PlacentalAbruptionPlacentalAbruptionGeneralConsiderationDefinition

separationofthenormallylocatedplacentaafterthe20thgestationalweekandpriortobirth.Incidence

0.51%-2.33%(ourcountry)0.5%(othercountries)Incidenceoffetaldeath

200‰-350‰GeneralConsiderationDefinitioThemostimportantcauseofvaginalbleedinginlatepregnancyCauseofbleedingproportionPlacentalAbruption31.7%Placentaprevia12%Lesionofcervix7%FactorsofCord1%Nocause40%ThemostimportantcauseofvaSeverecomplicationofpregnancyCausesofhemorrhageNumber(%)PlacentalAbruption141(19)Laceration/uterinerupture125(16)Uterineatony115(15)Coagulopathies108(14)Placentaprevia50(7)Placentaaccreta/increta/percreta44(6)Uterinebleeding47(6)Retainedplacenta32(4)Causesof763pregnancy-relateddeathsduetohemorrhage1999SeverecomplicationofpregnanEtiologyUncertain(primarycause)RiskfactorsVasculardiseases:preeclampsia,chronichypertension,renaldisease.Mechanicalfactors:abdomenstrick,intercourse,extremeshortnessofumbilicalcord（臍帶過短）amniocentesis（羊膜穿刺術）

uterinevolumesuddenlynarrowanduterinecavitypressuredrop：ruptureofmembranewhenpolyhydramnios（羊水過多）IncreasedageandparitySuddenincreaseinuterinevenouspressure：Supinehypotensivesyndrome（仰臥位低血壓）other：Smoking,cocaineuse,uterinemyoma，RaceEtiologyUncertain(primarycauPathologyMainchange

hemorrhageintothedeciduabasalis→deciduasplits→decidualhematoma→separation,compression,destructionoftheplacentaadjacenttoitTypesrevealedabruptionconcealedabruption,mixedtypeUteroplacentalapoplexy子宮胎盤卒中PathologyMainchange產科學英文課件：13-Placental-AbruptionTypesrevealedabruptionconcealedabruptionmixedtypeTypesrevealedabruptionconcealUteroplacentalapoplexy

Bleedingintothemyometriumoftheuterusgivingadiscoloredappearancetotheuterinesurface.UteroplacentalapoplexyBleAdjunctiveExaminationUltrasonographyPositionofplacenta,severityofabruption,survivaloffetusSigns:retroplacentalhematomaNegativefindingsdonotexcludeplacentalabruptionLaboratoryexaminationconsumptivecoagulopathy:Rt,DICFunctionofliverandkidney.AdjunctiveExaminationUltrason產科學英文課件：13-Placental-AbruptionManifestation

VaginalbleedingalongwithabdominalpainMildtypeabruption≤1/3,apparentvaginalbleedingSeveretypeabruption>1/3,largeretroplacentalhematoma,vaginalbleedingcompaniedbypersistentabdominalpain,tendernessontheuterus,changeoffetalheartrate.shockandrenalfailure.Manifestation

Vaginalbleeding0IIIIIIdefinedbypostpartumcheckplacentaabruptionarea<1/3

abruptionarea1/3

abruptionarea>1/2NoorlitterbleedingnoabdominalpainNo→moderatevaginalbleedingabdominalpainNo→severevaginalbleedingSeverepainuterine=gestationweeksuterine>gestationweeksuterine>gestationweeksuterinesoft，noorlittertenderness

moderate→severeuterinetenderness,maybeassociatedwithankylosingcontractionsseverepainwithankylosinguterusMaternalbloodpressureandheartrateisnormalMaternaltachycardia,bloodpressureandheartratechangesMaternalshockNocoagulationdisordersLowfibrinogenemia(150-250mg/dL)Hypofibrinogenemia

