妇产科学教学课件：Placental abruption

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1、Placental abruptionDefinition Occurs after 20th weeks, premature separation of the normally situated placenta before delivery of fetuslIncidence: in abroad: 1%-2% in our country: 0.46%-2.1%. lThe fetal mortality is depending on the degree of separation. lPlacental abruption is a severe complication

2、of late pregnancy. It is also a significant contributor to maternal mortality. peels away from the inner wall of the uterus before delivery deprive of oxygen and nutrients of the fetus heavy bleeding in the mother. mother and baby in jeopardy.Etiology(1)vascular lesion：PIH, especial severe pre-eclam

3、psia, chronic hypertension, chronic renal disease-vascular sclerosis spasm -Local vascular injury-vascular rupture into decidual basalis -bleeding, hematoma formation-shears off adjacent denuded vessels, separation of the placenta from the uterine wall. producing further bleeding and enlarging the s

4、eparated area Etiology uterine venous congestion-sudden rise in uterine venous pressure to intervillous space-congestion or rupture of venous bed-hematoma formation-separation of placenta and uterine wallEtiology(2) Sudden uterine decompression： premature rupture of membrane (especially the preterm

5、PROM) the first fetus is delivered rapidly in twin. amniotic fluid flowed rapidly in polyhydramnios, the uterine cavitys pressure decreased suddenly, uterus contracts, which cause the separation of the placenta and uterus.Etiology(3)Mechanical factors: trauma or injury to the abdomen short umbilical

6、 cord (absolute or relative) In amniocentesis, injure the vessel in the attachment of placenta-hematoma behind the placenta formation-separation of the placenta and uterine wallPredisposing factors Previous placental abruption. Advanced maternal age Multipara SmokingPredisposing factors Abnormal met

7、abolism Predisposing thrombosis. Uterus myoma. drug abuse.Pathological changesbleeding to decidual basalishematoma ofretroplacenta Separation of the placenta and uterine wallRevealed or external bleeding the complications are fewer and less severe. Small amount bleeding and quickly cease. No obvious

8、 symptoms.concealed or internal placental abruption The hemorrhage is confined within the uterine cavity, detachment of the placenta may be complete, and the complications are often severe.Mixed bleeding concealed or internal placental abruption The placenta marginal incomplete Utero-placental apopl

9、exy ( Couvelaire uterus) the placental margins remain adherent, hemorrhage that infiltrates the uterine wall. Uterine tetany follows extensive intra myometrial bleeding -purplish and copper-colored, ecchymosisloses its contractile power because of disruption of the muscle bundles.DIC (disseminated i

10、ntravascular coagulation ) The mother may then develop a widespread petechiae, active bleeding，shock, and failure of the normal clotting mechanism. Acute renal failure：acute renal cortical and tubular necrosis. thromboplastinfrom the villi and decidua of the stripping sideMothers circulationActivate

11、 blood coagulation systemMicro-thrombosis in capillary of the lung, kidney.Ischemia and dysfunction of the organs agglutinantMothers circulationActivate fibrinolytic systemFDPHyperfibrinolysisDICEnter intoEnter intoformsecondaryConsume blood coagulation factorClinical findings and diagnosis patients

12、 report of her symptoms physical examination performed. tested to evaluate the possibility of life-threatening problems with the mothers clotting system.Symptoms and signs begin anytime after 20 weeks of pregnancy. Classic signs and symptoms of placental abruption depending on the site and extent of

13、 bleeding, there are 3 grades. clinical findings correspond to the degree of separation. About 30% of separations are small, produce few or no symptoms , and usually are not noted until the placenta is inspected.Symptoms degree: External bleeding, often seen during labor Separated area is small No p

14、ain in the abdomen or back, no anemia Uterus：soft Fetus：normalSymptoms degree: Separated area is about 1/3 of the placenta. No or small vaginal bleeding, anemia of the patient is not match to bleeding. Sudden occurred abdominal pain, sore waist or low back pain. Uterus：enlarged, uterine height incre

15、ased, tenderness of the separated place, intermittence during uterine contraction. Fetus：survivalSymptoms degree: Separated area is 1/2 of the placenta. Nausea, vomitting, pale, blood pressure decrease, pulsation extenuate etc shock symptoms, which is correspond to the maternal blood loss. Uterus：ha

