高危孕产妇的管和理救治.ppt

高危孕产妇的管理和临床救治 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 高危孕产妇的早识别早诊断 首先依赖于各位、依赖于我们县、乡、 村的三级网络。 网底清数管理，村妇女主任、责任医生 培训，充分发挥由下而上网底作用。 早建卡（孕13周前）、孕4月、孕6月复 诊进行产前筛查及三围B超检查、孕28 周以后要求所有孕妇都应该到县级医院 妇产科再次高危筛查。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 开始于受孕及孕前 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 常见高危因素 孕妇基本情况：年龄、身高、体质、不 孕史 不良孕产史 内外科合并症 产科并发症 社会因素：经济、文化、交通等 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 高危管理原则（1） 不论早、中、晚孕，每一次的检查 都应该是系统全面的，以尽早地筛 查、识别、诊断高危妊娠，规范高 危管理。 想方设法不断提高高危妊娠管理的“ 三率”：检出率、随诊率、住院分娩 率。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 孕4月产前筛查 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 中孕及晚孕各期检查 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 高危管理原则（2） 筛查出妊娠禁忌症的，给会诊后，动员 尽早终止妊娠。可以继续妊娠的，要选 择最佳时机、最有利的分娩方式，有计 划地分娩。 同时要强调的是我们必须注重宣教：通 过注意饮食、环境、避免感染及药物影 响等多环节来积极预防。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 孕产妇的危急重症（1） 气道：阻塞 呼吸：25-30次或 6次，端坐呼吸， SPO2 90%,紫绀、 哮鸣音 循环：血压、心率 130次，胸痛背痛 泌尿：少尿无尿血尿 血液：出血、不凝、 淤斑、三系减少 高热 神经：意识下降、紊 乱、抽搐 消化：腹痛腹胀黄疸 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 危急重症（2） 需关注的病人：疼痛不止、治疗无效、 不能及时得到急救、有纠纷可能的，有 不良孕产史 胎儿因素：巨大儿、胎位异常、双胎妊 娠 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 院内急救管理 急诊往往以发热、腹痛、阴道出血、呼 吸困难等症状就诊，必要时应该在内、 外科医生配合下进行快速鉴别，初步诊 断，将产科的急诊识别出来，积极处理 ，防止发展到危重程度。 对急诊做出最快速的反应 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 院内急救管理（一） （一）急诊的初步处理 任何急诊的最初步骤包括： 1.让患者平静，医务人员的思考要有逻 辑，关注患者的需要 2.要时刻有人关照患者。 3.专人负责，以免造成混乱 4.呼救 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 院内急救管理（一） 5.如患者昏迷则评估其呼吸道是否通畅 ，呼吸、循环状况。 6.如已表现为休克，则即刻进行抢救（ 保持呼吸道通畅、建立静脉通道等）； 如怀疑休克，应立即治疗；对有可能发 展为休克的，应立即做好预防。 7.患者左侧卧位，下肢抬高，解开衣服 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 院内急救管理（一） 8.与患者交谈，帮其平静，询问病史 9.在询问、安顿同时，尽快检查：生命 体征、皮肤颜色、估计失血量、评估症 状及体征。 10.若需转诊的，紧急转诊到上级医院， （转诊前完成所有紧急治疗） Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 院内急救管理（二） （二）院内急救组织的管理 1.人员配备：院领导、总值班、科主任 、检验、药剂、麻醉人员、内外科 2.现场抢救人员的组织分工：总指挥、 行动组、监测组、评估、沟通 3.急救小组人员知识技能：基础理论、 基本知识、基本技能 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 院内急救管理（三） （三）急救药品和器械设备管理 1.在产科门诊、产科病房、产房、手术 室都应有急救柜和急救车 2.每天专人负责核查急救车、柜中的药 品、用品是否齐全、完好，并记录。 3.急救用品度必须有明确的标识，人员 都能清楚并熟练使用。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 孕产妇抢救管理要求（一 ） 建立各级绿色通道（急救组织及组织职能:人 员、设备、药品、血源， 院内孕产妇抢救绿色通道：1.各级人员在岗在 位，随时准备应对危重患者，确保绿色通道 24小时畅通。2.危重患者就诊的整个过程要有 绿色通道标志，各环节均快速优先实施。3.门 诊病人抢救由门诊妇产科主任与急诊护士长负 责实施，并与病房主任联系，入病房途中派医 护陪同。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 孕产妇抢救管理要求（二 ） 急救小组成员必须随叫随到，要求10分钟内到 达抢救现场。有特殊情况不在位时，要安排好 相应职称的临时替班人。 药品、设备放于固定位置，保持完备和使用状 态。 人员分工明确、各负其责、紧密配合，严密观 察、详细记录。 抢救结束要及时总结经验教训，发现不足及时 整改 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 产科出血是古老而又现代的问题，目前为止依 然是孕产妇死亡的前三位原因之一，产科出血 中又以产后出血为主。 孕6周起血容量逐渐增加到孕32周达高峰，维持 到产后，总血容量增加约3060%，所以， 出血在20%以下时常不出现明显的低血容量性 休克。这有利于耐受代偿，但也容易忽略危险 信号 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 早期识别产后出血 产后2小时达到400ml 即使产后出血量未达诊断标准，但产妇 血流动力学参数持续下降甚至出现休克 ，无法用其他疾病解释 出血量虽不足400ml，但出血迅猛者。