妇产科：胎儿窘迫等（英文课件）

1、Post Partum Hemorrhage Uterine Rupture, Fetal Distress,Post partum hemorrhage,Post partum hemorrhage,Past partum hemorrhage denotes excessive bleeding (500ml in vaginal delivery) during the first 24 hours after delivery；Cesarean section 1000ml Common cause of death and diseases in pregnant women glo

2、bally Leading cause of death in pregnant women in China Incidence 2%-3% of total number of deliveries,2000-2012年浙江省和全国孕产妇死亡率比较（1/10万）,Etiology,Uterine atony: 70% Obstetric lacerations: 20% Retained placental tissue: 10% Coagulation:1%,Uterine atony,General factors: extreme nervousness, weak， severe

3、anemia Obstetric factors: prolonged labour, placenta previa, placenta abruptio Uterine factors: uterine muscular fiber underdevelopment, such as uterine deformity or myoma; uterine overstretched, such as macrosomia, multiple pregnancy, polyhydramnios Drug factors: sedative, anesthesia, tocolytics,Pl

4、acental factors,Retained placenta Placental incarceration（嵌顿 ） Incomplete placental separation Placental adhesion Placental implantation (accreta, increta, percreta) Residual placenta and amniotic membrane,Implantation of placenta,Birth canal injury,Laceration during labour are usually associated wi

5、th: Poor vulval elasticity Strong labour force, emergency delivery, macrosomia Inadequate skills at assisted vaginal delivery Inadequate cessation of bleeding during episiotomy repair, missing out tears at cervix or fornices,Coagulation disorder,Complications associated with obstetric: amniotic flui

6、d embolism, pregnancy induced hypertensive diseases, placenta abruptio and intrauterine demise Pregnancy liver disease: acute fatty liver, severe hepatitis Hematology diseases: primary thrombocytopenic purpura, aplastic anemia etc,Clinical presentation,Vaginal bleeding: If bleeding occurs immediatel

7、y after delivery of baby, consider birth canal injury If bleeding occurs minutes after delivery of baby, consider placenta factors If bleeding occurs minutes after delivery of placenta, main reasons are uterine atony or retained products of conception Persistent bleeding and blood do not coagulate,

8、consider coagulation disorder,Clinical presentation,Vaginal hematoma Shock: dizziness, paleness, weak pulse, low blood pressure etc,Diagnosis,Estimation of blood loss Ascertain cause of post partum hemorrhage,Estimation of blood loss,Visual observation: only 50%-70% of blood loss Container: kidney d

9、ish, measuring cup Surface area: blood stained 10cmx10cm = 10ml Weighing: 1.05g = 1ml Hct1000ml Hourly urine output 2500ml Shock index = pulse rate/systolic pressure,Shock index (SI),SI =0.5, normal blood volume SI = 0.5-1, blood loss 20%, 500-750ml SI = 1, blood loss 20-30%, 1000-1500ml SI = 1.5, b

10、lood loss 30-50%, 1500-2500ml SI = 2, blood loss 50-70%, 2500-3500ml,Ascertain cause,Uterine atony Fundus goes up Uterine consistency soft After uterine massage or using oxytocin, uterus harden, per vaginal bleeding lessen Categorize into primary and secondary, with direct and indirect causes,Ascert

11、ain cause,Placental factors: Placenta not delivered within 10 minutes of delivery of baby, with massive per vaginal bleed, consider placental factors Residual placenta is a common cause of post partum hemorrhage Must examine the placenta and membrane carefully,Ascertain cause,Birth canal injury Cerv

12、ical tear Vaginal tear Vulval tear,Degree of vulval tear,Degree I: vulval skin and vaginal opening mucosa tear, not reaching muscular layer Degree II: tear into perineal body muscular layer, involving posterior vaginal wall mucosa, may extend up on both sides, making it hard to recognise original an

13、atomy Degree III: external anal sphincter tear Degree : vaginal rectal septum and anterior rectal wall,Degree of vulval tear,Ascertain cause,Coagulation disorder: Patients with blood disorder or DIC caused by delivery etc Sustained per vaginal bleeding, non-clotting, difficulty in hemostasis May hav

14、e bleeding at any parts of the body Diagnose based on history, bleeding characteristics, platelet count, prothrombin time, fibrinogen etc tests,Management,Principal of management Rapid hemostasis according to the cause Replenish volume, correct shock Prevent infection,Management of uterine atony,Rem

15、ove cause Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy,Uterine massage,Management of uterine atony,Remove cause U

16、terine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy,Management of uterine atony,Remove cause Uterine massage: Abdominal f

