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胎盘早剥 Prolonged placental abruption 2008-9-19

  • 来源:cfl
  • 作者:cfl
  • 更新日期:2019-07-19 21:04
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妊娠20周后或分娩期,正常位置的胎盘在胎儿娩出前,部分或全部从子宫壁剥离,称为胎盘早剥(placental abruption)。胎盘早剥是妊娠晚期的一种严重并发症,起病急、进展快,若处理不及时,可危及母儿生命。轻型胎盘早剥于临产前可无明显症状,只在产后检查胎盘

妊娠20周后或分娩期,正常位置的胎盘在胎儿娩出前,部分或全部从子宫壁剥离,称为胎盘早剥(placental abruption)。胎盘早剥是妊娠晚期的一种严重并发症,起病急、进展快,若处理不及时,可危及母儿生命。轻型胎盘早剥于临产前可无明显症状,只在产后检查胎盘时,发现早剥处有凝血块压迹,此类患者易被忽略。

After 20 weeks of pregnancy or delivery, the placenta in its normal position is partially or completely detached from the uterine wall before the fetus is delivered, known as placenta abruption. Prolonged placenta abruption is a serious complication of late pregnancy, which causes rapid and rapid progress. If it is not handled in a timely manner, it can endanger the life of the mother and child. Light placenta exfoliation can have no obvious symptoms before the birth. Only after the postpartum examination of the placenta, it was found that there was a clot pressure trace in the early exfoliation, and such patients were easily ignored.

(一) 胎盘早剥的原因(I) Causes of premature placenta abruption

胎盘早剥的病因可分为直接原因和间接原因。直接原因有创伤和脐带过短胎先露下降牵拉胎盘;间接原因为有胎盘早剥史,慢性高血压或妊娠高血压患者,吸烟以及多胎妊娠。同时,羊水过多,下腔静脉受压,叶酸缺乏的孕妇,胎盘早期剥离发生的机会会明显增加。

The etiology of placental abruption can be divided into direct and indirect causes. The direct causes are trauma and umbilical cord hypoplasia. Indirect causes include early placental exfoliation, chronic hypertension or hypertensive pregnancy, smoking, and multiple pregnancies. At the same time, excessive amniotic fluid, pressure on the inferior vena Cava, and folic acid deficiency in pregnant women, the chance of early placental stripping will increase significantly.

(二) 胎盘早剥的危害(II) Hazard of premature placental abruption

胎盘早剥最大的危害是不可控的出血,可能为内出血,这种出血导致的休克和临床所见的显性失血所造成的休克不一样,即出血的量和休克的程度不成正比。由于这种出血最终可导致凝血功能的障碍和脏器功能的受损,因此,在孕期可导致胎死宫内;在分娩过程中,可导致死产;在产后还可导致产后出血的发生。

The greatest danger of placental abruption is uncontrolled bleeding, which may be internal bleeding. The shock caused by this bleeding is not the same as the shock caused by the visible blood loss seen in the clinic. That is, the amount of bleeding is not proportional to the degree of shock. Since this bleeding can eventually lead to disorders of coagulation function and damage to the organ function, it can lead to fetal death during pregnancy; During childbirth, it can lead to stillbirth; Postpartum bleeding can also occur after the birth.

(三) 胎盘早剥的临床表现(III) Clinical manifestations of placental abruption

胎盘与宫壁分离后,胎膜与宫壁之间的出血经宫颈、阴道流出为外出血。若出血只积存于胎盘后为隐性出血。病人的症状取决于胎盘早期剥离的类型、剥离面的大小及失血量。

After the placenta and the palace wall are separated, the bleeding between the fetal membrane and the palace wall is bleeding through the cervix and vagina. If the bleeding only accumulates in the placenta, it is recessive hemorrhage. The patient's symptoms depend on the type of early placental stripping, the size of the stripping surface, and the amount of blood loss.

