General conditionnName: Zeng XX nAge: 36y nLMP: not clearnG8P1+6: 6 times artificial abortion, 1 time term CS(2004)nAdmission date : 3/12/2016Case 1Chief complainn amenorrhea for 8+ monthsn itching for 2+ monthsn vaginal bleeding for 5 hoursn no fetal movement for 2 hoursCase 1Current pregnant experience n Regular menstruation, unclear exact LMP . amenorrhea for about 8+ M. ultrasound estimated early pregnancy 2 m after amenorrhea. No morning sickness during early pregnancy, without regular antenatal care during pregnancy. n Feel itching especially during night about 2+ m on both legs, abdomen and chest , without complicating nausea, vomiting or uncomfortable upper abdomen. n5 hrs ago, vaginal bleeding about 50ml with slight abdominal pain, No dizziness, dim eyesight et al. transferred to our hospital immediately by local hospital. nOn the way of transport , no feeling of fetal movement anymore. nDeny abnormal previous medical historyCase 1Situation at admissionn, P:64bpm, R:21/min, BP:150/104mmHg, No pale of face (skin), conscious and fluent speaking with doctors nPhysical examination : (-)nObstetric examination: tender uterus, height of uterus:30cm, abdominal circumference:89cm, ROA, fetal heart beat: not to hear. No obvious vaginal bleeding .nBlood test(急诊): WBC 9.1109/L, N 69.4%,RBC 3.191012/L, HB 98g/L, PLT 186109/L, PT 18.3s, APTT 55.4s, Fg 103mg/LnUrine test (急诊)：Glu (+)，Pro (+)，WBC (+)，RBC(-)Case 1Questions ?nWhat are the common causes of vaginal bleeding during third trimester ? nWhats the possible cause of vaginal bleeding for this patient ? nWhat are the common causes of fetal deaths? Whats the most possible reason of fetal death for this patient? nWhat are the diagnosis for this women ?nWhat are the assisted examinations that you suggest to do ? Case 1Diagnosis ?Assisted examinationsnUnltrasound: BPD8.9cm,FL6.8cm,A 4.1cm.The placenta was located on the posterior wall of the uterus without signs of covering the inner os of the cervix and the thickness of placenta was 3.1cm without identified mass between the placenta and the uterus. No fetal heart or fetal movement was detected.nLiver functionmol/LnRepeated blood test: Hb 98g/L, abnormal Coagulation function. nBlood type: A, Rh(+)nGDM screen test: (-)nTP: (-)nTORCH : (-)Make decisionsnWhen to terminate the pregnancy?nHow to terminate the pregnancy?lVaginal delivery?lCS?患者帅XX，女，41岁。既往体健。生育史：1998年 人工流产1999年 因“难产”在双流某医院剖宫产，女儿，健在1999年 人工流产2010年 人工流产2011年 因“瘢痕子宫”在双流某医院剖宫产，儿子，健在2013年 人工流产此次妊娠Case 2停经12+周来我院建卡Case 2妊娠妊娠23+周周 彩超彩超胎盘胎盘Case 2胎盘胎盘妊娠妊娠31+周周 彩超彩超Case 2胎盘胎盘MRI结果（34+2周）胎盘胎盘Case 2术中见：子宫前壁下段明显膨隆凸起，遍布迂曲增粗的血窦；膀胱表面遍布细蚯蚓状增生血管。