【DOC】目婦產科學

1、【科 目】婦產科學 【授課教師】喻玲【授課對象】2002級七年制一大班 【授課地點】第1教室【授課章節(jié)】第二十二章 【學 時】2學時【授課內容】產后出血、子宮破裂、產褥感染【授課時間】200一、 教學目的與要求：1、 了解產后出血的原因2、 掌握產后出血的臨床表現(xiàn)、診斷、處理方法及各種防治措施二、 教學重點：1不同原因所致產后出血的臨床特點及治療原則；2加強孕期保健、孕期管理對預防產后出血的意義三、 教學難點：臨床上如何及時診斷和有效治療四、 教學的類型與教學方法：1. 啟發(fā)式教學，問題式、病例式、并配合多媒體課件講授2. 一般了解的內容同學自學3.研究新進展五、 教具：多媒體課件、多媒體電腦

2、、多媒體投影儀、激光筆、揚聲器、粉筆及粉筆刷六、 時間分配： （一）Definition3分鐘（二）Etiology10分鐘（三）Clinical findings15分鐘（四）Diagnosis3分鐘（五）Treatment10分鐘（六）Prevention3分鐘（七）Analyse of case6分鐘七、教學內容和步驟：產 后 出 血Postpartum Hemorrhage.Definition: Loss of 500ml or more of blood (greater than 1% of body weight) following delivery during the f

3、irst 24 hours is called Postpartum Hemorrhage. three important causes of death from obstetric abnormalities:Postpartum Hemorrhage-the first cause of deathPregnancy complicated heart diseasePregnancy induced hypertension .Etiology:1. Uterine atony(inertia)-the most common causes2. Retention of placen

4、ta-common cause of 3rd stage bleedingl Incomplete separation of placenta-usu. In uterine atonyl Retention of separated placenta- usu. In uterine atonyl Incarceration of placenta-contraction ringl Adherent placental Placenta accretal Retention of placenta fragment3. Soft tissue injury4.Coagulation de

5、fects: mainly in abruption of placenta, Pregnancy induced hypertension, intrauterine death of fetus & .Clinical findings:1. Bleeding:l Before delivery of placenta-injury, retained placenta;l After delivery of placenta-uterine atony2. Shock:l Generally, pregnant women ,because of the expanded blo

6、od volume ,will stand hemorrhage better than do non pregnant women.l Normally, loss of 1/51/4of total blood volume, shock may occur.l palefaced, apathetic, sweated ,yawn ,nausea ,vomiting ,shortness of breath ,restless, pulse weak & hypertention.Diagnosis:1. Atony: hemorrhage after delivery ,lnt

7、ermittent massive bleeding;2. Retention of placenta: hemorrhage before delivery, prolonged trickcle3. Soft tissue injury : bleeding persist4. Coagulation defect: bleeding without clots.Treatment: Early diagnosis & active treatment1. Uterine atony:l massage the uterusl give ergonoving; oxytocin o

8、r prostaglandinl uterine packingl hysterectomy2. retained placental compress the fundus to expel the placental adhere-manual removal, fragment-curettagel accreta-hysterectomy3. soft tissue laceration-repair4. Coagulation defects：l heparin-in early stage of DIC;l Antifibrinolytic agents (like EACA)-l

9、n late stage.Prevention:1. During pregnancy: anemia should be treated ,hospital confinement delivery2. During labor: intrapartum care(enough nutrition, rest &sleep);ergovin or oxytocin after delivery3. During postpartum: observe in the delivery room for at least 2 hours.病案 病史：患者，女，25歲，因停經39周，1小時

10、前發(fā)現(xiàn)陰道流液入院。末次月經1999年6月17日，預產期2000年3月24日。既往身體健康，否認其他疾病史，孕1產0。孕期一直定期產檢，結果正常。 入院體檢：一般情況好，較緊張， T36, P64次/分, R20次/分, Bp110/60mmHg, 心肺正常,肝脾觸診不滿意，下肢無水腫，宮高34cm，腹圍99cm，LOA位，頭未完全固定，胎心128次/分，宮縮弱，持續(xù)15-20秒/6-7分。肛診：宮頸未完全消退，宮口開指尖，胎膜已破，頭先露，高位-2，有清亮羊水流出。B超顯示臍帶繞頸一周。 入院診斷：1、宮內孕39+4周，LOA；2、胎膜早破；3、臍帶繞頸一周。 入院后行CST（-），因宮縮弱

