1-2-胎膜早破教学查房

胎膜早破教学查房1患者资料及疾病概述（PatientInformationAndDiseaseOverviview）2实验室检查（LaboratoryTests）病因及临床表现（CauseOfDisease，ClinicalManifestations）34体格检查（PhysicalExamination）目录Contents5治疗要点（Keypointsoftreatment）67护理诊断及措施（Nursingdiagnosisandmeasures）健康教育（HealthyEducation）患者资料及疾病概述PatientInformationAndDiseaseOverviview1姓名：张晶

年龄：25床号：15床住院号：0207941诊断：1.未足月胎膜早破2.G1PO孕36+5周头位待产3.妊娠期糖尿病4.脐带绕颈5.胎盘血窦患者资料Name:ZhangJingAge:25Bednumber:15Admissionnumber:0207941Diagnosis:1.Prematureruptureofmembranesbeforeterm2.G1P0pregnancy36+5weeksfirstpositionwaitingforlabor3.Gestationaldiabetes4.Umbilicalcordaroundneck5.Placentalsinusblood疾病概述胎膜早破(prematureruptureofmembranes,PROM)是指胎膜在临产前自然破裂。依据发生的孕周分为足月胎膜早破和未足月胎膜早破（pretermprematureruptureofmembranes，PPROM），后者指在娠满20周到36＋6周发生的胎膜破裂。Prematureruptureofmembranesmeansthatthemembranesrupturenaturallybeforelabor.Accordingtothegestationalage,prematureruptureofmembranescanbedividedintotermprematureruptureandnon-termprematurerupture.Thelatterreferstoruptureofmembranesoccurringinthefirst20weeksto36+6weeksofpregnancy.2024/10/30简要病史：停经9月余，阴道流液1小时。此次系第1次怀孕，平素月经规律，经期3-5天，周期30天。末次月经2022年12月26日。预产期:2023年10月03日。停经1月余自测尿HCG阳性提示“怀孕”，2023年2月11日至我院行B超示宫内妊娠6周+，停经后有恶心、呕吐等明显早孕反应，持续至孕3月余。孕4月余自觉胎动至今。患者孕期在官渡区大板桥社区服务中心建档(建档号53011262846)。孕期在我院规律产检，2023年5月13日我院行白带常规提示:霉菌性阴道炎，予“克霉唑阴道膨胀栓”“川百止痒洗剂”后症状好转。2023年7月10日我院行OGTT:4.24-9.54-10.22mmoL/L,诊断为妊娠期糖尿病，指导患者饮食+运动调节血糖，并自行监测小轮廓，自诉空腹血糖控制在:3.9-4.3mmo1/L,餐后2小时血糖控制在5.4-6.5mmo1/L，血糖控制佳。孕期NT-B超、二阶段B超、术前四项无异常，生殖道GBS未行，NIPT-Plus回报低风险。孕期无心悸、胸闷，无头晕、头痛，无视物模糊，无阴道流血、流液、腹痛等不适。2023年9月9日5时许无明显诱因出现阴道流液，无腹痛，立即到我院就诊，考虑“未足月胎膜早破”予以收住。孕期精神、饮食可、睡眠可，大、小便正常，孕期体重增加15kg。实验室检查LaboratoryTests2实验室检查（1）阴道液酸碱度测定:正常妊娠阴道液pH为4.5-6.0，羊水PH为7.0-7.5。胎膜破裂后，阴道液PH升高。通常采用硝嗪或石蕊试纸测试。但宫颈炎、阴道炎、血液、尿液及精液等可能造成假阳性。VaginalfluidpHmeasurement:NormalpregnancyvaginalfluidpHis4.5-6.0,andamnioticfluidpHis7.0-7.5.Aftertheruptureofthefetalmembrane,thepHofvaginalfluidincreases.Usuallytestedwithnitrazineorlitmustestpaper.Butcervicitis,vaginitis,blood,urine,andsemenmaycausefalsepositives.（2）阴道液涂片检查:阴道后穹窿积液涂片检查见到羊齿植物状结晶，可考虑为羊水。Vaginalfluidsmearexamination:Asmearexaminationoftheposteriorfornixofthevaginashowsaplantlikecrystalofamnioticteeth,whichcanbeconsideredamnioticfluid.（3)阴道窥器检查:可见液体从宫口流出或阴道后穹隆有液体聚积。Vaginoscopyexamination:Liquidcanbeseenflowingoutofthecervixoraccumulatingintheposteriorfornixofthevagina.(4)超声检查:可发现羊水量较破膜前有所减少。Ultrasoundexamination:Itcanbefoundthattheamountofamnioticfluidhasdecreasedcomparedtobeforemembranerupture.辅助检查：2023年7月10日我院行OGTT:4.24-9.54-10.22mmoL/L。2023年7月31日我院B超提示:宫内妊娠，单活胎，胎儿大小相当于30周6天：双顶径：7.78cn，头围：28.41cm,腹围:28.68cm,股骨长:5.65cm，肱骨长：4.93cm，胎儿体重1790士161克，羊水指数：16.4cm:胎儿脐带绕颈壹周；胎盘血窦声像。Auxiliaryinspection:OnJuly10,2023,ourhospitalOGTT:4.24-9.54-10.22mmoL/L.OnJuly31,2023,Bultrasoundinourhospitalindicated:intrauterinepregnancy,singlelivebirth,fetalsizeequivalentto30weeksand6days:doubleparietaldiameter:7.78cn,headcircumference:28.41cm,abdominalcircumference:28.68cm,femurlength:5.65cm,humeruslength:4.93cm,fetalweight:1790oz161g,amnioticfluidindex:16.4cm:fetalumbilicalcordaroundtheneckforoneweek;Placentalsinussoundimage.病因，临床表现CauseOfDisease，ClinicalManifestations3病因1.生殖道感染胎膜早破的主要原因。GenitaltractinfectionsThemaincauseofprematureruptureofmembranes.2.羊膜腔压力增高