胎盘早剥最常见的临床表现为伴有腹痛的暗红色阴道出血。严重的胎盘早剥腹痛可似刀割样或撕裂样,这主要是由于血液的刺激引起宫缩,而且这种宫缩可以导致子宫收缩的不迟缓。在早期可以引起胎动的异常,开始时有剧烈的胎动,继之胎动停止,一般剥离面积若大于50 %常发生胎儿死亡。如果血液破入羊膜腔,会出现血性羊水。病人出现休克以后会表现为恶心、烦渴,失血量过多时,可以出现晕厥等症状。 体格检查时可发现子宫张力增高,有明显的压痛、反跳痛。隐性出血时有宫底上升,胎心消失,出血多时产妇可出现休克。轻度胎盘早期剥离出血量少,有时甚至产前不会发现,子宫易激惹,可有轻压痛,一般不伴有胎儿窘迫,产后检查胎盘可证实。

The most common clinical manifestation of placental abruption is dark red vaginal bleeding with abdominal pain. Severe placental early peeling abdominal pain can be similar to knife cutting or tearing, which is mainly due to blood irritation causing contractions, and this contractions can lead to hysteresis. In the early stages, abnormal fetal movement can be caused. At the beginning, there is severe fetal movement. Following the fetal movement stops, fetal death often occurs if the stripping area is greater than 50 %. If the blood breaks into the amniotic cavity, there will be bloody amniotic fluid. After the patient has a shock, he will show nausea and thirst. When there is too much blood loss, symptoms such as syncope can occur. Medical examination can be found to increase uterine tension, there is obvious pressure pain, rebound pain. Recessive bleeding has a rise in the bottom of the palace, the fetal heart disappeared, bleeding for a long time can occur in the maternal shock. Mild placenta early exfoliation bleeding amount is small, sometimes not even before the birth will not be found, uterus irritable, may have light pressure pain, generally not accompanied by fetal distress, postpartum examination placenta can be confirmed.

(四)胎盘早剥的诊断

(IV) Diagnosis of premature placental abruption

胎盘早剥的诊断目前主要依赖于临床症状,对有出血、腹痛、宫缩或子宫收缩不迟缓的孕妇,应特别注意。对于胎盘早剥的辅助检查,不应依赖超声检查,超声检查只能用来明确胎盘的位置和胎儿的状况,对于胎盘早剥的诊断不具有特异性。另外,有部分病人,在产程或分娩过程中,并不能做出诊断,而在产后检查胎盘时,可见胎盘母面有血凝块或压迹,这类病人胎盘剥离范围比较小,没有引起胎儿的异常,所以在产后才能诊断。

The diagnosis of placenta abruption is mainly dependent on clinical symptoms. Special attention should be paid to pregnant women with bleeding, abdominal pain, contractions, or uterine contractions. For the auxiliary examination of placenta abruption, it should not rely on ultrasound examination. Ultrasound examination can only be used to determine the location of the placenta and the condition of the fetus. It is not specific to the diagnosis of placenta abruption. In addition, some patients can not make a diagnosis during the labor or delivery. When the placenta is examined after the birth, blood clots or indentation can be seen on the placenta parent surface. The placenta of such patients is relatively small and does not cause fetal abnormalities., That's why it's only diagnosed after childbirth.

依据胎盘剥离的程度,临床上将胎盘早剥分为三个等级:According to the degree of placental stripping, placental abruption is clinically divided into three levels:

一级,出血量少,可伴有少量的宫缩,但无胎儿窘迫和母体低血压的表现。Level 1, the amount of bleeding is small, can be accompanied by a small amount of contractions, but no fetal distress and maternal hypotension.

二级,轻到中等量的出血,有宫缩,腹痛引起宫缩的不迟缓,胎心率有变化。Secondary, light to moderate bleeding, contractions, abdominal pain causing contractions are not slow, fetal heart rate changes.