17、undus massage Abdominal-vaginal bimanual uterine massage Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy,Uterine packing,Management of uterine atony,Remove cause Uterine massage: Abdominal fundus massa

18、ge Abdominal-vaginal bimanual uterine massage Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy,Pelvis vessel ligation,Management of uterine atony,Remove cause Uterine massage: Abdominal fundus massage A

19、bdominal-vaginal bimanual uterine massage Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy,B-Lynch suture,Management of uterine atony,Remove cause Uterine massage: Abdominal fundus massage Abdominal-vag

20、inal bimanual uterine massage Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy,Arterial embolism,Management of uterine atony,Remove cause Uterine massage: Abdominal fundus massage Abdominal-vaginal bima

21、nual uterine massage Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy,Management of placental factors,Retained placenta remove separated placenta quickly Residual placenta or membrane curettage Placenta

22、l adhesion manual removal of placenta Placental implantation never separate forcefully, usually hysterectomy,Management of laceration,Thorough hemostasis Stitch according to anatomical layering First stitch must be 0.5cm above top end When stitching do not leave cavity Avoid stitching through rectal

23、 mucosa Manage cervical tear Manage birth canal hematoma,Manage cervical tear,Management of coagulation disorder,First exclude bleeding caused by uterine atony, placental factors and birth canal injury Actively transfuse fresh whole blood, platelets, fibrinogen or prothrombin complex, clotting facto

24、rs etc If DIC set in, manage DIC,Prevention,Comprehensive antenatal care Appropriate labour management Aggressive post partum monitoring: 2 hours post partum is the peak of post partum hemorrhage, patient must be monitored in labour room for 2 hours,Rupture of uterus,Definition,The body uterine or l

25、ower uterine segment happens to rupture during late pregnancy or labor Rupture of the pregnant uterus is a obstetric catastrophe and major cause of maternal death,Etiology,Descending of presenting part obstruction Inappropriate use of oxytocin、prostaglandin etc Uterine scar: fibroidectomy, caesarean

26、 section Surgical trauma Other: uterine muscular fiber underdevelopment, uterine deformity,Clinical presentation,Happens at late pregnancy or during labour, more during labour Complete rupture and incomplete rupture Spontaneous rupture or traumatic rupture Body rupture or lower segment rupture impen

27、ding uterine rupture uterine rupture,Impending uterine rupture,Obstructed descend of fetal presenting part, prolong labor Pathologic retraction ring Mother shows distress, rapid breathing and heart rate, unbearable pain Urination difficulty, hematuria Fetal heart rate change or unclear,Complete uter

28、ine rupture,sudden abdominal tearing pain uterine contraction ceases temporary relieve of abdominal pain Following blood、amniotic fluid、fetus going into the abdominal cavity, abdominal pain progressively worsen shock manifestations： rapid breathing, paleness, weak pulse, decreasing blood pressure et

29、c,Complete uterine rupture,Tenderness and rebound tenderness throughout abdomen Fetal parts and small uterine body may be easily palpable under abdominal wall Disappearing of fetal movement and fetal heart Vaginal examination Fresh bleeding Cervix becomes smaller Ascend of fetal presenting part Able

30、 to palpate uterine wall rupture per vaginal,Complete uterine rupture,Uterine body scar rupture, usually complete rupture, no obvious impending rupture presentations As the scar tear progressive widens, pain and other presentations progressively worsen, but might not have typical tearing pain,Incomp

31、lete uterine rupture,Usually seen in lower segment caesarean section scar Usual pain symptoms and signs are not obvious May have obvious tenderness at the site of incomplete rupture Incomplete rupture involving uterine artery, may lead to acute massive bleeding May cause broad ligament hematoma and

32、progressively enlarges Irregular fetal heart,Diagnosis,Typical uterine rupture is easily diagnose based in the history, symptoms and signs Incomplete uterine rupture, as signs and symptoms are not obvious, diagnosis is difficult. Ultrasound examination: may show position between fetus and uterus, co

33、nfirming site of rupture,Differential diagnosis,1. Severe placenta abruptio Unbearable abdominal pain, uterine tenderness Disproportion between bleeding volume and degree of anemia Ultrasound may shows retro-placental hematoma, fetus is intrauterine Usually associated with pregnancy induced hyperten

34、sive diseases or trauma,Differential diagnosis,2. Intrauterine infection Usually seen in premature rupture of membrane, prolonged labour, multiple vaginal examination May have abdominal pain and uterine tenderness etc Temperature rise Abdominal examination: fetus is intrauterine White blood cell and

