分娩并发症(双语)课件.ppt

1、 Complication of Labor&Complication of Labor&DeliveryDelivery分娩并发症分娩并发症SyllabuslPostpartum Hemorrhage（产后出血）（产后出血）lAmniotic Fluid Embolism（羊水栓塞）羊水栓塞）lRupture of Uterus（羊水栓塞）（羊水栓塞）lDysfunction of Cord（脐带异常）（脐带异常）Postpartum Postpartum HemorrhageHemorrhage产后出血产后出血1.1.熟悉熟悉产后出血的原因、临床表现及诊产后出血的原因、临床表现及诊断断 2

2、.2.掌握掌握产后出血的各种预防措施和处理产后出血的各种预防措施和处理方法方法 3.3.了解了解产科产科DICDIC的诊断和处理方法。的诊断和处理方法。教教 学学 大大 纲纲 General considerationlPostpartum hemorrhage is the leading obstetric causes of maternal deathlThe incidence is 2%2%3%3%of the total deliverylHemorrhagic shock is the immediate cause of deathlThe postpartum hypote

3、nsion may lead to necrosis of pituitary or Hanns syndromeDefinitionl Postpartum hemorrhage denotes excessive bleeding(500mL in vaginal delivery)following delivery.l Blood lost during the first 24 hours after delivery is early postpartum hemorrhage.病病 因因 子宫收缩乏力：子宫收缩乏力：常见原因常见原因 全身因素全身因素（紧张、恐惧、虚弱）（紧张、恐

4、惧、虚弱）产科因素产科因素（产程长、并发症及合并症）（产程长、并发症及合并症）子宫因素子宫因素（子宫肌纤维过分伸展，肌壁（子宫肌纤维过分伸展，肌壁损伤、子宫病变）损伤、子宫病变）药物因素药物因素EtiologyRetained placental tissue:retained placenta滞留滞留 placenta accreta or increta 粘连粘连/植入植入 residual part of the placenta部分部分残留残留EtiologylObstetric laceration:uterus,cervix,vagina,vulvalCoagulation def

5、ects:congenital or acquired(obstetric and medical disorders)DiagnosislClinical findingslDetermination of blood loss:Weighting method,volumetric method,planimetry(面积法面积法)Shock index=pulse rate/systolic pressureIndex0.51.01.52.0Loss bloodnormal103030505070%ml-50015001500200025003000Etiological diagnos

6、islUterine atonylPlacental factors lLaceration of the lower genital tractlCoagulation defects 诊诊 断断子宫收缩乏力子宫收缩乏力宫底升高宫底升高子宫质软、轮廓不清子宫质软、轮廓不清阴道流血多阴道流血多按摩或缩宫后子宫变硬按摩或缩宫后子宫变硬 阴道流血减少或停止阴道流血减少或停止 诊诊 断断胎盘因素胎盘因素胎儿娩出后胎儿娩出后10分钟胎盘未娩出分钟胎盘未娩出胎盘胎膜不完整胎盘胎膜不完整胎盘胎儿面有断裂血管胎盘胎儿面有断裂血管 诊诊 断断软产道裂伤软产道裂伤宫颈、阴道、会阴裂伤宫颈、阴道、会阴裂伤宫颈裂伤

7、常在宫颈裂伤常在3 3、9 9点处、可延伸点处、可延伸I度裂伤度裂伤II度裂伤度裂伤III度裂伤度裂伤IV度裂伤度裂伤 诊诊 断断凝血功能障碍凝血功能障碍持续阴道流血持续阴道流血血液不凝血液不凝止血困难止血困难全身多部位出血全身多部位出血凝血功能检查异常凝血功能检查异常TreatmentTreatmentlCountershock抗休克抗休克lEtilogical treatment(Uterine atony)1.Manipulative treatment:p Utrine massage and packing 2.MedicationpOxytocine,Methergine,Pros

