1、Placental AbruptionGeneral Consideration Definition separation of the normally located placenta after the 20th gestational week and prior to birth.Incidence 0.51%-2.33%(our country)0.5%(other countries)Incidence of fetal death 200-350The most important cause of vaginal bleeding in late pregnancyCaus
2、e of bleedingproportionPlacental Abruption31.7%Placenta previa12%Lesion of cervix7%Factors of Cord1%No cause40%Severe complication of pregnancyCauses of hemorrhageNumber(%)Placental Abruption141(19)Laceration/uterine rupture125(16)Uterine atony115(15)Coagulopathies108(14)Placenta previa50(7)Placenta
3、 accreta/increta/percreta44(6)Uterine bleeding47(6)Retained placenta32(4)Causes of 763 pregnancy-related deaths due to hemorrhage 1999EtiologyUncertain(primary cause)Risk factors1.Vascular diseases:preeclampsia,chronic hypertension,renal disease.2.Mechanical factors:abdomen strick,intercourse,extrem
4、e shortness of umbilical cord（脐带过短）（脐带过短）amniocentesis（羊膜穿刺术）（羊膜穿刺术）3.uterine volume suddenly narrow and uterine cavity pressure drop：rupture of membrane when polyhydramnios（羊水过多）（羊水过多）4.Increased age and parity5.Sudden increase in uterine venous pressure：Supine hypotensive syndrome（仰卧位低血压）（仰卧位低血压）6
5、.other：Smoking,cocaine use,uterine myoma，RacePathology Main change hemorrhage into the decidua basalis decidua splits decidual hematoma separation,compression,destruction of the placenta adjacent to it Types revealed abruption concealed abruption,mixed type Uteroplacental apoplexy 子宫胎盘卒中子宫胎盘卒中Typesr
6、evealed abruptionconcealed abruptionmixed typeUteroplacental apoplexy Bleeding into the myometrium of the uterus giving a discolored appearance to the uterine surface.Adjunctive ExaminationUltrasonography1.Position of placenta,severity of abruption,survival of fetus2.Signs:retroplacental hematoma3.N
7、egative findings do not exclude placental abruptionLaboratory examination1.consumptive coagulopathy:Rt,DIC2.Function of liver and kidney.Manifestation Vaginal bleeding along with abdominal pain Mild type abruption 1/3,apparent vaginal bleeding Severe type abruption 1/3,large retroplacental hematoma,
8、vaginal bleeding companied by persistent abdominal pain,tenderness on the uterus,change of fetal heart rate.shock and renal failure.0IIIIIIdefined by postpartum check placentaabruption area 1/2 No or litter bleeding no abdominal pain No moderate vaginal bleedingabdominal pain No severe vaginal bleed