11、，不規(guī)則，未正式臨產，給哌替啶100mg肌注休息，休息后仍未臨產，產婦十分緊張。因胎膜早破予催產靜滴引產后臨產。臨產7小時宮口開大6cm，S。此后產程停頓，宮縮乏力，宮頸水腫，有產溜，枕后位，行子宮下剖宮產，胎兒體重3770g，術中胎兒娩出后立即宮壁注射催產素20U及靜滴10U。胎盤娩出后，因宮縮差，將子宮托出腹腔，按摩子宮同時肌注麥角新堿0.2mg，術中已出血800-1000ml，輸血400ml，子宮收縮仍不好，于宮腔填塞熱鹽水紗墊，觀察宮縮變好，將子宮送回腹腔并取走紗墊。再觀察宮縮，一陣好，一陣差，又給宮壁注射麥角新堿0.2mg，并持續(xù)按摩子宮，但子宮仍反復變軟，且發(fā)現(xiàn)子宮切口有滲血，其表

12、面有凝血塊。此時估計失血約2000ml，決定行雙側髂內動脈結扎術。術中血壓持續(xù)平穩(wěn)，結扎后，未再出血。術后患者恢復好，術后9天母子平安出院。(1)請?zhí)岢鲈\斷及診斷依據(jù)。(2)請總結處理過程。(3)分析引起產后出血的原因。八、思考題：已發(fā)給學生九、參考資料1、樂杰主編，婦產科學(第六版教材)，北京；人民出版社，20042、曹澤毅主編，中華婦產科學，北京；人民出版社，19993、豐有吉摘編，現(xiàn)代婦產科學英語摘要(英文教材)，北京，人民出版社，20034、F.Gary Cunningham etal,Williams Obstetrics(22th Edition),2005參考網站ww.dxy,c

13、n/bbs十、板書提綱：見幻燈片子 宮 破 裂Rupture of Uterus一、教學目的與要求： 1、了解子宮破裂的原因2、熟悉臨床診斷及表現(xiàn)3、掌握子宮破裂的防治措施。二、教學重點：子宮先兆破裂及子宮破裂的臨床表現(xiàn)及處理原則，子宮破裂的預防三、教學難點：不同原因所致子宮破裂的特點四、授課的類型與授課方法：1. 啟發(fā)式教學，問題式、病例式、并配合多媒體課件講授2. 一般了解的內容同學自學3.研究新進展五、教具：多媒體課件、多媒體電腦、多媒體投影儀、激光筆、揚聲器、粉筆及粉筆刷六、時間分配： （一）Definition2分鐘（二）Etiology2分鐘（三）Clinical findings

14、3分鐘（四）Classification2分鐘（五）Clinical course of development10分鐘 （六）Diagnosis2分鐘（七）Prophylaxis2分鐘（八）Treatment2分鐘七、教學內容和步驟：.Definition:.Etiology: the most common causesl previous cesarean sectionl probably simulation of labor with oxytocine.Clinical classification according to etiology:1. Spontaneous rup

15、ture: obstruction of fetal presenting parts:l contractedpelvisl cephalopelvic disproportion malpresentationl hydrocephalus,pelvic tumors,etc;rupture of previous uterine scar: cesarean section, myorectomy, perforationpathologic changes of uterine myometrium: numerous curettages, numerous pregnancy or

16、 congenital uterine defects2. Traumatic rupture: misuse of oxytocin uterine injury during delivery: such as internal version, breech extraction ,manual removal of placenta ,destruction operation, difficult forceps.Classification:1. according to cause of rupture:l spontaneous rupturel traumatic ruptu

17、re2. according to time of rupture: l during laborl during pregnancy3. according to site of laceration:l lower segmentl upper segment4. according to course of development of rupture:l threatened rupturel rupture of uterus5. according to degree of laceration:l complete rupture :tear involves whole thi

18、ckness of uterine wall ,including the serosal peritoneum ,the uterie cavity communicates directly with the peritoneal cavityl incomplete rupture: complete or partial tears of myometrium but serosal layer is completely intact.Clinical course of development:1. Threatened rupture of uterus:Symptoms:the