8、taglandin 3.Surgical treatmentpLigation结扎术结扎术,arterial embolization栓塞术栓塞术,Hysterectomy子宫切除术子宫切除术正面观背面观正面观B-LynchB-Lynch子宫缝合法子宫缝合法 处处 理理胎盘因素胎盘因素及时检查阴道及宫腔及时检查阴道及宫腔及时取出已剥离的胎盘及时取出已剥离的胎盘徒手剥离胎盘徒手剥离胎盘如胎盘植入，切除子宫如胎盘植入，切除子宫如残留行清宫术如残留行清宫术 处处 理理软产道损伤软产道损伤彻底止血、逐层缝合彻底止血、逐层缝合宫颈裂伤宫颈裂伤1cm1cm，活动性出血，应缝合，活动性出血，应缝合第一针应超

9、过裂口顶端第一针应超过裂口顶端不留死腔、避免穿透直肠黏膜不留死腔、避免穿透直肠黏膜避免损伤膀胱和输尿管避免损伤膀胱和输尿管血肿应切开，彻底止血后缝合血肿应切开，彻底止血后缝合必要时引流必要时引流 处处 理理凝血功能障碍凝血功能障碍应排除其它引起产后出血的因素应排除其它引起产后出血的因素输新鲜血输新鲜血补充血小板、凝血物质补充血小板、凝血物质并发并发DIC后积极处理后积极处理 处处 理理失血性休克失血性休克正确估计出血量及休克程度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、升压建立有效静脉通道、补液、血浆、升压给氧、纠正酸中毒、保

10、护脏器功能给氧、纠正酸中毒、保护脏器功能防治感染防治感染预预 防防加强产检，加强对高危妊娠的管理加强产检，加强对高危妊娠的管理搞好计划生育，减少人流次数搞好计划生育，减少人流次数有高危因素者，加强产前检查有高危因素者，加强产前检查正确处理产程正确处理产程加强产后观察，特别是加强产后观察，特别是产后产后2 2小时小时Amniotic Fluid Embolism,AFE羊水栓塞羊水栓塞1.1.熟悉熟悉羊水栓塞的临床表现、诊断以及羊水栓塞的临床表现、诊断以及处理原则处理原则 2.2.熟悉熟悉羊水栓塞的预防措施羊水栓塞的预防措施 3.3.了解了解羊水栓塞的病因、病理生理变化。羊水栓塞的病因、病理生理

11、变化。教教 学学 大大 纲纲lAmniotic Fluid Embolism is a complex condition characterized by the abrupt onset of pulmonary embolism,shock and DIC,renal failure or sudden death.lIncidence is low lCharacteristic:It is hard to predict and is a dangerous obstetrics complication,the death rate is about 70%-80%Definiti

12、onEtiologylThe formed elements in amniotic fluid enter into maternal circulation during delivery or cesarean section.EtiologylCondition:opening vessels ,uterine hypertonuslInducement 诱因诱因:rupture of uterus,laceration of cervix,placenta praevia,placental abruptionlPredilection factors:primiparity 初产初

13、产,allergy,precipitate labor急产急产,tetanic contraction 强直性宫缩强直性宫缩lPulmonary artery hypertension,PAH肺动脉高压肺动脉高压lAllergic shocklDisseminated intravascular coagulation,DIClAcute renal failure;ARF PathophysiologyFormed elementsPAHAcute cor dextrum failurePEaRCFSEPaSTNB.SPFClinical findingl stage-Shock,Respi

14、ratory and circulatory failure and hypoxemia低氧血症低氧血症l stage-DIC:bleeding,blood clotting disorder and then hemorrhagic shockl stage-Acute renal failure(ARF):oliguria少尿少尿 and renal dysfunction肺动脉高压：肺动脉高压：羊水有形物质形成栓子进羊水有形物质形成栓子进入肺循环，阻塞小血管，血栓形成，血入肺循环，阻塞小血管，血栓形成，血管痉挛，可导致右心衰管痉挛，可导致右心衰 竭，休克，甚至死亡。竭，休克，甚至死亡。过

15、敏性休克：过敏性休克：I I型变态反应、血压骤降型变态反应、血压骤降 心肺功能衰竭心肺功能衰竭DICDIC：羊水中促凝物质形成大量微血栓，羊水中促凝物质形成大量微血栓，消耗凝血物质，形成消耗凝血物质，形成DICDIC，极易发生严，极易发生严重产后出血及失血性休克重产后出血及失血性休克急性肾衰竭：急性肾衰竭：DICDIC及休克导致肾急性缺及休克导致肾急性缺血血 呼吸循环衰竭和休克呼吸循环衰竭和休克DIC引起的出血引起的出血急性肾衰竭急性肾衰竭起病急骤、来势凶险、多在分娩过程中！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！症状可不典型、也可只出现部分症状！Diagnosi

