胎盘前置状态孕中期终止妊娠47例病例分析及个案分析3例

发布时间：2018-04-03 18:19

本文选题：胎盘前置状态　切入点：孕中期　出处：《河北医科大学》2014年硕士论文

【摘要】：妊娠28周之前，胎盘附着在子宫下部，其下缘达到或覆盖子宫内口称为胎盘前置状态[1]。子宫峡部从妊娠12周后逐渐拉长而形成子宫体腔的下部，至妊娠晚期，进一步拉伸形成子宫下段。胎盘前置状态在妊娠期子宫峡部拉伸扩张逐步形成子宫下段的过程中可由于胎盘生长与子宫峡部扩张不同步，发生局部剥离引起反复性无痛性出血，并引起先兆流产、流产等。部分胎盘前置状态孕妇，，由于反复出血、难免流产、胎儿畸形的需要终止妊娠，选择适当的方式可以有效减少病人创伤、减轻经济负担。目的：探讨不同情况下孕中期前置胎盘状态终止妊娠的最适宜方式。方法：采用回顾分析方法，收集2007年4月至2013年3月六年间河北医科大学第二医院住院分娩的胎盘前置状态孕中期终止妊娠的病例47例，并回顾分析其中3个特殊病例。结果：47名患者中初始决定的分娩方式，24例阴道分娩，23例剖宫取胎。11例自然临产成功阴道分娩。13例病例行药物引产，成功12例。一例羊膜腔注药引产，胎盘娩出后出血汹涌，剖腹探查术，术中大量出血，行子宫全切术。23例行剖宫取胎术，其中7例因出后出血多改行子宫切除术，16例剖宫取胎术并保留子宫。总体患者年龄28.19±5.00岁(18～40岁)，结束妊娠孕周23.29±3.49周(14.43～27.71周)，出血量1021.49±1654.23mL(90～6500mL)，输入血液成分平均1010.64±1580.31mL(0～5600mL)。阴道分娩成功病例，出血平均值448.26±419.84mL(90～1500mL)。剖宫取胎成功病例，术中出血平均值218.25±208.87mL(100～1000mL)。子宫切除8例，经手术及病理证实均为胎盘植入，全部为中央性前置胎盘，均有剖宫产史。患者年龄28.19±1.92岁(27～33岁)，结束妊娠的孕周22.4464±4.05周(14.43～26.57周)，术中出血量4150.00±1953.75mL(800～6500mL),输入血液成分3950.00±1419.00mL(0～5600mL)。案例1患者为孕24+6周，经产妇，无剖宫产史，以阵发性腹痛为主要原因入院，入院前无阴道出血，5天前产科彩超示：胎盘前置状态。宫颈软，宫口开6cm行人工破膜术后，阴道出血汹涌1000mL，伴血压下降，及时建立双液路，补充血容量，及静脉输入红细胞，为缩短产程行碎胎术，术后子宫收缩良好，阴道出血不多生命体征平稳。个案2：患者孕23+2周第一孕，中央性前置胎盘，经阴道分娩，胎盘先娩出，其后胎儿娩出，产前及产中出血共约300mL。个案3患者孕24+2周第三孕，凶险性前置胎盘、胎盘粘连，剖宫取胎术中胎盘取出后子宫下段出血多，依次给予卡前列素氨丁三醇促进宫缩、止血带捆绑子宫峡部、8字缝合宫壁止血、双侧子宫动脉结扎术及子宫下段宫腔填塞，缝合子宫，查无出血后关腹，术中出血约900Ml,术中输入悬浮红细胞2单位及血浆300mL，术后1+小时，再次阴道出血并逐渐增多、出血性休克、DIC，复行开腹探查术，切除子宫。结论： 1不同处理方式需参考胎盘位置、剖宫产史、流产史等行综合评估，并与病人进行良好沟通后决定。 2若边缘性胎盘前置状态、部分性胎盘前置状态及完全性胎盘前置状态中无剖宫产史，孕产妇基础状况较好时，提前建立液路、合血并做好抢救准备情况下，阴道分娩具备一定安全性，虽有时出血量较多，但产后恢复时间短，对孕妇损伤较小。 3对既往有剖宫产史同时存在前置胎盘状态孕产妇明确诊断、谨慎处理，严格区分是否存在胎盘植入。如影像学提示可能存在胎盘植入，应放弃阴道试产，行剖宫取胎术终止妊娠，以方便产后出血的处理。同时应密切观察产后出血情况，及时发现及处理各种分娩并发症。
[Abstract]:Before 28 weeks of pregnancy, the placenta attached to the bottom of the lower edge of the uterus or cover is called placenta previa uterine isthmus from [1]. after 12 weeks of pregnancy and uterine cavity formed gradually stretched to the lower part of late trimester of pregnancy, further stretching formation of lower uterine segment. Placenta previa state in the period of uterine isthmus pregnancy stretch expansion gradually formed in the lower uterine segment due to placental growth and expansion of uterine isthmus is not synchronized, the occurrence of local peeling caused by repeated painless bleeding, and caused by threatened abortion, abortion. Partial placenta previa pregnant women, due to repeated bleeding, abortion, fetal malformation need to terminate pregnancy, select the appropriate method can effectively reduce the trauma patients and to reduce the economic burden.
Objective: To explore the best way to terminate pregnancy in different cases of placenta previa under different conditions.
Methods: a retrospective analysis method was used to collect 47 cases of placenta previa in the second hospital of Hebei Medical University from April 2007 to March 2013, and 47 cases were terminated in the second trimester. 3 cases were retrospectively analyzed.
Results: the mode of delivery in 47 patients the initial decision, 24 cases of vaginal delivery, 23 cases of caesarean section in.11 cases of natural labor successful vaginal delivery.13 patients received drug abortion, 12 cases were successful. One case of amniotic cavity injection induced abortion, placenta bleeding after surging, laparotomy, with large amount of bleeding total hysterectomy was performed,.23 underwent caesarean operation, including 7 cases with bleeding after diverted hysterectomy, 16 cases of caesarean operation and preservation of the uterus. The average age of patients