胎盘早剥的诊断和处理策略

胎盘早剥是妊娠晚期发生的一种危急重症,多致严重的产前和（或）产后出血,危及母儿生命。其典型症状为突发持续性腹痛,伴或不伴阴道流血,危重者可出现休克、弥漫性血管内凝血（DIC）等。超声、实验室检查及胎心监护可实时监测病情的进展,根据病情进展和胎儿宫内状况综合评估终止妊娠的时机和方式,争取良好的母儿结局。     

胎盘早剥的几个问题

日本近期统计资料,胎盘早剥占整个分娩总数的0.28%,因胎盘早剥致产妇死亡明显减少。妊高征所致胎盘早剥发生DIC占87%。 发生胎盘早剥的危险因素有:①妊高征及其他高血压病合并妊娠,胎盘基底膜螺旋动脉退行性变,血管痉挛致使胎盘缺血,形成胎盘后血肿。②胎儿畸形可能伴有胎盘血管异常。重症IUGR是妊高征     

双胎之一子宫内死亡并发孕妇慢性DIC期待治疗成功四例报告及分析

随着体外受精-胚胎移植(IVF-ET)技术的开展,双胎妊娠的发生率较以往明显上升,其特殊并发症——双胎之一宫内死亡的发生率也明显上升,当发生于中期妊娠阶段胎儿尚未成熟时,易发生凝血功能障碍,如立即终止妊娠,存活胎儿的生存率就会大大降低,而采用期待疗法则死亡胎儿滞留过久可能引发孕妇慢性DIC,导致存活胎儿和母体凝血功能障碍和脏器损伤.以往认为,孕妇一旦出现DIC必须立即终止妊娠[1].温州医学院附属第一医院产科于2006年6月至2010年5月发生中晚期妊娠双胎之一死亡共44例,发生慢性DIC 4例,经积极治疗成功4例,现报道如下.     

妊高征并发急性肾功能衰竭11例分析

目的 :了解妊高征并发急性肾功能衰竭 (ARF)的发病特点、探讨其发生规律及防治措施。方法 :对 30 5 2 0例产妇进行回顾性分析。结果 :30 5 2 0例产妇中 ,妊高征患者 5 14例 ,急性肾功能衰竭患者 11例 (占分娩总数的 0 .0 4 % ,占妊高征总数的 2 .1% )。诱因 :感染 (2 7.2 % )、心力衰竭 (18.2 % )、原有肾炎 (占 18.2 % )、妊娠肾病综合征、药物、胎盘早剥、DIC(各占 9.1% )。结论 :妊高征并急性肾功能衰竭的发病率为 2 .1% ,与原有肾损害、产时合并感染、心功能衰竭、DIC、胎盘早剥等有关。及时终止妊娠 ,控制高血压和各种诱因是关键 ,内科保守治疗加透析疗法 ,可减少母婴死亡 ,提高 ARF抢救成功率     

HELLP综合征14例临床分析

目的 探讨产科并发症HELLP综合征的母儿预后。方法 回顾性分析研究14例HELLP综合征的患者妊娠结局和围产儿预后。结果 14例中12例发生在产前，2例发生在产后，平均孕龄为32．5周，孕妇的严重并发症包括：急性肾衰、DIC、肺水肿、严重腹水和胎盘早剥等。其中8例需要输血或血液制品，12例采用剖宫产结束分娩。围产儿死亡5例，主要与胎盘早剥有关，另外胎儿宫内窘迫及早产也是重要原因。结论 HELLP综合征是一种严重的产科并发症，其高的母婴并发症和病死率要求我们对有妊娠高血压疾病的患者进行密切随访和治疗，一旦确诊为HELLP综合征应转入中心级以上医院进行治疗，尽快终止妊娠。     