16、slEmergent:typical clinical manifestationlAuxiliary examination Amniotic fluid components are find in blood DIC examination ECG Chest X-ray Autopsy尸解尸解 Treatment principle抗过敏的同时，改善低氧血症抗过敏的同时，改善低氧血症-呼吸功能呼吸功能保持心输出量和血压保持心输出量和血压-循环功能循环功能防止血管内凝血防止血管内凝血-凝血功能凝血功能防治肾衰防治肾衰-脏器功能脏器功能Treatment steplOxygen:Trach

17、eal intubation气管插管气管插管 lRelief PAH:Papaverine hydrochloride(罂粟罂粟硷硷),Atropine（阿托品）（阿托品），Aminophylline（氨茶碱）（氨茶碱），Phentolamine（酚妥拉明）（酚妥拉明）lAnti-anaphylaxis：Dexamethasone(地塞米地塞米松松)lAnti-shock：Dopamine（多巴胺）（多巴胺），Metaraminol（间羟胺间羟胺），5%Sodium Bicarbonate（5%碳酸氢钠）碳酸氢钠），Lanatoside C（西地兰）（西地兰）Treatment of DICl

18、Mechanism of obstetric DIC:1Extrinsic coagulation system 外源性凝血系统外源性凝血系统2Intrinsic coagulation system 内源性凝血系统内源性凝血系统Treatment of DICThe stages of DICl高凝期高凝期 凝血酶凝血酶 血球压积血球压积 微血微血栓形成栓形成l 消耗性低凝期消耗性低凝期 血小板血小板 纤维蛋纤维蛋白原白原 凝血因子凝血因子、l 纤溶亢进期纤溶亢进期 FDP FDP 继而继而D-2D-2聚体聚体Treatment of DIClTreatmentI.Anticoagulati

19、on 抗凝抗凝(Heparin 肝素肝素):Hypercoagulable periodII.Blood coagulation factorsIII.Anti-fibrinolysis 抗纤溶抗纤溶The stage of organ exhaustionTo prevent renal failure-blood-volume,diuretica 利尿剂利尿剂To prevent cerebral palsy-ice cap,dehydrater 脱水剂脱水剂Anti-infectionTo prevent digestive systemTreatment of obstetricsuT

20、ermination of pregnancy（终止妊娠）（终止妊娠）I.Operative vaginal deliveryII.Cesarean deliveryuIndicatio of hysterectomy:hemorrhoea,blood clotting disorder Rupture of Uterus 子宫破裂子宫破裂1.1.掌握掌握子宫破裂的临床表现、诊断及病子宫破裂的临床表现、诊断及病理缩复环的临床意义理缩复环的临床意义 2.2.熟悉熟悉子宫破裂的原因子宫破裂的原因 3.3.了解了解子宫破裂的防治措施子宫破裂的防治措施 教教 学学 大大 纲纲lThe rupture

21、of uterine body or lower uterine segment occurs during the third-trimester or the course of laborl Rupture of uterus is a potential obstetric catastrophe and a major cause of maternal and fetal death DefinitionEtiologyObstructive dystocia 梗阻性难产梗阻性难产Injured rupture of uterus产科子宫损伤产科子宫损伤Scar uterus疤痕子

22、宫疤痕子宫The misuse of hysterotonics 宫缩剂宫缩剂 ClassificationlBy reason:spontaneous rupture injured rupturelBy time:rupture during pregnency rupture during deliverylBy level of rupture:complete rupture incomplete rupturelBy the position of rupture:rupture at body of uterus rupture at lower uterine segmentC

23、linical manifestationlThreatened uterine rupture:Pathologic retration ring 病理性缩复环病理性缩复环 Abdominal tenderness下腹痛下腹痛 Alteration in fetal heart rate胎心异常胎心异常 Hematuria 血尿血尿lRupture of uterus Complete&incomplete临床表现：临床表现：不完全性子宫破裂不完全性子宫破裂 子宫肌层部分或全层破裂，浆膜层子宫肌层部分或全层破裂，浆膜层完整完整 宫腔与腹腔不相通宫腔与腹腔不相通 胎儿及其附属物仍在宫腔胎儿及其

