分娩并發(fā)癥(雙語)課件

ComplicationofLabor&Delivery

分娩并發(fā)癥SyllabusPostpartumHemorrhage（產(chǎn)后出血）AmnioticFluidEmbolism（羊水栓塞）RuptureofUterus（羊水栓塞）DysfunctionofCord（臍帶異常）PostpartumHemorrhage

產(chǎn)后出血GeneralconsiderationPostpartumhemorrhageistheleadingobstetriccausesofmaternaldeathTheincidenceis2%~3%ofthetotaldeliveryHemorrhagicshockistheimmediatecauseofdeathThepostpartumhypotensionmayleadtonecrosisofpituitaryorHann'ssyndromeDefinitionPostpartumhemorrhagedenotesexcessivebleeding(＞500mLinvaginaldelivery)followingdelivery.Bloodlostduringthefirst24hoursafterdeliveryisearlypostpartumhemorrhage.

病因

子宮收縮乏力：常見原因

全身因素（緊張、恐懼、虛弱）產(chǎn)科因素（產(chǎn)程長、并發(fā)癥及合并癥）子宮因素（子宮肌纖維過分伸展，肌壁損傷、子宮病變）藥物因素EtiologyRetainedplacentaltissue:retainedplacenta滯留

placentaaccretaorincreta

粘連/植入

residualpartoftheplacenta部分殘留DiagnosisClinicalfindingsDeterminationofbloodloss:Weightingmethod,volumetricmethod,planimetry(面積法)Shockindex=pulserate/systolicpressureIndex0.51.01.52.0Lossbloodnormal10~3030~5050~70%ml-500~15001500~20002500~3000

診斷子宮收縮乏力宮底升高子宮質(zhì)軟、輪廓不清陰道流血多按摩或縮宮后子宮變硬陰道流血減少或停止

診斷軟產(chǎn)道裂傷宮頸、陰道、會陰裂傷宮頸裂傷常在3、9點(diǎn)處、可延伸I度裂傷II度裂傷III度裂傷IV度裂傷

診斷凝血功能障礙持續(xù)陰道流血血液不凝止血困難全身多部位出血凝血功能檢查異常正面觀背面觀正面觀B-Lynch子宮縫合法

處理軟產(chǎn)道損傷徹底止血、逐層縫合宮頸裂傷>1cm，活動性出血，應(yīng)縫合第一針應(yīng)超過裂口頂端不留死腔、避免穿透直腸黏膜避免損傷膀胱和輸尿管血腫應(yīng)切開，徹底止血后縫合必要時(shí)引流

處理凝血功能障礙應(yīng)排除其它引起產(chǎn)后出血的因素輸新鮮血補(bǔ)充血小板、凝血物質(zhì)并發(fā)DIC后積極處理

處理失血性休克正確估計(jì)出血量及休克程度針對病因止血的同時(shí)積極抗休克建立有效靜脈通道、補(bǔ)液、血漿、升壓給氧、糾正酸中毒、保護(hù)臟器功能防治感染預(yù)防加強(qiáng)產(chǎn)檢，加強(qiáng)對高危妊娠的管理搞好計(jì)劃生育，減少人流次數(shù)有高危因素者，加強(qiáng)產(chǎn)前檢查正確處理產(chǎn)程加強(qiáng)產(chǎn)后觀察，特別是產(chǎn)后2小時(shí)AmnioticFluidEmbolism,AFE

羊水栓塞1.熟悉羊水栓塞的臨床表現(xiàn)、診斷以及處理原則

2.熟悉羊水栓塞的預(yù)防措施

3.了解羊水栓塞的病因、病理生理變化。

教學(xué)大綱AmnioticFluidEmbolismisacomplexconditioncharacterizedbytheabruptonsetofpulmonaryembolism,shockandDIC,renalfailureorsuddendeath.IncidenceislowCharacteristic:Itishardtopredictandisadangerousobstetricscomplication,thedeathrateisabout70%-80%DefinitionEtiologyTheformedelementsinamnioticfluidenterintomaternalcirculationduringdeliveryorcesareansection.EtiologyCondition:openingvessels,uterinehypertonusInducement誘因:ruptureofuterus,lacerationofcervix,placentapraevia,placentalabruptionPredilectionfactors:primiparity初產(chǎn)