三级,中到重度出血,有的病人为内出血型,子宫收缩不迟缓,腹痛剧烈,可出现低血压或休克,此种类型胎儿死亡率较高。Grade III, medium to severe hemorrhage, some patients are internal blood type, uterine contraction is not slow, abdominal pain is severe, hypotension or shock can occur, this type of fetal mortality is higher.

(五)胎盘早剥的治疗(V) Treatment of premature placental abruption

目前,没有一个有效的办法能阻止胎盘的剥离,也没有办法能将已剥离的胎盘重新附着在子宫壁上。At present, there is no effective way to prevent the removal of the placenta, and there is no way to reattach the removed placenta to the uterine wall.

胎盘早剥的治疗原则为控制出血、补血,及时终止妊娠。对于胎盘早剥的病例,依据不同患者治疗方法也有所不同,治疗时应注意:①妊娠史、既往史和药物过敏史;②病情严重程度;③对药物和治疗方案的耐受程度;④病程估计。

The principle of treatment of placenta abruption is to control bleeding and blood supply, and to terminate pregnancy in a timely manner. For cases of placental abruption, according to the treatment methods of different patients, attention should be paid to: 1 history of pregnancy, history of past history, and history of drug allergies; 2 Disease Yanzhongchengdu; 3 tolerance to drugs and treatment options; 4 Estimated course of illness.

对于比较严重的胎盘早剥,尤其出现了胎心的异常或者母体血液循环的异常,需要快速补血、补液,迅速纠正低血容量性休克,可通过测中心静脉压、肺毛细血管楔压来监测血容量,以指导治疗,并需留置导尿管,每小时测尿量至少应在30 ml以上。同时,应尽早结束分娩,至少在胎盘早期剥离后6h内完成。

For the more serious placental premature abruption, especially the abnormal fetal heart or abnormal maternal blood circulation, it is necessary to quickly replenish blood and fluid, and quickly correct hypovolemic shock. Blood volume can be monitored by measuring central venous pressure and pulmonary capillary wedge pressure. To guide treatment, And need to keep the catheter, the amount of urine measured per hour should be at least 30 ML. At the same time, the delivery should end as soon as possible, at least within 6 H after the early removal of the placenta.

初产妇宫颈条件不成熟,出血多时应考虑尽快剖宫产。经产妇或已临产,宫颈条件好,可人工破膜加催产素静脉点滴,以减少子宫张力而使胎盘早期剥离出血减少,并尽早娩出胎儿及胎盘。若经产妇宫颈条件不好,出血多时,亦应考虑剖宫产结束分娩。手术台上发现有子宫卒中,可按摩,温热盐水热敷子宫,并用宫缩剂,观察子宫恢复情况,即要注意保留今后生育功能,也要权衡保留子宫可能引起产后大出血的问题,据以决定子宫的留或取。

The condition of cervix is not mature, bleeding should be considered as soon as possible cesarean section. After the maternal or already labor, cervical conditions are good, can artificially break the membrane plus oxytocin venous drip, to reduce uterine tension and reduce the placenta's early exfoliation bleeding, and as soon as possible out of the fetus and placenta. If the condition of cervix is not good, bleeding for a long time, Caesarean section should also be considered to end delivery. On the operating table, uterine apoplexy was found, massages, warm and hot saline applied to the uterus, and contractions were used to observe the recovery of the uterus, both to pay attention to the retention of future fertility functions, and to weigh the retention of the uterus may cause postpartum hemorrhage. To decide on the retention or withdrawal of the uterus.

胎盘早剥本身有出血,并能导致凝血功能障碍,所以要做好输血的准备。部分严重胎盘早剥的病人由于休克,血液的丢失可导致其他脏器的衰竭,所以在治疗终止妊娠的同时要密切注意各脏器功能的变化。

Placental abruption itself has bleeding and can lead to coagulation dysfunction, so be prepared for blood transfusion. In some patients with severe placental abruption, due to shock, the loss of blood can lead to the failure of other organs, so pay close attention to the changes in the function of organs while treating the termination of pregnancy.

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