<150mg/dLCoagulationdisordersNoFetaldistressFetaldistress，fetusaliveFetaldeath0IIIIIIdefinedbypostpartumcDiagnosissignandsymptomVaginalbleedingUterinetendernessorbackpainFetaldistressHighfrequencycontractionsHypertonus(高張力)IdiopathicpretermlaborFetaldeathDiagnosissignandsymptomDiagnosisUltrasonographyDifferentialdiagnosisPlacentaprevia：Painlessbleedingthreatenedruptureofuterus：dystociaDiagnosisUltrasonographyComplicationDICandcoagulationdisordersHypovolemicshockAmnionicfluidembolism（羊水栓塞）AcuterenalfailureFetaldeathComplicationDICandcoagulatioTreatmentTreatmentwillvarydependingupongestationalageandthestatusofmotherandfetusTreatmentofhypovolemicshock:intensivetransfusionwithbloodAssessmentoffetusTerminationofpregnancy:CSorVaginaldeliveryTreatmentTreatmentwillvarydTreatmentofhypovolemicshockGeneraltreatmentoxygenuptakewithoxygenmaskQuicklymakeupthevolume:

bloodloss,estimatedphysiologicalneedTherehydrationselect:freshwholebloodorplasmaCorrectiveshockindicators

thehematocrit≥30%urinevolume≥30ml/h,bloodpressureandheartratestableTreatmentofhypovolemicshockTerminationofpregnancyMaternalconditionisgood,estimatedaquicklychildbirthImmediateruptureofmembraneShortenthesecondstageoflaborManualremovaloftheplacentaPreventionofpostpartumhemorrhage:

massagetheuterus,contractionagentVaginaldeliveryTerminationofpregnancyVaginaCesareansectionSeveretype，impossiblydeliveryinashorttimeMildtypebutwithfetaldistress;Thelaborprogression:noPreventionofbleedingUteroplacentalapoplexytreatmentTerminationofpregnancyCesareansectionTerminationofTreatmentofDIC

Timely,adequateinputoffreshblood.Infusionoffreshplateletconcentrates.Givefibrinogen:Averageamountof3-6gInfusionoffreshplasma:theadditionoffibrinogen,VIIIfactorTheapplicationofheparin:TheantifibrinolyticdrugapplicationTreatmentofDICMakeupthevolumeDrug:

20%mannitolof250m1rapidintravenousfurosemide40mgintravenousDialysistherapyTreatmentofAcuteRenalFailureWhenurine

<

17mlornourine,renalfailuremayoccured.MakeupthevolumeTreatmentofCaseDiscussion病史患者，女，45歲，2001年12月4日12:10入院因“停經8月余，抽搐2次，神志不清3小時”入院。平素月經不詳，LMP：2001年4月？。孕期未行產前檢查。3小時前突然倒地，口吐白沫，神志不清，四肢抽搐（持續5分鐘）。即刻送當地中心醫院，查體發現血壓176/90mmHg，雙側瞳孔增大，對光放射存在，皮膚黃染，心肺正常，雙下肢水腫（＋＋）。擬診“重度妊高征，子癇”而給予硫酸鎂、降壓藥等治療。在診治過程中又抽搐一次，持續10分鐘。因病情危重，治療效果不佳，轉入我院。26歲時曾患甲肝，生育史：1-0-0-1，順產。CaseDiscussion病史體檢T:37℃;BP:200/110mmHg;P:108;R:28神志不清，面色萎黃，全身皮膚中度黃染，淺表淋巴結無腫大。雙側瞳孔輕度擴大，對光反射存在，心率108次/分，律齊，未及雜音。呼吸有鼾聲，肺部聽診無異常。妊娠腹，腹壁軟，肝脾未及。宮高29.5cm，腹圍93cm，FHR:150-157次/分，子宮壁張力較高，胎位不清，宮縮20秒/5-10分鐘。雙下肢水腫（＋＋），膝反射亢進，病理性反射未引出。陰道檢查：陰道有暗紅色血液流出，量100ml，宮口3cm，胎膜未破，先露頭－2。留置導尿見尿量約100ml，淡醬油色。體檢輔助檢查血常規：WBC:18.4×109/L;N:84.7%;RBC:4.2×1012/L;Hb:137g/L;PLT:59×109/L;HCT:39.4%;尿蛋白4+。電解質：K3.45mmol/L;Na134mmol/L;Cl80mmol/L肝腎功能:LDH:2185U/L;sGPT:310U/L;sGOT:751U/L;AKP:237U/L;總膽紅素:179.3umol/L;直接膽紅素:120.9umol/L;血氨:169umol/L;血糖:6.7mmol/L;肌酐:55umol/L;尿酸:577umol/L;尿素氮:5.9umol/L。D二聚體弱陽性;FDP(+)產科B超：宮內見一活胎，雙頂徑8.1cm，胎盤II級，位于前壁，羊水指數13.7cm，胎盤與子宮壁之間見一液性暗區，大小為7×6.5×4cm3。輔助檢查肝膽B超提示：肝內光點增多、增粗、分布不均，血管紋理欠清，膽囊壁毛糙。入院診斷孕8+月，先兆早產，胎盤早剝，重度妊高征，子癇，HELLP綜合征，妊娠合并重癥肝炎？肝昏迷？肝膽B超提示：肝內光點增多、增粗、分布不均，血管紋理欠清，膽治療經過（12:10入院）硫酸鎂解痙、硝普鈉降壓、甘露醇降低顱內壓、保肝、抗感染及輸新鮮血漿等治療，病情得到控制，仍神志不清，血壓控制在(150-160)/(100-110)mmHg，尿量逐漸增多，尿色變淡。血小板下降為42×109/L；PT和KPTT正常；纖維蛋白原無進行性下降。頭顱CT示：腦水腫，右側顳、頂部皮下血腫人工破膜，羊水為淡血性，宮縮逐漸增強15:25經陰道娩出一活男嬰，體重2390克，新生兒重度窒息，轉兒科醫院。治療經過（12:10入院）產后宮縮好，陰道出血少，檢查胎盤可見胎盤母面有壓跡及陳舊性血塊。剝離面積接近1/320:10血小板29×109/L，輸血小板2單位。血壓150/100mmHg，改用酚妥拉明維持降壓。入院第二天（5日5AM）患者清醒，皮膚黃染明顯消退，尿色清，繼續解痙、降壓、保肝和維持電解質平衡。復查：LDH:1111U/L;sGPT:165U/L;sGOT:132U/L;總膽紅素:34umol/L;直接膽紅素:20.5umol/L;尿酸:473umol/L;血小板:55×109/L。入院第三天（6日）：血壓120/80mmHg，降壓藥改為柳胺芐心定和硝苯啶口服，血小板:65×109/L產后宮縮好，陰道出血少，檢查胎盤可見胎盤母面有壓跡及陳舊性血ThanksThanksPlacentalAbruptionPlacentalAbruptionGeneralConsiderationDefinition