,allergy,precipitatelabor急產(chǎn),tetaniccontraction強(qiáng)直性宮縮Pulmonaryarteryhypertension,PAH肺動脈高壓AllergicshockDisseminatedintravascularcoagulation,DICAcuterenalfailure;ARFPathophysiologyFormedelementsPAHAcutecordextrumfailurePEaRCFSEPaSTNB.SPFClinicalfindingⅠstage---Shock,Respiratoryandcirculatoryfailureandhypoxemia低氧血癥Ⅱstage---DIC:bleeding,bloodclottingdisorderandthenhemorrhagicshockⅢstage---Acuterenalfailure(ARF):oliguria少尿

andrenaldysfunction肺動脈高壓：羊水有形物質(zhì)形成栓子進(jìn)入肺循環(huán)，阻塞小血管，血栓形成，血管痙攣，可導(dǎo)致右心衰竭，休克，甚至死亡。過敏性休克：I型變態(tài)反應(yīng)、血壓驟降心肺功能衰竭病理生理DIC：羊水中促凝物質(zhì)形成大量微血栓，消耗凝血物質(zhì)，形成DIC，極易發(fā)生嚴(yán)重產(chǎn)后出血及失血性休克急性腎衰竭：DIC及休克導(dǎo)致腎急性缺血病理生理

臨床表現(xiàn)

呼吸循環(huán)衰竭和休克DIC引起的出血急性腎衰竭起病急驟、來勢兇險(xiǎn)、多在分娩過程中?。?！癥狀可不典型、也可只出現(xiàn)部分癥狀！?。iagnosisEmergent:typicalclinicalmanifestationAuxiliaryexamination

AmnioticfluidcomponentsarefindinbloodDICexaminationECGChestX-rayAutopsy尸解

Treatmentprinciple抗過敏的同時(shí)，改善低氧血癥--呼吸功能保持心輸出量和血壓--循環(huán)功能防止血管內(nèi)凝血--凝血功能防治腎衰--臟器功能TreatmentstepOxygen:Trachealintubation氣管插管

ReliefPAH:Papaverinehydrochloride(罌粟鹼),Atropine（阿托品），Aminophylline（氨茶堿），Phentolamine（酚妥拉明）Anti-anaphylaxis：Dexamethasone(地塞米松)Anti-shock：Dopamine（多巴胺），Metaraminol（間羥胺），5%SodiumBicarbonate（5%碳酸氫鈉），LanatosideC（西地蘭）TreatmentofDICMechanismofobstetricDIC:Extrinsiccoagulationsystem

外源性凝血系統(tǒng)Intrinsiccoagulationsystem

內(nèi)源性凝血系統(tǒng)TreatmentofDICThestagesofDIC高凝期凝血酶↑血球壓積↑微血栓形成消耗性低凝期血小板↓纖維蛋白原↓凝血因子Ⅴ、Ⅷ、Ⅻ↓

纖溶亢進(jìn)期FDP↑繼而D-2聚體↑TreatmentofDICTreatmentAnticoagulation抗凝

(Heparin肝素):HypercoagulableperiodBloodcoagulationfactorsAnti-fibrinolysis抗纖溶ThestageoforganexhaustionTopreventrenalfailure----

blood-volume,diuretica利尿劑Topreventcerebralpalsy----

icecap,dehydrater脫水劑Anti-infectionTopreventdigestivesystemTreatmentofobstetricsTerminationofpregnancy（終止妊娠）OperativevaginaldeliveryCesareandeliveryIndicatioofhysterectomy:hemorrhoea,bloodclottingdisorderRuptureofUterus

