分娩并发症(双语)课件

ComplicationofLabor&Delivery

分娩并发症SyllabusPostpartumHemorrhage（产后出血）AmnioticFluidEmbolism（羊水栓塞）RuptureofUterus（羊水栓塞）DysfunctionofCord（脐带异常）PostpartumHemorrhage

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

病因

子宫收缩乏力：常见原因

全身因素（紧张、恐惧、虚弱）产科因素（产程长、并发症及合并症）子宫因素（子宫肌纤维过分伸展，肌壁损伤、子宫病变）药物因素EtiologyRetainedplacentaltissue:retainedplacenta滞留

placentaaccretaorincreta

粘连/植入

residualpartoftheplacenta部分残留DiagnosisClinicalfindingsDeterminationofbloodloss:Weightingmethod,volumetricmethod,planimetry(面积法)Shockindex=pulserate/systolicpressureIndex0.51.01.52.0Lossbloodnormal10~3030~5050~70%ml-500~15001500~20002500~3000

诊断子宫收缩乏力宫底升高子宫质软、轮廓不清阴道流血多按摩或缩宫后子宫变硬阴道流血减少或停止

诊断软产道裂伤宫颈、阴道、会阴裂伤宫颈裂伤常在3、9点处、可延伸I度裂伤II度裂伤III度裂伤IV度裂伤

诊断凝血功能障碍持续阴道流血血液不凝止血困难全身多部位出血凝血功能检查异常正面观背面观正面观B-Lynch子宫缝合法

处理软产道损伤彻底止血、逐层缝合宫颈裂伤>1cm，活动性出血，应缝合第一针应超过裂口顶端不留死腔、避免穿透直肠黏膜避免损伤膀胱和输尿管血肿应切开，彻底止血后缝合必要时引流

处理凝血功能障碍应排除其它引起产后出血的因素输新鲜血补充血小板、凝血物质并发DIC后积极处理

处理失血性休克正确估计出血量及休克程度针对病因止血的同时积极抗休克建立有效静脉通道、补液、血浆、升压给氧、纠正酸中毒、保护脏器功能防治感染预防加强产检，加强对高危妊娠的管理搞好计划生育，减少人流次数有高危因素者，加强产前检查正确处理产程加强产后观察，特别是产后2小时AmnioticFluidEmbolism,AFE

羊水栓塞1.熟悉羊水栓塞的临床表现、诊断以及处理原则

2.熟悉羊水栓塞的预防措施

3.了解羊水栓塞的病因、病理生理变化。

教学大纲AmnioticFluidEmbolismisacomplexconditioncharacterizedbytheabruptonsetofpulmonaryembolism,shockandDIC,renalfailureorsuddendeath.IncidenceislowCharacteristic:Itishardtopredictandisadangerousobstetricscomplication,thedeathrateisabout70%-80%DefinitionEtiologyTheformedelementsinamnioticfluidenterintomaternalcirculationduringdeliveryorcesareansection.EtiologyCondition:openingvessels,uterinehypertonusInducement诱因:ruptureofuterus,lacerationofcervix,placentapraevia,placentalabruptionPredilectionfactors:primiparity初产

,allergy,precipitatelabor急产,tetaniccontraction强直性宫缩Pulmonaryarteryhypertension,PAH肺动脉高压AllergicshockDisseminatedintravascularcoagulation,DICAcuterenalfailure;ARFPathophysiologyFormedelementsPAHAcutecordextrumfailurePEaRCFSEPaSTNB.SPFClinicalfindingⅠstage---Shock,Respiratoryandcirculatoryfailureandhypoxemia低氧血症Ⅱstage---DIC:bleeding,bloodclottingdisorderandthenhemorrhagicshockⅢstage---Acuterenalfailure(ARF):oliguria少尿

andrenaldysfunction肺动脉高压：羊水有形物质形成栓子进入肺循环，阻塞小血管，血栓形成，血管痉挛，可导致右心衰竭，休克，甚至死亡。过敏性休克：I型变态反应、血压骤降心肺功能衰竭病理生理DIC：羊水中促凝物质形成大量微血栓，消耗凝血物质，形成DIC，极易发生严重产后出血及失血性休克急性肾衰竭：DIC及休克导致肾急性缺血病理生理

临床表现

呼吸循环衰竭和休克DIC引起的出血急性肾衰竭起病急骤、来势凶险、多在分娩过程中！！！症状可不典型、也可只出现部分症状！！！DiagnosisEmergent:typicalclinicalmanifestationAuxiliaryexamination

AmnioticfluidcomponentsarefindinbloodDICexaminationECGChestX-rayAutopsy尸解

Treatmentprinciple抗过敏的同时，改善低氧血症--呼吸功能保持心输出量和血压--循环功能防止血管内凝血--凝血功能防治肾衰--脏器功能TreatmentstepOxygen:Trachealintubation气管插管