16、rd like a board, no relaxation during uterine contraction intermittence. Fetal position is not so clear Fetus：fetal heart rate vanish, fetal death. Concealed: no visible vaginal bleeding bleeding is trapped behind the placenta bleeding into the muscle of the uterus. abnormal contractions of the uter

17、us, particularly extremely hard, prolonged contractions. mother symptoms of organ failure as her organs are deprived of oxygen. a drop in blood pressureLaboratory findingsBlood cell and coagulation testPeripheral blood smearClot observation test Laboratory testing is not useful in making the diagnos

18、is of abruptio placentae, but sometimes supports a diagnosis of severe abruption. DIC occurs in 10 to 20 percent of cases of severe abruption with death of the fetus.3.Ultrasound help identify possible reasons of vaginal bleeding. diagnose an abruption high rate of missed or incorrect diagnoses rule

19、 out placenta previaDifferential diagnosisAbruptio placenta(severe)Placenta previaHistory Hypertension, renal disease, traumaNo any causeAbdominal painSudden attack, constantNoVaginal bleedingLess or noExist, red fresh, large amountAbdominal exam1.fundus is larger than expected gestational weeks2.ab

20、domen hard, wooden uterus, overdistension3.localized tenderness4.fetal outline no palpated5. fetal heart tone absent1.size of uterus is normal2.abdomen soft3.no tenderness4.fetal outline palpated clearly5.fetal heart tone presentRelation of anemia and blood lossCondition, pale is out of proportion t

21、o vaginal bleedingAnemia is in proportion to vaginal bleedingUltrasoundHematoma behind placentaPlacenta covers internal osTreatment Termination as soon as possible, expectant is not permittedExpectant and deliveryplacenta previa and placental abruption Placenta previa : beyond 28 weeks of gestation

22、age who presents with painless vaginal bleeding. Classically, the absence of abdominal pain and uterine contractions has been used to distinguish placenta previa from placental abruption. some women with placenta previa have painful uterine contractions in addition to bleeding, thus the diagnosis of

23、 placenta previa must be determined by sonographic examination.Complications Fetal death Disseminated intravascular coagulation(DIC) Postpartum hemorrhage Acute renal failure Amniotic fluid embolismAffect to mother and fetus: Mother: anemia, cesarean section rate, postpartum hemorrhage rate, the inc

24、idence of DIC. Fetus: acute distress, neonatal asphyxia, iatrogenic preterm labor, fetal mortality increasing and neonatal mortality increasingTreatment1.Emergency measures (antishock)Blood and fluid transfusion: fresh bloodAntishock measuresPrevention renal failure: supply blood volume (urine volum

25、e30ml/h)Detection and correction of coagulation disorders.(RBC, blood plasma, PLT, cryoprecipitate etc.)2. Terminate pregnancy in time(1)Cesarean section Indication Fetal distress in degree placental abruption Pregnancy with degree placental abruption can not be terminated in short term by vaginal d

26、elivery. Pregnancy with degree placental abruption can not be terminated immediately by vaginal delivery, whose condition get worse and the fetus is dead. Failed trial of labor(2)Vaginal deliveryIndication:Separation is limited, fetus is safe, cervix has dilated, pregnancy can be terminated in short

27、 term.Induction of labor Artificial rupture of membraneCarefully observe heart rate, blood pressure, uterine height, vaginal bleeding and the fetal condition.3.Treatment the complicationsPostpartum hemorrhage: oxytocin, carboprost tromethamine injection, uterine massage;Coagulation disorders: prompt

28、ly terminate pregnancy, correct the coagulation disorders (1) supplement blood volume and blood coagulation factor (RBC, blood plasma, PLT, cryoprecipitate, blood coagulation factor, fibrinogen) (2) anticoagulation (heparin) (3) anti-fibrolysis (tranexamic acid, amidocaproic acid etc.)Renal failure:

29、 fluid expansion, if the blood volume has supplemented fully and the urine volume is less than 17ml/h, we can use frusemide(20-40mg, intravenous injection), if necessary the drug can be used repeatedly. If uraemia occurred, hemodialysis can be used.Purpose and requestComprehend the etiology and Pathological changes of placental abruption. Comprehend the prevention of placental abruption. Familiar with the danger of the placental abruption to mother and fetus.Master the type, diagnosis points and treatment principle of placental abruption.Master the complications of placental abruption.