35、 neutrophil counts rise,Management of impending uterine rupture,Suppress uterine contraction :anesthesia, pethidine Oxygen Prepare for emergency surgery Immediate caesarean section, prevent uterine rupture,Management of uterine rupture,Manage shock and operate soonest possible Type of surgery：based

36、on maternal condition, degree of uterine rupture, duration of rupture and degree of infection Tear repair：neat tear, no obvious infection Hysterectomy：big tear, irregular tear or obvious infection, perform subtotal hysterectomy or total hysterectomy,Management of uterine rupture,During surgery caref

37、ully inspect cervix, vagina, bladder, urethra, rectum and all neighboring structures, repair accordingly if damage found Give high dose broad spectrum antibiotics perioperatively to prevent infection,Transfer,Uterine rupture presenting with shock, resuscitate immediately on site If transfer is neces

38、sary, it must be done under the condition where blood transfusion, fluid infusion, resuscitation. abdomen must be bandaged before transporting,Prevention,comprehensive antenatal care Patients of high risk admit hospital 1-2 weeks before expected date of delivery Strengthen observation ability of doc

39、tors and midwives, pick up abnormality during labour promptly Strict indication of usage of oxytocin Strict indication for caesarean section and all vaginal surgery, strict surgical steps, avoid careless surgery, pick up surgical damage promptly,Fetal distress,Definition,Fetus encountering acute or

40、chronic hypoxia intrauterine causing threat to its life and health, is known as fetal distress Fetal distress may be acute or chronic.,Etiology of acute fetal distress,Placenta previa, placental abruptio Cord prolapse, true entanglement, torsion Shock of mother respiratory depression of mother：sedat

41、ive, anesthesia Inappropriate use of oxytocin: too strong, too frequent and uncoordinated uterine contraction,Etiology of chronic fetal distress,Inadequate maternal blood oxygen saturation Utero-placental vascular sclerosis, stenosis placental pathological changes Fetal factor: severe cardiovascular

42、 deformity, all causes leading to hemolytic anemia, etc,Clinical presentations and diagnosis,Fetal heart rate abnormality Meconium stained amniotic fluid Reduced or absent fetal movement,Diagnosis of acute fetal distress,Fetal heart rate abnormality early stage tacchycardia160bpm; during severe hypo

43、xia 110bpm CST shows late deceleration, severe variable deceleration fetal heart rate 100bpm, with frequent late decelrations indicating severe fetal hypoxia, may die intrauterine any moment,Late deceleration,Variable deceleration,Diagnosis of acute fetal distress,Meconium stained amniotic fluid: gr

44、een color, dirty, thick and little volume I degree: light green, II degree: yellowish green, dirty, III degree:brownish yellow, thick,Diagnosis of acute fetal distress,Fetal movement: early stage frequent fetal movement, subsequently reduced to absent Fetal acidosis: fetal scalp blood analysis pH 60

45、mmHg (normal 35 55mmHg),Diagnosis of chronic fetal distress,Reduced or absent fetal movement Abnormal fetal monitoring Low fetal biophysical profile scoring Abnormal umbilical artery blood flow Meconium stained amniotic fluid,Reduced or absent fetal movement,Reduced fetal movement 6 times/2 hours, 5

46、0% drooprate Heart beat disappears：usually 24 hours after absent of fetal movement fetal Normal fetal movement count: 30-100 times/12hours,Abnormal fetal electronic monitoring,NST is known as non-reactive type, during 20 minutes continuous fetal movement fetal heart rate acceleration15bpm, sustainin

47、g15s, baseline variability 5bpm OCT frequent severe variable decelerations or late decelerations are seen,Low biophysical profile scoring,Based on ultrasound assessment of fetal body movement, breathing movement, flexor tone, amniotic fluid volume, couple with fetal electronic monitoring NST results

48、 combined scoring (each variable score 2, total score is 10) Score 3 indicates fetal distress, score 4-7 suspicious fetal hypoxia,Abnormal umbilical artery blood flow,umbilical artery diastolic blood flow reducing absence inversion,Meconium stained amniotic fluid,Amnioscopy examination shows dirty a

49、mniotic fluid in light green or brownish yellow color,Management,Acute fetal distress: emergent treatment Chronic fetal distress: management plan depends on severity of the pregnancy complications, gestational age, fetal maturity, fetal distress condition,Management of acute fetal distress,Give oxygen: face mask or nasal prong continuous oxygen at 10L/min flow Search for cause, active management supine hypotensive syndrome：lie the patient on left lateral position excessive oxytocin leading to uterine hyperstimulation：s