ReliefPAH:Papaverinehydrochloride(罂粟硷),Atropine（阿托品），Aminophylline（氨茶碱），Phentolamine（酚妥拉明）Anti-anaphylaxis：Dexamethasone(地塞米松)Anti-shock：Dopamine（多巴胺），Metaraminol（间羟胺），5%SodiumBicarbonate（5%碳酸氢钠），LanatosideC（西地兰）TreatmentofDICMechanismofobstetricDIC:Extrinsiccoagulationsystem

外源性凝血系统Intrinsiccoagulationsystem

内源性凝血系统TreatmentofDICThestagesofDIC高凝期凝血酶↑血球压积↑微血栓形成消耗性低凝期血小板↓纤维蛋白原↓凝血因子Ⅴ、Ⅷ、Ⅻ↓

纤溶亢进期FDP↑继而D-2聚体↑TreatmentofDICTreatmentAnticoagulation抗凝

(Heparin肝素):HypercoagulableperiodBloodcoagulationfactorsAnti-fibrinolysis抗纤溶ThestageoforganexhaustionTopreventrenalfailure----

blood-volume,diuretica利尿剂Topreventcerebralpalsy----

icecap,dehydrater脱水剂Anti-infectionTopreventdigestivesystemTreatmentofobstetricsTerminationofpregnancy（终止妊娠）OperativevaginaldeliveryCesareandeliveryIndicatioofhysterectomy:hemorrhoea,bloodclottingdisorderRuptureofUterus

子宫破裂1.掌握子宫破裂的临床表现、诊断及病理缩复环的临床意义

2.熟悉子宫破裂的原因

3.了解子宫破裂的防治措施

教学大纲Theruptureofuterinebodyorloweruterinesegmentoccursduringthethird-trimesterorthecourseoflaborRuptureofuterusisapotentialobstetriccatastropheandamajorcauseofmaternalandfetaldeathDefinitionEtiologyObstructivedystocia梗阻性难产Injuredruptureofuterus产科子宫损伤Scaruterus疤痕子宫Themisuseofhysterotonics宫缩剂

ClassificationByreason:spontaneousruptureinjuredruptureBytime:ruptureduringpregnencyruptureduringdeliveryBylevelofrupture:completeruptureincompleteruptureBythepositionofrupture:ruptureatbodyofuterusruptureatloweruterinesegmentClinicalmanifestationThreateneduterinerupture:Pathologicretrationring病理性缩复环

Abdominaltenderness下腹痛

Alterationinfetalheartrate胎心异常

Hematuria血尿RuptureofuterusComplete&incomplete临床表现：不完全性子宫破裂子宫肌层部分或全层破裂，浆膜层完整宫腔与腹腔不相通胎儿及其附属物仍在宫腔子宫一侧扪及血肿块胎心率异常临床表现：完全性子宫破裂子宫肌层全层破裂宫腔与腹腔相通下腹撕裂样剧痛、休克体征羊水血液进入腹腔后持续性腹痛腹壁下可扪及胎体、胎动消失阴道检查先露升高、宫口回缩DiagnosisMedicalhistoryThecourseofdeliveryClinicalsituationSignsDifferentialDiagnosis:placentalabruptionordystociacombinewithperitonitis腹膜炎TreatmentThreateneduterinerupture

InhibituterinecontractionimmediatelyCesareandeliveryRuptureofuterusAntishock,operationCrackmended,subtotalhysterectomy子宫次全切除术，totalhysterectomy预防搞好计划生育，减少人流多产有高危因素者，加强产前检查正确处理产程严格掌握缩宫素应用指征正确掌握产科手术助产的指征及操作规范正确掌握剖宫产指征DysfunctionofCord

脐带异常

脐带异常1.了解脐带先露与脐带脱垂的区别

2.了解脐带各种异常的概念脐带先露与脐带脱垂定义：

胎膜未破时脐带位于胎先露部前方或一侧，称为脐带先露或隐形脐带脱垂。当胎膜破裂，脐带脱出于宫颈口外，降至阴道内，甚至露于外阴部，称为脐带脱垂。FunispresentationandprolapseofcordEtiopathogenisis；abnormalofpelvis,cephalopelvicdisproportionabnormaloffetalpositionlongcordpolyhydramniosothers

脐带先露及脐带脱垂高危因素胎膜未破，胎动及宫缩后胎心率减速改变体位、上推先露及抬高臀部后胎心迅速恢复破膜后出现胎心率异常阴道检查触及脐带、脐带血管的搏动情况胎先露旁或前方触及脐带、脐带脱于外阴B超有助于诊断

处理：脐带先露

经产妇、胎膜未破、宫缩好，可阴道试产头低臀高位、密切