1-2-胎膜早破教學(xué)查房

胎膜早破教學(xué)查房1患者資料及疾病概述（PatientInformationAndDiseaseOverviview）2實驗室檢查（LaboratoryTests）病因及臨床表現(xiàn)（CauseOfDisease，ClinicalManifestations）34體格檢查（PhysicalExamination）目錄Contents5治療要點（Keypointsoftreatment）67護理診斷及措施（Nursingdiagnosisandmeasures）健康教育（HealthyEducation）患者資料及疾病概述PatientInformationAndDiseaseOverviview1姓名：張晶

年齡：25床號：15床住院號：0207941診斷：1.未足月胎膜早破2.G1PO孕36+5周頭位待產(chǎn)3.妊娠期糖尿病4.臍帶繞頸5.胎盤血竇患者資料Name:ZhangJingAge:25Bednumber:15Admissionnumber:0207941Diagnosis:1.Prematureruptureofmembranesbeforeterm2.G1P0pregnancy36+5weeksfirstpositionwaitingforlabor3.Gestationaldiabetes4.Umbilicalcordaroundneck5.Placentalsinusblood疾病概述胎膜早破(prematureruptureofmembranes,PROM)是指胎膜在臨產(chǎn)前自然破裂。依據(jù)發(fā)生的孕周分為足月胎膜早破和未足月胎膜早破（pretermprematureruptureofmembranes，PPROM），后者指在娠滿20周到36＋6周發(fā)生的胎膜破裂。Prematureruptureofmembranesmeansthatthemembranesrupturenaturallybeforelabor.Accordingtothegestationalage,prematureruptureofmembranescanbedividedintotermprematureruptureandnon-termprematurerupture.Thelatterreferstoruptureofmembranesoccurringinthefirst20weeksto36+6weeksofpregnancy.2024/10/30簡要病史：停經(jīng)9月余，陰道流液1小時。此次系第1次懷孕，平素月經(jīng)規(guī)律，經(jīng)期3-5天，周期30天。末次月經(jīng)2022年12月26日。預(yù)產(chǎn)期:2023年10月03日。停經(jīng)1月余自測尿HCG陽性提示“懷孕”，2023年2月11日至我院行B超示宮內(nèi)妊娠6周+，停經(jīng)后有惡心、嘔吐等明顯早孕反應(yīng)，持續(xù)至孕3月余。孕4月余自覺胎動至今?；颊咴衅谠诠俣蓞^(qū)大板橋社區(qū)服務(wù)中心建檔(建檔號53011262846)。孕期在我院規(guī)律產(chǎn)檢，2023年5月13日我院行白帶常規(guī)提示:霉菌性陰道炎，予“克霉唑陰道膨脹栓”“川百止癢洗劑”后癥狀好轉(zhuǎn)。2023年7月10日我院行OGTT:4.24-9.54-10.22mmoL/L,診斷為妊娠期糖尿病，指導(dǎo)患者飲食+運動調(diào)節(jié)血糖，并自行監(jiān)測小輪廓，自訴空腹血糖控制在:3.9-4.3mmo1/L,餐后2小時血糖控制在5.4-6.5mmo1/L，血糖控制佳。孕期NT-B超、二階段B超、術(shù)前四項無異常，生殖道GBS未行，NIPT-Plus回報低風(fēng)險。孕期無心悸、胸悶，無頭暈、頭痛，無視物模糊，無陰道流血、流液、腹痛等不適。2023年9月9日5時許無明顯誘因出現(xiàn)陰道流液，無腹痛，立即到我院就診，考慮“未足月胎膜早破”予以收住。孕期精神、飲食可、睡眠可，大、小便正常，孕期體重增加15kg。實驗室檢查LaboratoryTests2實驗室檢查（1）陰道液酸堿度測定:正常妊娠陰道液pH為4.5-6.0，羊水PH為7.0-7.5。胎膜破裂后，陰道液PH升高。通常采用硝嗪或石蕊試紙測試。但宮頸炎、陰道炎、血液、尿液及精液等可能造成假陽性。VaginalfluidpHmeasurement:NormalpregnancyvaginalfluidpHis4.5-6.0,andamnioticfluidpHis7.0-7.5.Aftertheruptureofthefetalmembrane,thepHofvaginalfluidincreases.Usuallytestedwithnitrazineorlitmustestpaper.Butcervicitis,vaginitis,blood,urine,andsemenmaycausefalsepositives.（2）陰道液涂片檢查:陰道后穹窿積液涂片檢查見到羊齒植物狀結(jié)晶，可考慮為羊水。Vaginalfluidsmearexamination:Asmearexaminationoftheposteriorfornixofthevaginashowsaplantlikecrystalofamnioticteeth,whichcanbeconsideredamnioticfluid.（3)陰道窺器檢查:可見液體從宮口流出或陰道后穹隆有液體聚積。Vaginoscopyexamination:Liquidcanbeseenflowingoutofthecervixoraccumulatingintheposteriorfornixofthevagina.(4)超聲檢查:可發(fā)現(xiàn)羊水量較破膜前有所減少。Ultrasoundexamination:Itcanbefoundthattheamountofamnioticfluidhasdecreasedcomparedtobeforemembranerupture.輔助檢查：2023年7月10日我院行OGTT:4.24-9.54-10.22mmoL/L。2023年7月31日我院B超提示:宮內(nèi)妊娠，單活胎，胎兒大小相當(dāng)于30周6天：雙頂徑：7.78cn，頭圍：28.41cm,腹圍:28.68cm,股骨長:5.65cm，肱骨長：4.93cm，胎兒體重1790士161克，羊水指數(shù)：16.4cm:胎兒臍帶繞頸壹周；胎盤血竇聲像。Auxiliaryinspection:OnJuly10,2023,ourhospitalOGTT:4.24-9.54-10.22mmoL/L.OnJuly31,2023,Bultrasoundinourhospitalindicated:intrauterinepregnancy,singlelivebirth,fetalsizeequivalentto30weeksand6days:doubleparietaldiameter:7.78cn,headcircumference:28.41cm,abdominalcircumference:28.68cm,femurlength:5.65cm,humeruslength:4.93cm,fetalweight:1790oz161g,amnioticfluidindex:16.4cm:fetalumbilicalcordaroundtheneckforoneweek;Placentalsinussoundimage.病因，臨床表現(xiàn)CauseOfDisease，ClinicalManifestations3病因1.生殖道感染胎膜早破的主要原因。GenitaltractinfectionsThemaincauseofprematureruptureofmembranes.2.羊膜腔壓力增高