with 28.19 + 5 years (18~40 years), the end of the gestational weeks of 23.29 + 3.49 weeks (14.43 ~ 27.71 weeks) the amount of bleeding, 1021.49 + 1654.23mL (90 ~ 6500mL), the input of blood components was 1010.64 + 1580.31mL (0 ~ 5600mL). Successful vaginal delivery cases, bleeding average 448.26 + 419.84mL (90 ~ 1500mL). The success of caesarean bleeding cases, average 218.25 + 208.87mL (100 ~ 1000mL) of uterus. After surgical resection in 8 cases. And the pathological results were placenta implantation, all central placenta previa, had a history of cesarean section patients. Age 28.19 + 1.92 years old (27~33 years old), the end of pregnancy gestational age 22.4464 + 4.05 weeks (14.43 ~ 26.57 weeks), the amount of intraoperative bleeding was 4150 + 1953.75mL (800 ~ 6500mL), the input of blood components 3950 + 1419.00mL (0 ~ 5600mL).
1 cases of patients with gestational age of 24+6 weeks, multipara, no history of cesarean section, with paroxysmal abdominal pain as the main reason for admission, no vaginal bleeding before admission, 5 days before the obstetric ultrasound showed: placenta previa. Cervical soft, cervix 6cm for artificial rupture of membranes, vaginal bleeding surging 1000mL, with a decrease of blood pressure, the timely establishment of double liquid, supplement the blood volume and infusion of red blood cells, to shorten the production process for embryotomy, postoperative uterine contraction, vaginal bleeding more stable vital signs.
Case 2: Patients with 23+2 weeks pregnant the first pregnancy, placenta praevia, vaginal delivery, the placenta before childbirth, after fetal childbirth, prenatal bleeding and produced a total of about 300mL.
3 cases of patients with pregnancy 24+2 weeks gestation third, placenta previa, placenta accreta, caesarean section after remove the placenta fetal lower segment uterine bleeding, in order to give carboprost ammonia butyl alcohol three to promote uterine contraction, the tourniquet tied the uterine isthmus, 8 uterine wall suture hemostasis, bilateral uterine artery ligation and uterus uterine tamponade, uterine suture, no abdominal hemorrhage, bleeding is about 900Ml, the input of suspended red blood cells and plasma 300mL 2 units in operation, 1+ hours after the surgery, vaginal bleeding again and gradually increased, hemorrhagic shock, DIC, complex laparotomy, removal of the uterus.
Conclusion:
1 the different methods of treatment should refer to the placental position, the history of cesarean section, the history of abortion and so on, and make a good communication with the patients.
2 if the marginal placenta previa, no history of cesarean section of placenta previa and complete placenta previa in pregnant women, based in good condition, advance the establishment of fluid, blood and ready for rescue cases, vaginal delivery has certain safety, although sometimes more blood, but postpartum recovery time is shorter. Less damage to pregnant women.
3 with a history of cesarean section and maternal placenta previa diagnosis, careful treatment, strictly distinguish the existence of placenta implantation. Such as imaging suggests the presence of placenta implantation, should give up for vaginal delivery, caesarean operation termination of pregnancy, with convenient treatment of postpartum hemorrhage. At the same time should closely observe the situation of postpartum hemorrhage, discover and deal with all kinds of complications of childbirth.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R719.3

【引证文献】