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 产后出血紧急处理原则 吸氧5-6升/分、两条静脉通路，积极抗休克 监测生命指标：T,P,R,BP,尿量/hr、记出入量 、心电监护、验血配血等检查 寻找原因，有针对性止血：用手正确按压子宫 检查软产道, 同时请会诊、呼救 防治并发症：DIC，ARDS，肾衰、感染, Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 抢救处理要求 血压大于100mmHg，心率小 于100次/分，尿量大于 30ml/小时，HCT大于30% 。 血小板50*109/L以上,纤维蛋 白原1.5g/L以上 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 产后出血四大原因 宫缩乏力：70% 子宫及产道损伤：20% 组织残留、胎盘植入：9% 凝血功能异常：1% Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 宫缩乏力 催产素：受体饱和。抗利尿。避免直接快速静 滴，否则易致低血压。 麦角：宫体和子宫下段强直性收缩，胎盘没有 剥离之前，催产素好于麦角。高血压患者禁用 米索前列醇或卡孕栓 卡前列腺素（如欣母沛）：能控制86%其他方 法无效的出血，可15分钟重复使用。10%可 能有副作用，其他药物无效时使用。哮喘禁用 。可能致心动过速、发热、腹泻 一次宫缩可增加回心血量500ml(缩宫剂、喂 奶） Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 损伤性出血9% 内出血、外出血：症状与出血量不相符 血肿（有时可能没有阴道或会阴烈伤） 。 合适的患者体位，足够的医师协助、良 好的灯光、适当的器械、良好的麻醉 解剖结构的修复。 不典型子宫破裂 保守与积极治疗的选择时机 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 胎盘因素20% 仔细检查胎盘是否完整，副胎盘 植入胎盘的处理： MTX 50mg im 息隐 25mg po bid 天花粉 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 血凝异常1% 子痫前期 死胎 胎盘早剥 羊水栓塞（不典型羊水栓塞；氢化考的松500 -1000mg或者甲强龙500mg,罂粟碱） 严重感染 特发性血小板减少性紫癜 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 试管内凝血观察试验 提供了了解纤维蛋白原的一个简单方法 采患者5ml血液置于干净的15ml试管， 若纤维蛋白原浓度大于150mg/dl,血液会 在6分钟内凝固并保持完整。如果纤维蛋 白原浓度低于100mg/dL，试管里血液 30分钟内不会凝固或凝后又溶解 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 产科休克与出血量 出血20%,1000ml,血压不降、心率 加快 出血30%,1500ml,血压下降等休克 症状 出血40%,2000ml,血压下降、重度 休克 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. DIC诊断 1.同时具有以下三项异常：血小板低于 100*109/L,纤维蛋白原 低于150mg/dl,PT大于15秒 ，3P试验阳性 2.试管内凝血试验 3.休克程度 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 是妊娠期特有的疾病，严重危害母婴健 康的妊娠并发症，发生率2-7%。 发生于孕20周以后，表现为高血压、蛋 白尿、浮肿、重者头痛、呕吐、胸闷、 抽搐、昏迷，甚至死亡。 基本病变是全身小动脉痉挛 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 妊娠期高血压疾病分类 根据病情可分为：妊娠期高血压、子痫 前期（轻度、重度）、子痫。 根据发病时间早晚分为早发型、晚发型 早发型重度子痫前期约占妊娠期高血压 疾病的0.9%。目前国内多以孕34周为界 进行划分。 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 早发型重度子痫前期 对母亲的影响 胎盘早剥（出血、死胎、DIC）、产后 出血（血管内皮损伤性疾病、子宫小动 脉变性硬化坏死、子宫肌细胞水肿、收 缩力下降；镇静降压药子宫肌肉松弛） 、肾微动脉损害（可以出现管型）、心 肺、 HELLP综合征（溶血、肝酶升高、 血小板减少）、脑出血、视网膜病变 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 早发型重症对胎儿的影响 子宫胎盘循环阻力增加、绒毛浸润受阻 、胎盘钱着床，血管粥样硬化、绒毛血 管广泛梗塞、功能不足，胎儿缺氧 小孕周早产儿、胎儿生长受限、肺透明 膜病变、缺陷儿增加（慢性呼吸异常、 智力发育迟缓、脑瘫、视网膜病变导致 的视觉、听力障碍丧失 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 轻度患者可在家休息，保证睡眠，必要 时住院 左侧卧位，注意蛋白质维生素、铁钙剂 的摄入，全身浮肿者可适当限制食盐 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 中重度处理原则 一经确诊，就应住院治疗，积极防止病情发 展加重。空气、安静、检查治疗护理轻柔 解痉：首选25%硫酸镁，抑制运动神经末梢对乙 酰胆碱的释放，阻止神经肌肉间的传导，骨骼 肌松弛。每日用量15-20克，滴速每时1-2克 毒性反应（正常孕妇血镁1.0，1.7-3mmol/L）， 注意事项 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 镇静： 地西泮（在抽搐发作时静注可能致心跳骤 停） 冬眠1号合剂（哌替啶100mg，氯丙嗪 50mg，异丙嗪50mg） Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 降压 硝酸甘油1ml(5mg) 加入生理盐水49ml 静脉 微泵，3-6-9 ml/h 立其丁50mg 加入40ml生理盐水微泵，3-4-6 ml/h 硝苯地平 拉贝洛尔 Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 扩容（白蛋白血浆、右旋糖酐、平衡液 ） 利尿（呋塞米对脑水肿、无尿或少尿者 效果显著，对心衰肺水肿效果良好；甘 露醇为渗透性利尿剂，重症若少尿或需 降颅内压时，但若出现心衰、肺水肿的 患者禁用） Evaluation only.Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile .Created with Aspose.Slides for .NET 3.5 Client Profile . Copyright 2004-2011 Aspose Pty Ltd.Copyright 2004-2011 Aspose Pty Ltd. 适时终止妊娠 终止妊娠指征：子痫前期经积极治疗24-48小 时无明显好转；子痫