多胎妊娠、羊水過多等。IncreasedpressureintheamnioticcavityMultiplepregnancies,polyhydramnios,etc.

3.前羊膜囊受力不均

頭盆不稱、胎位異常等。Unevenforceintheanterioramnioticsac,cephalopelvicdisproportion,abnormalfetalposition,etc.2024/10/304.營養(yǎng)因素

缺乏維生素、鈣、鋅及銅。NutritionalfactorsLackofvitamins,calcium,zincandcopper.5.創(chuàng)傷

羊膜腔穿剌不當(dāng)、妊娠晚期性生活不當(dāng)及腹部受碰撞。Traumawithimproperamnioticpenetration,inappropriatesexualintercourseinlatepregnancy,andabdominalcollision.臨床表現(xiàn)孕婦突感有較多液體自陰道流出，不伴有腹痛，當(dāng)腹壓增加時，陰道流液增加是典型癥狀。少數(shù)孕婦僅感到外陰較平時濕潤.足月胎膜早破時，陰道檢查摸不到前羊膜囊，上推胎兒先露部陰道流液量增加，可見胎脂等。Pregnantwomenhavealargeoutflowoffluidfromthevaginawithoutabdominalpain,andwhenabdominalpressureincreases,increasedvaginaldischargeisatypicalsymptom.Asmallnumberofpregnantwomenonlyfeelthatthevulvaiswetterthanusual.Whenthetermfetalmembranesruptureprematurely,theanterioramnioticsaccannotbefeltduringvaginalexamination,andthevaginaldischargeintheexposedpartofthefetusisincreased,andfetalfatcanbeseen.體格檢查PhysicalExamination4體格檢查生命體征測量體格檢查腹部四部觸診體格檢查宮高腹圍測量治療要點Keypointsoftreatment5足月胎膜早破應(yīng)及時終止妊娠。未足月胎膜早破應(yīng)根據(jù)孕周、有無感染、胎兒宮內(nèi)情況、所在地新生兒救治水平、孕婦和家屬意愿等制訂合理的處理方案或及時轉(zhuǎn)診。對于未足月胎膜早破的期待治療包括預(yù)防感染、促胎肺成熟、抑制宮縮、胎兒神經(jīng)系統(tǒng)保護等。Prematureruptureofmembranesattermshouldpromptterminationofpregnancy.Pretermprematureruptureofmembranesshouldbebasedongestationalage,whetherthereisinfection,intrauterineconditionsofthefetus,thelevelofneonataltreatmentinthelocality,andthewishesofpregnantwomenandtheirfamilies,etc.Expectantmanagementofpretermpretermruptureofmembranesincludesinfectionprevention,promotionoffetallungmaturation,inhibitionofuterinecontractions,andfetalneurologicalprotection.治療要點護理Nursing6