妊娠合并播散性血管内凝血45例临床分析

<正> 早在1901年Delee曾描述1例胎盘早剥孕妇伴有凝血功能障碍性流血,当时称之为“暂时性血发病”,此后文献中即有关于凝血因子消耗性疾病引起流血的报道。近年来研究分析认为产科凝血功能障碍主要是播散性血管内凝血(DIC)所引起,而较多产科并发症如妊娠合并重症肝炎、胎盘早剥、妊娠高血压综合证、死胎、及分娩时羊水栓塞等均可能产生DIC而致流血。迄今,产科     

妊娠期糖尿病合并妊娠期肝内胆汁淤积症母儿结局探讨

目的:探讨妊娠期糖尿病合并妊娠期肝内胆汁淤积症对孕产妇和国产儿结局的影响。方法:分析17例GDM合并ICP患者和85例单纯GDM患者的临床资料。结果:两组间孕妇分娩孕周差异有统计学意义(P<0.05)。两组先兆早产、早产、酮症、胎膜早破、羊水过多、胎盘早剥、剖宫产、产后出血、宫内生长受限、胎儿宫内窘迫、巨大儿、新生儿低血糖、新生儿窒息和呼吸窘迫综合征、胎儿畸形、死胎、死产发生率比较,差异均无统计学意义(P>0.05)。结论:对妊娠期糖尿病合并妊娠肝内胆汁淤积症患者早诊早治,有效控制血糖及胆汁酸,适时终止妊娠可改善围产儿结局。     

凝血功能障碍致产后出血的防治

凝血功能障碍所致产后出血主要为产科并发症(如胎盘早期剥离、重度妊高征、羊水栓塞、死胎或过期流产等)导致的弥散性血管内凝血,或为妊娠合并血液病,特别是原发性血小板减少性紫癜、血友病或再生障碍贫血等均为发生产后出血的原因。 1 产科DIC所致之出血 1.1 胎盘早期剥离:主要是胎盘中的组织凝血活酶进入母体血循环,从而激发外凝血系统所致,发生DIC者约占25％,因而产前、产后出血,特别是伴有中、重度妊高征者,尤其是在妊娠32周左右出现宫缩而张力高或腹痛时,必须考虑发生了胎盘早剥,不可盲目应用硫酸镁或硫酸舒喘灵抑制宫缩,应行B超检查及严密观察。如一旦确诊为胎盘早剥,鉴于此病发展迅速,为确保母体安全及抢救胎儿,既使并发DIC,亦应在输鲜     

妊娠晚期出血终止妊娠的时机及方式的选择

妊娠晚期出血是产科的常见并发症,主要包括前置胎盘、胎盘早剥、血管前置及胎盘边缘血窦破裂,其中以前置胎盘和胎盘早剥最常见。这些并发症往往起病急、进展快、病情重,若处理不当可直接威胁母儿生命安全。正确选择终止妊娠的时机和方式,可明显降低母儿围产期病死率。     

妊娠合并肝衰竭的产科处理

妊娠合并肝衰竭严重影响母亲和胎婴儿健康,治疗上缺乏特效药物和手段,积极恰当的产科处理可改善患者预后、降低母亲和胎儿死亡率。临床上应以个体化治疗为原则,针对肝衰竭的病因、病情的严重程度、孕妇和胎儿情况选择终止妊娠的时机和方式,同时做好分娩期的综合处理。     

Successful pregnancy outcome following maternal intravenous immunoglobulin treatment in a woman with recurrent perinatal haemochromatosis

