763例产科出血患者死亡分析- 上海交通大学医学院精品课程.pptVIP

！！！ 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 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，部分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 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 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） 诊断 症状和体征 B超检查 试验室检查 症状和体征 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 胎盘早剥症状和体征变化较大，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