護理診斷1.有感染的危險：與胎膜破裂后易造成羊膜腔內(nèi)感染有關(guān)。2.有胎兒受傷的危險：與臍帶脫垂、早產(chǎn)和新生兒感染有關(guān)。3.恐懼：與胎膜早破、誘發(fā)早產(chǎn)，擔(dān)心胎兒、新生兒有關(guān)。4.潛在并發(fā)癥：早產(chǎn)、臍帶脫垂，胎盤早剝。2024/10/301.Riskofinfection:itisrelatedtotheruptureoffetalmembranesthatcaneasilycauseintra-amnioticinfection.2.Riskoffetalinjury:relatedtoumbilicalcordprolapse,prematurebirthandneonatalinfection.3.Fear:relatedtoprematureruptureofmembranes,inducingprematurebirth,andworryingaboutthefetusandnewborn.4.Potentialcomplications:prematurebirth,umbilicalcordprovexation,placentalabruption.護理措施1、住院待產(chǎn)防止臍帶脫垂，胎先露沒有街接者應(yīng)絕對臥床休息，臀高頭低臥位為佳。Hospitalizedtopreventumbilicalcordprolapse,fetalfirstexposurewithoutstreetcontactshouldbeabsolutelybedrest,hipshighheadlowlyingpositionispreferred.未足月胎膜早破Pretermprematureruptureofmembranes護理措施2、期待療法:延長孕周同時避免或控制感染。保持床單位的整潔，勤換會陰墊。保持外陰清潔，每日用消毒液擦洗會陰。定時監(jiān)測孕婦體溫、脈搏情況，觀察感染征象。遵醫(yī)囑應(yīng)用抗生素，嚴格無菌操作。加強營養(yǎng)，提高機體抵抗力。Expectantmanagement:prolonginggestationalagewhileavoidingorcontrollinginfection.Keepthebedunittidyandchangetheperinealpadfrequently.Keepthevulvacleanandscrubtheperineumdailywithanantisepticsolution.Regularlymonitorthetemperatureandpulseofpregnantwomenandobservesignsofinfection.Applyantibioticsasdirectedbyadoctorandoperatestrictlyaseptically.Strengthennutritionandimprovethebody'sresistance

3、觀察宮內(nèi)感染的象征護理措施①母體體溫>38℃;②陰道分泌物異味；③胎心率增快(胎心率基線≥160次/分)或母體心率增快(心率≥100次/分);④母體外周血白細胞計數(shù)升高(≥15x10∧9/L或核左移);子宮呈激惹狀態(tài)、宮體有壓痛孕婦體溫升高的同時伴有上述任何一項表現(xiàn)可診斷絨毛膜羊膜炎

護理措施3.Lookforsignsofintrauterineinfection①Maternalbodytemperature>38°C;②odorofvaginaldischarge;③Increasedfetalheartrate(baseline2160beats/min)ormaternalheartrate(heartrate≥100beats/min);④increasedmaternalperipheralbloodwhitebloodcellcount(215x10∧9/Lorleftnuclearshift);Uteruswasirritated,uterinebodytenderness

Chorioamnioticinflammationcanbediagnosedwhenawoman'sbodytemperatureincreaseswithanyoftheabovesymptoms密切觀察胎兒宮內(nèi)情況4、配合治療，觀察宮縮情況，預(yù)防早產(chǎn)，未足月抑制宮縮。Closelyobservethefetalsituationinutero4.Cooperatewithtreatment,observeuterinecontractions,preventprematuredelivery,andi