24、附属物仍在宫腔 子宫一侧扪及血肿块子宫一侧扪及血肿块 胎心率异常胎心率异常临床表现：临床表现：完全性子宫破裂完全性子宫破裂p子宫肌层全层破裂子宫肌层全层破裂p宫腔与腹腔相通宫腔与腹腔相通p下腹撕裂样剧痛、休克体征下腹撕裂样剧痛、休克体征p羊水血液进入腹腔后持续性腹痛羊水血液进入腹腔后持续性腹痛p腹壁下可扪及胎体、胎动消失腹壁下可扪及胎体、胎动消失p阴道检查先露升高、宫口回缩阴道检查先露升高、宫口回缩DiagnosisMedical historyThe course of deliveryClinical situationSigns Differential Diagnosis:placen

25、tal abruption or dystocia combine with peritonitis 腹膜炎腹膜炎TreatmentlThreatened uterine rupture Inhibit uterine contraction immediately Cesarean deliverylRupture of uterusAntishock,operationCrack mended,subtotal hysterectomy 子宫次子宫次全切除术全切除术，total hysterectomy预预 防防搞好计划生育，减少人流多产搞好计划生育，减少人流多产有高危因素者，加强产前检查

26、有高危因素者，加强产前检查正确处理产程正确处理产程严格掌握缩宫素应用指征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正确掌握产科手术助产的指征及操作规范规范正确掌握剖宫产指征正确掌握剖宫产指征Dysfunction of Cord 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脐带先露与脐带脱垂Funis presentation and prolapse of cordEtiopathogenisis；abnormal of pelvis,cephalopelvic disproportionabnormal of fetal po

27、sitionlong cordpolyhydramniosothers 脐带先露及脐带脱垂脐带先露及脐带脱垂高危因素高危因素胎膜未破，胎动及宫缩后胎心率减速胎膜未破，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、脐带脱于外阴胎先露旁或前方触及脐带、脐带脱于外阴B超有助于诊断超有助于诊断 处处 理：脐带先露理：脐带先露 经产妇、胎膜未破、宫缩好，可阴道试产经产妇、胎膜未破、宫缩好，可阴道试产 头低臀高位

28、、密切观察胎心头低臀高位、密切观察胎心 密切观察产程进展密切观察产程进展 初产妇、足先露或横位，剖宫产初产妇、足先露或横位，剖宫产 处处 理：脐带脱垂理：脐带脱垂 宫口开全、胎头已入盆，产钳或臀牵引术宫口开全、胎头已入盆，产钳或臀牵引术 宫口未开全，立即头低臀高宫口未开全，立即头低臀高 上推先露部上推先露部 抑制宫缩抑制宫缩 尽快剖宫产尽快剖宫产 The other dysfunction of cordlCord entanglement 缠绕缠绕lKnot 打结打结 of umbilical cordlTorsion 扭转扭转 of cordlCord velamentous insert

29、ion 帆状附着帆状附着 脐带缠绕脐带缠绕 胎先露部下降受阻胎先露部下降受阻 胎儿窘迫胎儿窘迫 胎心监护出现频繁变异减速胎心监护出现频繁变异减速 超声检查见胎儿颈部发现脐血流信号或压迹超声检查见胎儿颈部发现脐血流信号或压迹 尽快剖宫产尽快剖宫产I.Normal length:30-70cm average 50-60cmII.Short cord 30cmIII.Long cord 70cmThe length of cord 脐带长度异常脐带长度异常 临产后先露部下降、脐带受牵拉，出现胎心临产后先露部下降、脐带受牵拉，出现胎心 率异常、胎盘早剥、第二产程延长率异常、胎盘早剥、第二产程延长 过长脐带易致脐带绕颈、绕体、打结、脱垂过长脐带易致脐带绕颈、绕体、打结、脱垂 或脐带受压或脐带受压 尽快剖宫产尽快剖宫产脐带打结脐带打结脐带扭转脐带扭转脐带附着异常脐带附着异常The EndThe End