separationofthenormallylocatedplacentaafterthe20thgestationalweekandpriortobirth.Incidence

0.51%-2.33%(ourcountry)0.5%(othercountries)Incidenceoffetaldeath

200‰-350‰GeneralConsiderationDefinitioThemostimportantcauseofvaginalbleedinginlatepregnancyCauseofbleedingproportionPlacentalAbruption31.7%Placentaprevia12%Lesionofcervix7%FactorsofCord1%Nocause40%ThemostimportantcauseofvaSeverecomplicationofpregnancyCausesofhemorrhageNumber(%)PlacentalAbruption141(19)Laceration/uterinerupture125(16)Uterineatony115(15)Coagulopathies108(14)Placentaprevia50(7)Placentaaccreta/increta/percreta44(6)Uterinebleeding47(6)Retainedplacenta32(4)Causesof763pregnancy-relateddeathsduetohemorrhage1999SeverecomplicationofpregnanEtiologyUncertain(primarycause)RiskfactorsVasculardiseases:preeclampsia,chronichypertension,renaldisease.Mechanicalfactors:abdomenstrick,intercourse,extremeshortnessofumbilicalcord（臍帶過短）amniocentesis（羊膜穿刺術）

uterinevolumesuddenlynarrowanduterinecavitypressuredrop：ruptureofmembranewhenpolyhydramnios（羊水過多）IncreasedageandparitySuddenincreaseinuterinevenouspressure：Supinehypotensivesyndrome（仰臥位低血壓）other：Smoking,cocaineuse,uterinemyoma，RaceEtiologyUncertain(primarycauPathologyMainchange

hemorrhageintothedeciduabasalis→deciduasplits→decidualhematoma→separation,compression,destructionoftheplacentaadjacenttoitTypesrevealedabruptionconcealedabruption,mixedtypeUteroplacentalapoplexy子宮胎盤卒中PathologyMainchange產科學英文課件：13-Placental-AbruptionTypesrevealedabruptionconcealedabruptionmixedtypeTypesrevealedabruptionconcealUteroplacentalapoplexy

Bleedingintothemyometriumoftheuterusgivingadiscoloredappearancetotheuterinesurface.UteroplacentalapoplexyBleAdjunctiveExaminationUltrasonographyPositionofplacenta,severityofabruption,survivaloffetusSigns:retroplacentalhematomaNegativefindingsdonotexcludeplacentalabruptionLaboratoryexaminationconsumptivecoagulopathy:Rt,DICFunctionofliverandkidney.AdjunctiveExaminationUltrason產科學英文課件：13-Placental-AbruptionManifestation