19、 uterine contraction becomes more frequent &furious; the patient complains of pain in lower abdomen and become exhausted with a rise in pulse and respiratory rates. Sign: pathological retraction ringfetus becomes progressively asphyxiated hematuria2. Rupture of uterus:Complete rupture:Symptoms:

20、sharp & shorting pain in lower abdomen followed by cessation of uterine contractions; the severy labor pain cease but are replaced by continuous abdominal pain may be some vaginal bleeding but the great part is internal bleedingSigns: fetal heart tones disappeared; ascending of presenting part;

21、easily palpable fetal parts in abdomenIncomplete rupture:Symptoms:cessation of fetal movement; continuous lower abdomen pain; weakness of uterine contraction.Signs:fetal heart sounds weaken or disappear; hematuria in broadligament with tenderness.Diagnosis:1. according to the clinical manifestations

22、;2. vaginal examination;3. ultrasonography.Prophylaxis:1. family planning;2. good antenatal care;3. intelligent care during labor & proper use of oxytocin;4. avoidance of difficult vaginal operation;5. in case of suspected rupture of uterus or of threatened rupture of utures,vaginal deliveries a

23、re not allowed never try.Treatment1. threatened rupture of uterus :cesarean section at once 2. rupture of uterus:l hyperectomyl Repairl After operation ,wide spectrum antibiotics are given to prevent infection.八、思考題：已發(fā)給學生九、參考資料：1、樂杰主編，婦產科學(第六版教材)，北京；人民出版社，20042、曹澤毅主編，中華婦產科學，北京；人民出版社，19993、豐有吉摘編，現(xiàn)代婦產

24、科學英語摘要(英文教材)，北京，人民出版社，20034、F.Gary Cunningham etal,Williams Obstetrics(22th Edition),2005參考網站http:/www.dxy,cn/bbs十、板書提綱：見幻燈片產褥感染Puerperal Infection一、教學目的和要求：1、熟悉產褥感染的誘因及致病菌，產褥感染的病理及臨床表現(xiàn)2、掌握產褥感染的診斷、鑒別診斷及防治3、掌握產褥感染和產褥病率兩個概念的區(qū)別和聯(lián)系二、教學重點：1產褥感染和產褥病率的概念；2產褥感染的病理、臨床表現(xiàn)及診斷、鑒別診斷和防治；三、教學難點：不同病原體所致的病理及臨床特點，診斷注意

25、確定病原。四、授課內容和教學方法：1. 啟發(fā)式教學，問題式、病例式、并配合多媒體課件講授2. 一般了解的內容同學自學3.研究新進展五、教具：多媒體課件、多媒體電腦、多媒體投影儀、激光筆、揚聲器、粉筆及粉筆刷六、時間分配：（一）Definition3分鐘（二）Causative microorganisms :the most common pathogens5分鐘（三）Types of puerperal infection and clinical manifestations8分鐘（四）Diagnosis3分鐘（五）Treatment3分鐘（六）Prophylaxis3分鐘七、教學內容和步

26、驟：.Definition: Puerperal morbidity is an oral temperature of 38 or more on any of the first 10 postpartum days ,excluding the first 24 hours. Puerperal Infection is any postpartum infection of the genital tract complicating labor or delivery. Puerperal Infection is different from Puerperal morbidity

27、. Risk factors:1. General infection risk:anemia ,poor nutrition,lack of prenatal care, sexual intercourse during pregnancy.2. Laboring risk factors: prolong rupture of membranes, chorioamnniotitis, intrauterine fetal monitoring, number of examines during labor.3. Operative risk factors: cesarean sec

28、tion, manual placental removal ,forceps delivery, episiotomy, lacaration, hemorrhage.Causative microorganisms: the most common pathogens 1. Group B Streptococci2. Escherichia coli3. Anaerobic streptococci4. Bacteroides fragilis5. Enterococci.Types of puerperal infection and clinical manifestations:

29、1. Episiotomy infection2. infection of the laceration of vagina and cervix3. Endometritis4. Pelvic cellulites5. Peritonitis6. Thrombophelebitis7. Salpingitis.Diagnosis: 1. History and physical examination2. Cultures should be taken from the endometrial cavity, any draining,or infected wound. 3. To make sure of lesions.Treatment: 1. Supporting methods2. Infected wo