9、ingSevere pain uterine=gestation weeks uterinegestation weeksuterinegestation weeks uterine soft，no or litter tenderness moderate severe uterine tenderness,may be associated with ankylosing contractionssevere pain with ankylosing uterusMaternal blood pressure and heart rate is normalMaternal tachyca
10、rdia,blood pressure and heart rate changesMaternal shockNo coagulation disordersLow fibrinogenemia(150-250mg/dL)Hypofibrinogenemia 150 mg/dL Coagulation disordersNo Fetal distressFetal distress，fetus alive Fetal deathDiagnosissign and symptom1.Vaginal bleeding2.Uterine tenderness or back pain3.Fetal
11、 distress4.High frequency contractions5.Hypertonus(高张力高张力)6.Idiopathic preterm labor7.Fetal deathDiagnosisUltrasonographyDifferential diagnosis Placenta previa：Painless bleeding threatened rupture of uterus：dystociaComplication DIC and coagulation disorders Hypovolemic shock Amnionic fluid embolism（
12、羊水栓塞）Acute renal failure Fetal death Treatment Treatment will vary depending upon gestational age and the status of mother and fetus Treatment of hypovolemic shock:intensive transfusion with blood Assessment of fetus Termination of pregnancy:CS or Vaginal deliveryTreatment of hypovolemic shock Gener
13、al treatment oxygen uptake with oxygen mask Quickly make up the volume:blood loss,estimated physiological need The rehydration select:fresh whole blood or plasma Corrective shock indicators the hematocrit 30%urine volume 30ml/h,blood pressure and heart rate stableTermination of pregnancy Maternal co
14、ndition is good,estimated a quickly childbirth Immediate rupture of membrane Shorten the second stage of labor Manual removal of the placenta Prevention of postpartum hemorrhage:massage the uterus,contraction agentVaginal deliveryCesarean section Severe type，impossibly delivery in a short time Mild
15、type but with fetal distress;The labor progression:no Prevention of bleeding Uteroplacental apoplexy treatmentTermination of pregnancyTreatment of DIC Timely,adequate input of fresh blood.Infusion of fresh platelet concentrates.Give fibrinogen:Average amount of 3-6g Infusion of fresh plasma:the addi
16、tion of fibrinogen,VIII factor The application of heparin:The antifibrinolytic drug application Make up the volume Drug:20%mannitol of 250m1 rapid intravenous furosemide 40mg intravenous Dialysis therapyTreatment of Acute Renal FailureWhen urine 17ml or no urine,renal failure may occured.Case Discus
