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Case presentation : placental abruption

Case presentation : placental abruption. by R2 王鎮華. 故事敘述. 背景 時間:民國93年12月08日凌晨 地點:五樓產房 現場實況 婦產科醫師的反應: 病人的情況: 我們對病人的準備狀況:. 故事敘述. 我的心情: 我的處置: 事情往後的發展:. Patient profile. 36 y/o ; female ; G1P0 ; GA :26weeks Hospitalization due to antepartum hemorrhage

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Case presentation : placental abruption

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  1. Case presentation : placental abruption by R2 王鎮華

  2. 故事敘述 • 背景 時間:民國93年12月08日凌晨 地點:五樓產房 • 現場實況 婦產科醫師的反應: 病人的情況: 我們對病人的準備狀況:

  3. 故事敘述 • 我的心情: • 我的處置: • 事情往後的發展:

  4. Patient profile • 36 y/o ; female ; G1P0 ; GA :26weeks • Hospitalization due to antepartum hemorrhage • Preterm uterine contraction under Yutopar

  5. Event course • Massive vaginal bleeding at 02:50 AM • FHB < 60/min. at 03:10 AM , then the patient was immediately sent to OR • A baby was born at 03:37 • Intubation at 03:45 ( Nimbex 10 mg , Fentanyl 100microgram) • Blood gas : PH:7.35, HCO3:19.1,Ca:0.63, Hb:6.7,Hct:20

  6. Event course • Apgar score:0---5 • Blood loss:1500ml • U/O:200ml • Transfusion:PRBC 4U,FFP 4U, PLT 12U • Transferred to 4C1 at 04:50 ; H.R.:90, B.P.:187/111, O2 saturation:100

  7. Event course • Blood Gas: PH:7.48, PCO2:29.1, PaO2:360, HCO3:22.2, Hct:25, Hb:8.3, Electrolytes are all within normal range • Transferred to 5B the next day • Discharged on 12/13

  8. Placental Abruption • Definition : separation of the placenta from the decidua basalis before delivery of the fetus. • Result : acute bleeding results from exposed decidual vessels. Fetal distress occurs because of loss of area for maternal-fetal gas exchange.

  9. Pathophysiology • Major complications:hemorrhagic shock, acute renal failure (ARF), coagulopathy, fetal distress or demise. • Major fetal risk:Hypoxia. Fetal oxygenation depends on adequate maternal oxygen­carrying capacity, uteroplacental blood flow, and transplacental exchange. Large maternal blood loss causes maternal hypotension, decreased uterine blood flow, and decreased maternal oxygen-carrying capacity. Abruption also causes a decrease in the placental surface available for exchange of oxygen.

  10. Pathophysiology • A vicious cycle may be established in which a small placental abruption stimulates uterine contractions, causing further separation of the placenta. • Respiratory distress syndrome is the most common neonatal complication; it occurs in as many as 50% of deliveries complicated by abruption.

  11. Anesthetic management • Epidural anesthesia? Spinal anesthesia? General anesthesia ? • General anesthesia is preferred for most of these cases.

  12. Anesthetic management • Thiopental and propofol may precipitate severe hypotension in patients with unrecognized hypovolemia. Ketamine and etomidate are better options for the patient with unknown or decreased intravascular volume. • A rapid-sequence induction with cricoid pressure is performed.

  13. Anesthetic management • Maintenance of anesthesia:A common approach is to administer 50% nitrous oxide in oxygen in combination with a low concentration of a volatile halogenated agent • Aggressive volume resuscitation is critical. In cases of severe hemorrhage, management is aided by the insertion of central venous and arterial catheters.

  14. Anesthetic management • A minority of patients, notably those with prolonged hypotension, coagulopathy, and massive blood volume/ product replacement, are best monitored and followed in a multidisciplinary intensive care unit.

  15. Reference • Miller’s anesthesiology (2005) • Clinical anesthesiology (2002) • Obstetric Anesthesia principles and practice (2004)

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