胎盘覆盖子宫中下份各壁，完全覆盖宫颈内口，且有大量的胎盘组织凸向子宫前壁下段并深入宫颈管内；胎盘与宫壁粘连、植入。剖宫产术中所见剖宫产术中所见Case 2HbPLTPTAPTTFg术前术前1371341231.2282术中术中529517.815065术后术后757712.240.2161术中出血估计术中出血估计4500ml，共输入红细胞悬液，新鲜冰冻，共输入红细胞悬液，新鲜冰冻血浆血浆600ml，冷沉淀，冷沉淀6U，自体回收血，自体回收血220ml。术毕再。术毕再输入新鲜冰冻血浆输入新鲜冰冻血浆500ml术前术中术后患者血常规、凝血功能变化Case 2凶险性前置胎盘的定义是什么？凶险性前置胎盘为什么“凶险”？凶险性前置胎盘的治疗原则？终止妊娠的方式？终止妊娠的时机？围手术期可采取哪些 措施减少出血？Case 2患者，患者，3333岁，因岁，因“停经停经37+437+4周，要求待产周，要求待产”入院。入院。现病史现病史：患者平素月经规律，：患者平素月经规律，LMP2016-11-26LMP2016-11-26，因，因双侧输卵管阻塞在我院于双侧输卵管阻塞在我院于2016-12-122016-12-12宫腔植入冻宫腔植入冻胚胚2 2枚。早孕期超声提示为双绒毛膜双胎。孕期定枚。早孕期超声提示为双绒毛膜双胎。孕期定期产检无特殊。现停经期产检无特殊。现停经37+437+4周，入院待产。周，入院待产。Case 3既往史既往史：20142014年因不孕在我院行腹腔镜下盆腔粘连年因不孕在我院行腹腔镜下盆腔粘连松解术，松解术，20162016年年1 1月因异位妊娠在我院行腹腔镜下月因异位妊娠在我院行腹腔镜下患侧输卵管切除术患侧输卵管切除术+ +对侧输卵管结扎术。余无特殊。对侧输卵管结扎术。余无特殊。月经婚育史月经婚育史：初潮：初潮1111岁，经期岁，经期4 4天，周期天，周期3030天，。天，。已婚，配偶体健，宫外孕已婚，配偶体健，宫外孕1 1次，人工流产次，人工流产1 1次。次。家族史家族史：无特殊。：无特殊。Case 3查体查体：，P95P95次次/ /分，分，R21R21次次/ /分，分，BP120/76mmHgBP120/76mmHg。心肺（心肺（- -） ，腹部膨隆，张力较大，宫高，腹部膨隆，张力较大，宫高49cm49cm，腹，腹围围113cm113cm，余（，余（- -）。）。辅助检查辅助检查：B B超（超（2017-8-142017-8-14）：胎）：胎1 1：横位，胎：横位，胎心率心率145145次次/ /分，羊水。胎分，羊水。胎2 2：头位，胎心率：头位，胎心率148148次次/ /分，羊水。分，羊水。Case 3血常规血常规：X10X109 9/L,/L,中性粒细胞百分比中性粒细胞百分比78%78%，1212/L,HGB /L,HGB 125g/L,PLT 130X10125g/L,PLT 130X109 9/L;/L;凝血功能凝血功能：秒；秒，：秒；秒，Fg 450mg/dlFg 450mg/dl。肝肾功能正常。肝肾功能正常。Case 3入院诊断入院诊断：1.1.双绒毛膜双羊膜囊双胎；术后；双绒毛膜双羊膜囊双胎；术后；3.3.羊水过多；羊水过多；4.G3P0+2 37+44.G3P0+2 37+4周宫内一横位一头位双周宫内一横位一头位双活胎待产活胎待产入院后处理入院后处理：监测胎心胎动，完善相关检查，择：监测胎心胎动，完善相关检查，择期终止妊娠。期终止妊娠。Case 3患者入院后第三天行择期剖宫产，术中见：子宫明显大于患者入院后第三天行择期剖宫产，术中见：子宫明显大于孕周，取子宫下段横切口，娩出大婴，男，重孕周，取子宫下段横切口，娩出大婴，男，重3260g3260g，身，身长长50cm50cm，羊水清亮，量约，羊水清亮，量约2000ml2000ml。小婴，女，重。小婴，女，重2720g2720g，身长身长49cm49cm，羊水清亮，量约，羊水清亮，量约2200ml2200ml。胎儿娩出后立即予缩。胎儿娩出后立即予缩宫素宫素10U10U宫壁注射，宫壁注射，10U10U静脉滴注，胎盘自然剥离，子宫收静脉滴注，胎盘自然剥离，子宫收缩极差呈口袋状，出血多且迅速。缩极差呈口袋状，出血多且迅速。Case 3干纱布干纱布3030张张 湿纱布湿纱布1010张张HR：156次次/分分 BP：75/41mmHg负压引流：血液负压引流：血液 800ml800ml会阴垫，无菌单大面积血染，称重会阴垫，无菌单大面积血染，称重1020g病人目前情况病人目前情况血常规：血常规：HGB 68g/L PLT:140*109/L凝血功能：凝血功能：PT：秒（参考值：秒）：秒（参考值：秒） APTT：秒（参考值：秒）：秒（参考值：秒） Fg：110mg/dLQuestions?1.1.目前估计出血量共计多少？产后出血的定义？目前估计出血量共计多少？产后出血的定义？2.2.该患者产后出血的主要原因？该患者产后出血的主要原因？3.3.导致该患者产后大出血的高危因素？导致该患者产后大出血的高危因素？4.4.下一步处理？下一步处理？Case 3持续双合诊按摩子宫，捆绑子宫下段持续双合诊按摩子宫，捆绑子宫下段, ,术中行双侧子术中行双侧子宫动脉上行支结扎。出血逐渐减少后迅速关腹，术毕宫动脉上行支结扎。出血逐渐减少后迅速关腹，术毕检查子宫收缩差，仍有活动性出血，急诊行双侧子宫检查子宫收缩差，仍有活动性出血，急诊行双侧子宫动脉介入术。出血明显减少。动脉介入术。出血明显减少。估计出血估计出血2700ml2700ml。输血：去白红细胞悬液。输血：去白红细胞悬液6U6U，新鲜冰，新鲜冰冻血浆冻血浆800ml800ml，纤维蛋白原，纤维蛋白原2g2g。术后血常规：术后血常规：RBC3.02*10RBC3.02*109 9/L/L，HGB94g/LHGB94g/L，凝血功能正，凝血功能正常。常。病人转归病人转归Case 3