregnancy:pregnancy nearing term with less fetal movement or OCT shows late decelerations,severe variable decelerations,or biophysical profile 3 score,caesarean is

22、 indicatedManagement of chronic fetal distress nExpectant treatment:early gestation,low chance of survival if delivered,prolong pregnancy while inducing fetal lung maturationnMust explain to the family that during the process of expectant treatment,there is risk of sudden fetal death,poor placental

23、function might affect fetal growth,poor outcomenFetal distress 胎儿窘迫nNeonatal asphyxia 新生儿窒息nFetal heart rate FHR 胎心率nFetal movement FM 胎动nCardiotocography 胎心监护nNon-stress test NST 无应激试验nOxytosin challenge test OCT 催产素激惹试验nContraction stress test CST 宫缩应激试验nsine wave 正弦波nBiophysical profile scores BPPs 生物物理评分