多胎妊娠、羊水过多等。IncreasedpressureintheamnioticcavityMultiplepregnancies,polyhydramnios,etc.

3.前羊膜囊受力不均

头盆不称、胎位异常等。Unevenforceintheanterioramnioticsac,cephalopelvicdisproportion,abnormalfetalposition,etc.2024/10/304.营养因素

缺乏维生素、钙、锌及铜。NutritionalfactorsLackofvitamins,calcium,zincandcopper.5.创伤

羊膜腔穿剌不当、妊娠晚期性生活不当及腹部受碰撞。Traumawithimproperamnioticpenetration,inappropriatesexualintercourseinlatepregnancy,andabdominalcollision.临床表现孕妇突感有较多液体自阴道流出，不伴有腹痛，当腹压增加时，阴道流液增加是典型症状。少数孕妇仅感到外阴较平时湿润.足月胎膜早破时，阴道检查摸不到前羊膜囊，上推胎儿先露部阴道流液量增加，可见胎脂等。Pregnantwomenhavealargeoutflowoffluidfromthevaginawithoutabdominalpain,andwhenabdominalpressureincreases,increasedvaginaldischargeisatypicalsymptom.Asmallnumberofpregnantwomenonlyfeelthatthevulvaiswetterthanusual.Whenthetermfetalmembranesruptureprematurely,theanterioramnioticsaccannotbefeltduringvaginalexamination,andthevaginaldischargeintheexposedpartofthefetusisincreased,andfetalfatcanbeseen.体格检查PhysicalExamination4体格检查生命体征测量体格检查腹部四部触诊体格检查宫高腹围测量治疗要点Keypointsoftreatment5足月胎膜早破应及时终止妊娠。未足月胎膜早破应根据孕周、有无感染、胎儿宫内情况、所在地新生儿救治水平、孕妇和家属意愿等制订合理的处理方案或及时转诊。对于未足月胎膜早破的期待治疗包括预防感染、促胎肺成熟、抑制宫缩、胎儿神经系统保护等。Prematureruptureofmembranesattermshouldpromptterminationofpregnancy.Pretermprematureruptureofmembranesshouldbebasedongestationalage,whetherthereisinfection,intrauterineconditionsofthefetus,thelevelofneonataltreatmentinthelocality,andthewishesofpregnantwomenandtheirfamilies,etc.Expectantmanagementofpretermpretermruptureofmembranesincludesinfectionprevention,promotionoffetallungmaturation,inhibitionofuterinecontractions,andfetalneurologicalprotection.治疗要点护理Nursing6