子宮破裂1.掌握子宮破裂的臨床表現(xiàn)、診斷及病理縮復(fù)環(huán)的臨床意義

2.熟悉子宮破裂的原因

3.了解子宮破裂的防治措施

教學(xué)大綱Theruptureofuterinebodyorloweruterinesegmentoccursduringthethird-trimesterorthecourseoflaborRuptureofuterusisapotentialobstetriccatastropheandamajorcauseofmaternalandfetaldeathDefinitionEtiologyObstructivedystocia梗阻性難產(chǎn)Injuredruptureofuterus產(chǎn)科子宮損傷Scaruterus疤痕子宮Themisuseofhysterotonics宮縮劑

ClassificationByreason:spontaneousruptureinjuredruptureBytime:ruptureduringpregnencyruptureduringdeliveryBylevelofrupture:completeruptureincompleteruptureBythepositionofrupture:ruptureatbodyofuterusruptureatloweruterinesegmentClinicalmanifestationThreateneduterinerupture:Pathologicretrationring病理性縮復(fù)環(huán)

Abdominaltenderness下腹痛

Alterationinfetalheartrate胎心異常

Hematuria血尿RuptureofuterusComplete&incomplete臨床表現(xiàn)：不完全性子宮破裂子宮肌層部分或全層破裂，漿膜層完整宮腔與腹腔不相通胎兒及其附屬物仍在宮腔子宮一側(cè)捫及血腫塊胎心率異常臨床表現(xiàn)：完全性子宮破裂子宮肌層全層破裂宮腔與腹腔相通下腹撕裂樣劇痛、休克體征羊水血液進(jìn)入腹腔后持續(xù)性腹痛腹壁下可捫及胎體、胎動消失陰道檢查先露升高、宮口回縮DiagnosisMedicalhistoryThecourseofdeliveryClinicalsituationSignsDifferentialDiagnosis:placentalabruptionordystociacombinewithperitonitis腹膜炎TreatmentThreateneduterinerupture

InhibituterinecontractionimmediatelyCesareandeliveryRuptureofuterusAntishock,operationCrackmended,subtotalhysterectomy子宮次全切除術(shù)，totalhysterectomy預(yù)防搞好計(jì)劃生育，減少人流多產(chǎn)有高危因素者，加強(qiáng)產(chǎn)前檢查正確處理產(chǎn)程嚴(yán)格掌握縮宮素應(yīng)用指征正確掌握產(chǎn)科手術(shù)助產(chǎn)的指征及操作規(guī)范正確掌握剖宮產(chǎn)指征DysfunctionofCord

臍帶異常

臍帶異常1.了解臍帶先露與臍帶脫垂的區(qū)別

2.了解臍帶各種異常的概念臍帶先露與臍帶脫垂定義：

胎膜未破時(shí)臍帶位于胎先露部前方或一側(cè)，稱為臍帶先露或隱形臍帶脫垂。當(dāng)胎膜破裂，臍帶脫出于宮頸口外，降至陰道內(nèi)，甚至露于外陰部，稱為臍帶脫垂。FunispresentationandprolapseofcordEtiopathogenisis；abnormalofpelvis,cephalopelvicdisproportionabnormaloffetalpositionlongcordpolyhydramniosothers

臍帶先露及臍帶脫垂高危因素胎膜未破，胎動及宮縮后胎心率減速改變體位、上推先露及抬高臀部后胎心迅速恢復(fù)破膜后出現(xiàn)胎心率異常陰道檢查觸及臍帶、臍帶血管的搏動情況胎先露旁或前方觸及臍帶、臍帶脫于外陰B超有助于診斷

處理：臍帶先露

經(jīng)產(chǎn)婦、胎膜未破、宮縮好，可陰道試產(chǎn)頭低臀高位、密切