Uterus hard as a plate

Introduction After 20 weeks of gestation or during childbirth, the placenta in the normal position is partially or completely detached from the uterine wall before the delivery of the fetus, called placental abruption. Placental abruption is a serious complication in the third trimester of pregnancy. It has an acute onset and rapid progress. If it is not treated in time, it can endanger the mother and child. The incidence of domestic reports is 4.6 to 21 , and the incidence rate abroad is 5.1 to 23.3 . The incidence is related to whether the placenta is carefully examined after delivery. Some patients with mild placental abruption can have no obvious symptoms before labor. Only when the placenta is examined after delivery, it is found that there is clot blockage in the early exfoliation. Such patients are easily overlooked. Abdominal examination: palpation of the uterus is as hard as a plate, with tenderness, especially at the place where the placenta is attached.

Cause

The pathogenesis of placental abruption has not been fully elucidated, and its onset may be related to the following factors.

1. Vascular lesions: pregnant women with placental abruption have severe pregnancy-induced hypertension, chronic hypertension and chronic kidney disease, especially those with systemic vascular disease. When the sacral sacral small artery is spasm or hardened, causing avascular necrosis of the distal capillary to cause hemorrhage, the blood flows to the sacral layer to form a hematoma, which causes the placenta to peel off from the uterine wall.

2. Mechanical factors: trauma (especially the direct impact of the abdomen or falling directly on the abdomen, etc.), the correction of the fetal position, the umbilical cord is too short or the umbilical cord around the neck, the first exposed part of the fetus during the delivery process, May cause placental abruption. In addition, the first fetus in a twin pregnancy is delivered too fast or the amniotic fluid is too much in the rupture of the membrane when the amniotic fluid flows out too quickly, so that the intrauterine pressure suddenly drops, and the uterus suddenly contracts, which may also cause the placenta to peel off from the uterine wall.

3. Uterine venous pressure suddenly increased: in the third trimester of pregnancy or after labor, when the pregnant woman takes the supine position for a long time, supine hypotension syndrome can occur. At this time, due to the huge uterus compression of the inferior vena cava, the amount of blood returning to the heart is reduced, the blood pressure is lowered, and the uterine vein is bleeding, and the venous pressure is increased, causing blood stasis or rupture of the aponeuric vein bed, resulting in partial or total placenta from the uterine wall. Stripped.

an examination

Related inspection

Gynecological Ultrasound Examination of Vaginal Palpation Placenta Prolactin (PL)

First, physical examination:

Light weight: abdominal examination, soft uterus, tenderness is not obvious or only mild localized tenderness (placental abruption). Its size is consistent with the month of pregnancy, fetal position, fetal heart sound is clear, but if the amount of bleeding is more, the fetal heart rate can be changed. The delivery is finished in a short time, and the placenta is examined after delivery. It can be seen that there are clots and pressure marks on the surface of the placenta.

Heavy: Abdominal examination, the uterus palpation is as hard as a plate, there is tenderness, especially the placenta attachment is most obvious, but if the placenta is attached to the posterior wall of the uterus, the uterus compression is not obvious. The uterus is larger than the month of pregnancy, and with the development of the disease, the hematoma of the placenta continues to increase, and the fundus is also increased accordingly, and the tenderness is more obvious. Occasionally, contractions, but the uterus can not relax very well in the interim period, but in a high state, so the fetal position is not clear. If the placenta is more than 1/2 of the exfoliation surface, the fetus will die due to severe intrauterine distress.

Second, auxiliary inspection:

1. B-mode ultrasonography: B-mode ultrasound examination of suspected and light patients can determine the presence or absence of placental abruption and estimated size of the stripping surface. If there is a hematoma after the placenta, an ultrasound sonogram shows a dark area between the placenta and the uterine wall, and the boundaries are not clear. It is helpful for suspicious and light. The B-ultrasound image of the severe patient is more obvious. In addition to the liquid dark area between the placenta and the uterine wall, light spot reflection (hemorrhage) sometimes occurs in the dark area, and the placental fluff protrudes into the amniotic cavity. And the state of the fetus (with or without fetal movement and fetal heartbeat).

2. Laboratory examination: mainly to understand the degree of anemia and coagulation function of patients. Blood routine examination to understand the degree of anemia in patients; urine routine understanding of renal function and urine protein. Severe placental abruption may be complicated by DIC. Laboratory tests should be performed, including DIC screening tests (such as platelet count, prothrombin time, fibrinogen assay, and 3P test) and fibrinolysis test (such as Fi test, FDP immunization). Test, thrombin time and euglobulin lysis time, etc.).

Differential diagnosis

In late pregnancy, in addition to placental abruption, there are still placenta previa, uterine rupture and bleeding of cervical lesions, etc., should be identified, especially in the identification of placenta previa and uterine rupture.

1. Placenta previa: Light placenta premature detachment can also be painless vaginal bleeding, the signs are not obvious, B-mode ultrasound examination to determine the lower edge of the placenta, you can confirm the diagnosis. Placental abruption on the posterior wall of the uterus, abdominal signs are not obvious, it is not easy to distinguish from the placenta previa, B-ultrasound can also be identified. The clinical manifestations of severe placental abruption are very typical and it is not difficult to distinguish from placenta previa.

2. Aura uterus rupture: often occurs during childbirth, strong contractions, lower abdominal pain, irritability, a small amount of vaginal bleeding, fetal distress signs. The above clinical manifestations are more difficult to distinguish from severe placental abruption. However, there are many uterine ruptures in the aura, uterine tube obstruction or cesarean section history, examination can be found in the uterus pathological retraction ring, catheterization has gross hematuria, etc., and placental abruption is often a patient with severe pregnancy-induced hypertension, check the uterus The plate is hard.

diagnosis:

The diagnosis is mainly based on medical history, clinical symptoms and intrinsic. Light placental abruption due to symptoms and signs are not typical, the diagnosis is often difficult, should be carefully observed and analyzed, and confirmed by B-mode ultrasound. The symptoms and signs of severe placental abruption are typical, and there is no difficulty in diagnosis. At the same time as the diagnosis of severe placental abruption, the severity should be judged. If necessary, the above laboratory tests should be carried out to determine whether there are complications such as coagulopathy and renal failure, so as to formulate a reasonable treatment plan.

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