OBJECTIVE: We report a case of successful pregnancy outcome following maternal intravenous immunoglobulin treatment in a woman with previous history of recurrent fetal hydrops secondary to perinatal haemochromatosis. METHODS: A 32-year old woman had two successive pregnancies complicated by fetal hydrops and perinatal deaths. Pathological examination of the fetus showed severe liver destruction with siderosis of hepatocytes at extrahepatic sites, but sparing of the reticulo-endothelial elements, consistent with the diagnosis of perinatal haemochromatosis. In the subsequent pregnancy, maternal intravenous immunoglobulin was administered weekly from the 18th week of gestation until delivery by elective caesarean section at 38 weeks. The infant was treated with desferrioxamine, N-acetylcysteine, vitamins K and E. RESULTS: The infant was born in good health, but had high serum ferritin levels, markedly elevated percent transferrin saturation, and mild transient derangement of liver and coagulation function. The infant made an excellent recovery and the treatment was stopped at 7 weeks of age. The liver and coagulation parameters and the serum ferritin levels returned to normal values. CONCLUSIONS: Haemochromatosis should be considered in the differential diagnosis of hydrops fetalis. The recurrence risk is high, and immunomodulation with intravenous immunoglobulin treatment appears to alter the course of the disease with better infant survival.     

妊娠期凝血功能障碍与产科多器官功能障碍综合征

妊娠期弥漫性血管内凝血(DIC)是病理妊娠的严重并发症,常与产科出血、重度子痫前期及子痫、羊水栓塞、妊娠期急性脂肪肝和感染等相关。出血、高血压和感染等可启动瀑布式病理生理反应,即全身炎症反应综合征(SIRS),致使孕产妇全身低灌注、低血流,最终导致多器官功能障碍综合征(MODS)、DIC的发生。只有尽早明确病因,评估母胎血流动力学的继发改变,及时正确地在治疗窗处理凝血功能障碍,纠正低容量、低血供和低灌注,维持血流动力学稳定,才能降低孕产妇的病死率。     

Treatment of severe preeclampsia and HELLP syndrome

Severe preeclampsia and HELLP syndrome are still one of the leading causes of maternal and perinatal morbidity and mortality. The current definitions of the diseases should be considered before treatment. The timely allocation to a perinatal center and an intensive monitoring of mother and child after admission are mandatory for successful management of these patients. The aim of therapy is immediate stabilization of the mother's condition by means of anticonvulsive prophylaxis with intravenous magnesium sulphate, well-controlled reduction of blood pressure by the administration of urapidil or nifedipine, controlled volume expansion and an adequate treatment of coagulation disorders by giving fresh frozen plasma (not heparin).Immediate delivery is the method of choice in cases of severe preeclampsia/HELLP syndrome > or = 34 weeks' gestations; we prefer cesarean section in patients with an unripe cervix and the full-blown picture of HELLP syndrome. In patients < 34 weeks' gestation expectant management is generally possible under intensive monitoring of the mother and the fetus. Maternal and fetal indications for immediate termination of pregnancy should be considered carefully. The systemic application of corticosteroids is a promising approach to prolong pregnancy. During the past decade the increasing awareness of obstetricians and other disciplines have led to a significant reduction of maternal mortality (< 1 %) and perinatal mortality (9.4-16.2 %) in cases of HELLP syndrome, in particular in the West European countries.     

2 486例妊娠期高血压疾病患者的临床分析

目的了解近年来南方医科大学附属深圳妇幼保健院收治的妊娠期高血压疾病患者的发病趋势、并发症情况及对妊娠结局的影响。 方法回顾性分析2009年1月至2013年12月在南方医科大学附属深圳妇幼保健院就诊并分娩的2 486例妊娠期高血压疾病患者的临床资料,包括发病率、孕妇年龄、住院天数、分娩方式、流动人口比例及母婴并发症等。 结果5年间我院重度子痫前期发生率呈现下降趋势,从2009年的1.74%降至2013年的1.34%(χ²＝12.321,P<0.05);流动人口所占比例较高(46.46%);分娩方式仍然以剖宫产为主(74.09%),高于阴道分娩(21.44%),(χ²＝736.084,P<0.001)。妊娠期高血压疾病孕妇严重并发症的构成依次是：产后出血、胎盘早剥、HELLP综合征、心功能不全、弥散性血管内凝血、急性肾衰竭、脑血管意外;其围产儿严重并发症的构成依次为：早产、胎儿生长受限、新生儿窒息、死胎、流产。 结论妊娠期高血压疾病仍是威胁孕产妇以及围产儿健康的严重疾病,必须加强产前保健,早发现、早诊断和早治疗,以改善母婴妊娠结局。     