护理诊断1.有感染的危险：与胎膜破裂后易造成羊膜腔内感染有关。2.有胎儿受伤的危险：与脐带脱垂、早产和新生儿感染有关。3.恐惧：与胎膜早破、诱发早产，担心胎儿、新生儿有关。4.潜在并发症：早产、脐带脱垂，胎盘早剥。2024/10/301.Riskofinfection:itisrelatedtotheruptureoffetalmembranesthatcaneasilycauseintra-amnioticinfection.2.Riskoffetalinjury:relatedtoumbilicalcordprolapse,prematurebirthandneonatalinfection.3.Fear:relatedtoprematureruptureofmembranes,inducingprematurebirth,andworryingaboutthefetusandnewborn.4.Potentialcomplications:prematurebirth,umbilicalcordprovexation,placentalabruption.护理措施1、住院待产防止脐带脱垂，胎先露没有街接者应绝对卧床休息，臀高头低卧位为佳。Hospitalizedtopreventumbilicalcordprolapse,fetalfirstexposurewithoutstreetcontactshouldbeabsolutelybedrest,hipshighheadlowlyingpositionispreferred.未足月胎膜早破Pretermprematureruptureofmembranes护理措施2、期待疗法:延长孕周同时避免或控制感染。保持床单位的整洁，勤换会阴垫。保持外阴清洁，每日用消毒液擦洗会阴。定时监测孕妇体温、脉搏情况，观察感染征象。遵医嘱应用抗生素，严格无菌操作。加强营养，提高机体抵抗力。Expectantmanagement:prolonginggestationalagewhileavoidingorcontrollinginfection.Keepthebedunittidyandchangetheperinealpadfrequently.Keepthevulvacleanandscrubtheperineumdailywithanantisepticsolution.Regularlymonitorthetemperatureandpulseofpregnantwomenandobservesignsofinfection.Applyantibioticsasdirectedbyadoctorandoperatestrictlyaseptically.Strengthennutritionandimprovethebody'sresistance

3、观察宫内感染的象征护理措施①母体体温>38℃;②阴道分泌物异味；③胎心率增快(胎心率基线≥160次/分)或母体心率增快(心率≥100次/分);④母体外周血白细胞计数升高(≥15x10∧9/L或核左移);子宫呈激惹状态、宫体有压痛孕妇体温升高的同时伴有上述任何一项表现可诊断绒毛膜羊膜炎

护理措施3.Lookforsignsofintrauterineinfection①Maternalbodytemperature>38°C;②odorofvaginaldischarge;③Increasedfetalheartrate(baseline2160beats/min)ormaternalheartrate(heartrate≥100beats/min);④increasedmaternalperipheralbloodwhitebloodcellcount(215x10∧9/Lorleftnuclearshift);Uteruswasirritated,uterinebodytenderness

Chorioamnioticinflammationcanbediagnosedwhenawoman'sbodytemperatureincreaseswithanyoftheabovesymptoms密切观察胎儿宫内情况4、配合治疗，观察宫缩情况，预防早产，未足月抑制宫缩。Closelyobservethefetalsituationinutero4.Cooperatewithtreatment,observeuterinecontractions,preventprematuredelivery,andi