VaginalbleedingalongwithabdominalpainMildtypeabruption≤1/3,apparentvaginalbleedingSeveretypeabruption>1/3,largeretroplacentalhematoma,vaginalbleedingcompaniedbypersistentabdominalpain,tendernessontheuterus,changeoffetalheartrate.shockandrenalfailure.Manifestation

Vaginalbleeding0IIIIIIdefinedbypostpartumcheckplacentaabruptionarea<1/3

abruptionarea1/3

abruptionarea>1/2NoorlitterbleedingnoabdominalpainNo→moderatevaginalbleedingabdominalpainNo→severevaginalbleedingSeverepainuterine=gestationweeksuterine>gestationweeksuterine>gestationweeksuterinesoft，noorlittertenderness

moderate→severeuterinetenderness,maybeassociatedwithankylosingcontractionsseverepainwithankylosinguterusMaternalbloodpressureandheartrateisnormalMaternaltachycardia,bloodpressureandheartratechangesMaternalshockNocoagulationdisordersLowfibrinogenemia(150-250mg/dL)Hypofibrinogenemia

<150mg/dLCoagulationdisordersNoFetaldistressFetaldistress，fetusaliveFetaldeath0IIIIIIdefinedbypostpartumcDiagnosissignandsymptomVaginalbleedingUterinetendernessorbackpainFetaldistressHighfrequencycontractionsHypertonus(高張力)IdiopathicpretermlaborFetaldeathDiagnosissignandsymptomDiagnosisUltrasonographyDifferentialdiagnosisPlacentaprevia：Painlessbleedingthreatenedruptureofuterus：dystociaDiagnosisUltrasonographyComplicationDICandcoagulationdisordersHypovolemicshockAmnionicfluidembolism（羊水栓塞）AcuterenalfailureFetaldeathComplicationDICandcoagulatioTreatmentTreatmentwillvarydependingupongestationalageandthestatusofmotherandfetusTreatmentofhypovolemicshock:intensivetransfusionwithbloodAssessmentoffetusTerminationofpregnancy:CSorVaginaldeliveryTreatmentTreatmentwillvarydTreatmentofhypovolemicshockGeneraltreatmentoxygenuptakewithoxygenmaskQuicklymakeupthevolume:

bloodloss,estimatedphysiologicalneedTherehydrationselect:freshwholebloodorplasmaCorrectiveshockindicators

thehematocrit≥30%urinevolume≥30ml/h,bloodpressureandheartratestableTreatmentofhypovolemicshockTerminationofpregnancyMaternalconditionisgood,estimatedaquicklychildbirthImmediateruptureofmembraneShortenthesecondstageoflaborManualremovaloftheplacentaPreventionofpostpartumhemorrhage:

massagetheuterus,contractionagentVaginaldeliveryTerminationofpregnancyVaginaCesareansectionSeveretype，impossiblydeliveryinashorttimeMildtypebutwithfetaldistress;Thelaborprogression:noPreventionofbleedingUteroplacentalapoplexytreatmentTerminationofpregnancyCesareansectionTerminationofTreatmentofDIC

Timely,adequateinputoffreshblood.Infusionoffreshplateletconcentrates.Givefibrinogen:Averageamountof3-6gInfusionoffreshplasma:theadditionoffibrinogen,VIIIfactorTheapplicationofheparin:TheantifibrinolyticdrugapplicationTreatmentofDICMakeupthevolumeDrug:

20%mannitolof250m1rapidintravenousfurosemide40mgintravenousDialysistherapyTreatmentofAcuteRenalFailureWhenurine

<

17mlornourine,renalfailuremayoccured.MakeupthevolumeTreatmentofCaseDiscussion病史患者，女，45歲，2001年12月4日12:10入院因“停經8月余，抽搐2次，神志不清3小時”入院。平素月經不詳，LMP：2001年4月？。孕期未行產前檢查。3小時前突然倒地，口吐白沫，神志不清，四肢抽搐（持續5分鐘）。即刻送當地中心醫院，查體發現血壓176/90mmHg，雙側瞳孔增大，對光放射存在，皮膚黃染，心肺正常，雙下肢水腫（＋＋）。擬診“重度妊高征，子癇”而給予硫酸鎂、降壓藥等治療。在診治過程中又抽搐一次，持續10分鐘。因病情危重，