妊娠合并慢性粒细胞性白血病患者的临床处理特点及妊娠结局分析

目的 探讨妊娠合并慢性粒细胞性白血病(CML)患者的临床处理特点及妊娠结局.方法 1980年6月至2010年2月北京大学人民医院产科共收治妊娠合并CML 16例,采用回顾性分析的方法对妊娠合并CML患者的孕期特点、临床处理及妊娠结局进行分析.结果 (1)孕期临床处理及妊娠结局:16例妊娠合并CML患者中,9例经应用羟基脲或甲磺酸伊马替尼控制病情后,在孕早、中期终止妊娠;该9例患者就诊时平均孕周为7周(5～13周),终止妊娠前、后对症输入红细胞纠正严重贫血,应用抗生素预防感染,未发生相关并发症.另7例妊娠至孕晚期分娩患者中,3例为孕前诊断CML,4例为孕期诊断CML.7例分娩患者就诊时平均孕周为36周(27～40周+2),孕期3例患者服用羟基脲,其中1例在用药过程中受孕,孕期仍继续用药.1例患者在孕40周入院后行白细胞单采术2次.1例行血小板单采术1次.3例未行任何治疗.孕期并发重度子痫前期3例(3/7),其中2例口服羟基脲治疗.7例患者平均分娩孕周为38周(33周+4～41周),其中早产2例.分娩方式为剖宫产2例,阴道顺产3例,产钳助娩2例.有2例阴道顺产者发生产后出血,产后24 h出血量达1500～1800 ml,并引起继发性DIC.7例患者共分娩新生儿7例,新生儿平均出生体质量2469 g(1820～2810 g).早产儿2例,低出生体质量儿2例,1例存在先天畸形,2例血常规检查异常.(2)产后治疗及预后随访:9例孕早、中期终止妊娠的患者中,失访4例;死亡1例,其病程3年;余4例随访5～72个月均存活,其中1例行骨髓移植术后治愈,2例坚持服用甲磺酸伊马替尼,1例服用羟基脲治疗.7例分娩的患者中,2例失访;2例死亡;3例存活.7例新生儿中2例失访,余5例随访4个月～9年,均生长发育正常.结论 妊娠合并CML并非为终止妊娠的绝对指征.孕期在严密监测病情变化的同时,选用相应的药物和(或)白细胞单采术治疗,监测妊娠并发症的发生,可以获得较好的妊娠结局.CML本身和孕期治疗会对母儿产生一定的影响,因此,需要在有条件的综合医院进行治疗和管理.     

Hypertensive illnesses in pregnancy: when is ambulatory management possible, when is hospitalization indicated?

Hypertensive disorders complicating pregnancy are the most common medical complications of pregnancy and are a major cause of maternal and perinatal morbidity and mortality. Thorough ambulatory obstetric care is likely to achieve a risk reduction. The main topics of ambulatory obstetric care are early identification of typical signs of preeclampsia, detection of uteroplacental insufficiency, and their consequences, detailed information of the patient, and early admission to a specialised obstetric care unit or perinatal center. Early diagnosis, close medical supervision, and timely delivery are the keys of the treatment of preeclampsia.     

The challenges of diagnosis and treatment of malaria in pregnancy in low resource settings

Malarial infestation in pregnancy is a major public health concern in endemic countries and ranks high amongst the commonest complications of pregnancy, especially in large areas of Africa and Asia. It is an important preventable cause of significant maternal morbidity and mortality with associated fetal as well as perinatal wastage. The burden of malaria is greatest in sub-Saharan Africa where it contributes directly or indirectly to maternal and perinatal morbidity and mortality. The need for prompt and accurate diagnosis as well as prevention and treatment of malaria during pregnancy cannot, therefore, be overemphasized. This commentary focuses on the challenges of diagnosis and treatment of malaria in pregnancy.     