17、sion病史病史1.患者，女，患者，女，45岁，岁，2001年年12月月4日日12:10入院入院2.因因“停经停经8月余，抽搐月余，抽搐2次，神志不清次，神志不清3小时小时”入院。入院。3.平素月经不详，平素月经不详，LMP：2001年年4月？。孕期未行产前月？。孕期未行产前检查。检查。3小时前突然倒地，口吐白沫，神志不清，四小时前突然倒地，口吐白沫，神志不清，四肢抽搐（持续肢抽搐（持续5分钟）。即刻送当地中心医院，查体分钟）。即刻送当地中心医院，查体发现血压发现血压176/90mmHg，双侧瞳孔增大，对光放射存双侧瞳孔增大，对光放射存在，皮肤黄染，心肺正常，双下肢水肿（）。在，皮肤黄染，心肺
18、正常，双下肢水肿（）。拟诊拟诊“重度妊高征，子痫重度妊高征，子痫”而给予硫酸镁、降压药而给予硫酸镁、降压药等治疗。在诊治过程中又抽搐一次，持续等治疗。在诊治过程中又抽搐一次，持续10分钟。分钟。因病情危重，治疗效果不佳，转入我院。因病情危重，治疗效果不佳，转入我院。4.26岁时曾患甲肝，生育史：岁时曾患甲肝，生育史：1-0-0-1，顺产。，顺产。体检体检1.T:37;BP:200/110mmHg;P:108;R:282.神志不清，面色萎黄，全身皮肤中度黄染，浅表淋神志不清，面色萎黄，全身皮肤中度黄染，浅表淋巴结无肿大。双侧瞳孔轻度扩大，对光反射存在，巴结无肿大。双侧瞳孔轻度扩大，对光反射存在，
19、心率心率108次次/分，律齐，未及杂音。呼吸有鼾声，肺部分，律齐，未及杂音。呼吸有鼾声，肺部听诊无异常。妊娠腹，腹壁软，肝脾未及。听诊无异常。妊娠腹，腹壁软，肝脾未及。3.宫高宫高29.5cm，腹围腹围93cm，FHR:150-157次次/分，子宫分，子宫壁张力较高，胎位不清，宫缩壁张力较高，胎位不清，宫缩20秒秒/5-10分钟。双下分钟。双下肢水肿（），膝反射亢进，病理性反射未引出。肢水肿（），膝反射亢进，病理性反射未引出。4.阴道检查：阴道有暗红色血液流出，量阴道检查：阴道有暗红色血液流出，量100ml，宫口宫口3cm，胎膜未破，先露头胎膜未破，先露头2。留置导尿见尿量约。留置导尿见尿量约
20、100ml，淡酱油色。淡酱油色。辅助检查辅助检查1.血常规：血常规：WBC:18.4109/L;N:84.7%;RBC:4.21012/L;Hb:137g/L;PLT:59109/L;HCT:39.4%;尿蛋白尿蛋白4+。2.电解质：电解质：K3.45mmol/L;Na134mmol/L;Cl80mmol/L3.肝肾功能肝肾功能:LDH:2185U/L;sGPT:310U/L;sGOT:751U/L;AKP:237U/L;总胆红素总胆红素:179.3umol/L;直接胆红素直接胆红素:120.9umol/L;血氨血氨:169umol/L;血血糖糖:6.7mmol/L;肌酐肌酐:55umol/L
21、;尿酸尿酸:577umol/L;尿尿素氮素氮:5.9umol/L。4.D二聚体弱阳性二聚体弱阳性;FDP(+)5.产科产科B超：宫内见一活胎，双顶径超：宫内见一活胎，双顶径8.1cm，胎盘胎盘II级，级，位于前壁，羊水指数位于前壁，羊水指数13.7cm，胎盘与子宫壁之间见胎盘与子宫壁之间见一液性暗区，大小为一液性暗区，大小为76.54cm3。6.肝胆肝胆B超提示：肝内光点增多、增粗、分布不均，血超提示：肝内光点增多、增粗、分布不均，血管纹理欠清，胆囊壁毛糙。管纹理欠清，胆囊壁毛糙。入院诊断入院诊断 孕孕8+月，先兆早产，胎盘早剥，重度妊高征，子痫，月，先兆早产，胎盘早剥，重度妊高征，子痫，HE
22、LLP综合征，妊娠合并重症肝炎？肝昏迷？综合征，妊娠合并重症肝炎？肝昏迷？治疗经过（治疗经过（12:10入院）入院）1.硫酸镁解痉、硝普钠降压、甘露醇降低颅内压、保硫酸镁解痉、硝普钠降压、甘露醇降低颅内压、保肝、抗感染及输新鲜血浆等治疗，病情得到控制，肝、抗感染及输新鲜血浆等治疗，病情得到控制，仍神志不清，血压控制在仍神志不清，血压控制在(150-160)/(100-110)mmHg，尿量逐渐增多，尿色变淡。尿量逐渐增多，尿色变淡。2.血小板下降为血小板下降为42109/L；PT和和KPTT正常；纤维蛋正常；纤维蛋白原无进行性下降。白原无进行性下降。3.头颅头颅CT示：脑水肿，右侧颞、顶部皮下
23、血肿示：脑水肿，右侧颞、顶部皮下血肿4.人工破膜，羊水为淡血性，宫缩逐渐增强人工破膜，羊水为淡血性，宫缩逐渐增强5.15:25经阴道娩出一活男婴，体重经阴道娩出一活男婴，体重2390克，新生儿重克，新生儿重度窒息，转儿科医院。度窒息，转儿科医院。6.产后宫缩好，阴道出血少，检查胎盘可见胎盘母面产后宫缩好，阴道出血少，检查胎盘可见胎盘母面有压迹及陈旧性血块。剥离面积接近有压迹及陈旧性血块。剥离面积接近1/37.20:10 血小板血小板29109/L，输血小板输血小板2单位。单位。8.血压血压150/100mmHg，改用酚妥拉明维持降压。改用酚妥拉明维持降压。9.入院第二天入院第二天（5日日5AM）患者清醒，皮肤黄染明显消患者清醒，皮肤黄染明显消退，尿色清，继续解痉、降压、保肝和维持电解质退，尿色清，继续解痉、降压、保肝和维持电解质平衡。平衡。10.复查：复查：LDH:1111U/L;sGPT:165U/L;sGOT:132U/L;总胆红素总胆红素:34umol/L;直接胆红素直接胆红素:20.5umol/L;尿尿酸酸:473umol/L;血小板血小板:55109/L。11.入院第三天入院第三天（6日）：血压日）：血压120/80mmHg，降压药改降压药改为柳胺苄心定和硝苯啶口服，血小板为柳胺苄心定和硝苯啶口服，血小板:65109/LThanks