Hyperemesis gravidarum: a current review

Hyperemesis gravidarum or pernicious vomiting of pregnancy affects between 0.3% and 2% of all pregnant patients. The objective of this paper is to review current literature pertaining to epidemiology, etiology, symptomatology, complications, treatment, and perinatal outcome of patients with hyperemesis gravidarum. We performed a MEDLINE search of the English literature from 1966 through January 2000 utilizing the keywords: hyperemesis gravidarum, nausea and vomiting, and pregnancy. Current data pertaining to epidemiology, etiology, clinical manifestations, differential diagnosis, complications, various treatment modalities, subsequent perinatal outcome and recent developments are presented. Review of the literature supports that hyperemesis gravidarum is a multifactorial disease in which pregnancy-induced hormonal changes associated with concurrent gastrointestinal dysmotility and possible Helicobacter pylori infection function as contributing factors. Therapeutic key elements are mainly supportive in conjunction with antiemetic medication. It appears perinatal outcome is unaffected.     

头位妊娠脐带绕颈对围产儿的影响

目的：本研究主要就头位妊娠脐带绕颈对围产儿预后的影响展开分析讨论，以此来为这类围产儿的临床处理提供参考依据。方法：选择我院2011年12月至2012年12月所收治的150例分娩产妇作为研究对象，其中有50例产妇存在头位妊娠脐带绕颈的情况，将其作为观察组，100例产妇未出现头位妊娠脐带绕颈的情况，将其做为对照组，比较两组产妇的围生儿受影响程度。结果：两组产妇的急性胎儿宫内窘迫、新生儿窒息的比例存在明显差异，具有统计学意义，P〈0．05。结论：产妇在妊娠过程中，头位脐带绕颈对围产儿存在巨大的不良影响，对于此类产妇必须早诊断，对其胎心音变化进行严密的观察，并采取积极有效的措施来对产妇进行治疗，这对降低围产儿的死亡率有着十分重要的意义。     

Chronic hepatitis B infection and pregnancy

It is estimated that 350 to 400 million individuals worldwide are chronically infected with hepatitis B virus (HBV). In regions of high endemicity, many of these are females of reproductive age who are an important source for perinatal transmission. There are a number of issues specific to the women of childbearing age who have chronic HBV infection, including the safety of antiviral therapy during pregnancy and breast-feeding, the changes in the immune system during pregnancy and postpartum that may impact on the natural history of HBV, and the emerging role of antivirals to reduce perinatal transmission of HBV. For women in their reproductive years who require treatment, many of the available antivirals have not been studied in pregnant or breast-feeding women and their use requires the development of a carefully considered strategy, considering the impact of both the disease and treatment on the mother and fetus/infant. The purpose of this article is to (1) review data regarding the mechanisms and timing of perinatal HBV infection; (2) review data on interventions, particularly antiviral therapy, to reduce perinatal transmission beyond the protection afforded by hepatitis B immunoglobulin and vaccination; (3) summarize the immunological changes associated with pregnancy and the potential effect these may have on the natural history of HBV infection; and (4) summarize the information currently available for antiviral therapy available for HBV treatment, focusing specifically on safety data pertaining to reproduction, pregnancy, and breast-feeding. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After completing this CME activity physicians should be better able to classify the interventions to reduce mother-to-child transmission of hepatitis B including antivirals, caesarean section, hepatitis B immunoglobulin and hepatitis B vaccine, assess the immunological changes associated with pregnancy and the potential effect this may have on the natural history of HBV infection and apply the information currently available for antiviral therapy licensed for HBV treatment, focusing specifically on safety data in pregnancy and during breastfeeding.