前置胎盘与胎盘早剥：无痛还是疼痛

🧠 为什么重要

前置胎盘：胎盘覆盖宫颈或位于宫颈附近，导致无痛的鲜红色阴道出血，通常发生在妊娠 20 周后，子宫柔软、无压痛。禁止阴道检查，因为检查可能撕裂胎盘；通过超声诊断，保持骨盆休息（禁止性交、冲洗或使用卫生棉条），并限制活动（活动性出血时卧床休息），同时进行胎儿监护，并计划剖宫产分娩，若出血量大或持续，在任何孕周都应紧急进行。胎盘早剥：胎盘过早剥离，导致疼痛性的、常为深色的出血（可能被隐匿），子宫僵硬、板状硬且有压痛，并出现与可见出血量不成比例的休克征象；危险因素包括高血压、外伤、使用 cocaine 和吸烟；它可导致胎儿窘迫和弥散性血管内凝血。按急症处理：建立大口径 IV 通路、给氧、持续胎儿监护、包括凝血检查在内的实验室检查，并按需给予血液制品。如果早剥严重、母亲不稳定、胎儿出现窘迫，或妊娠已足月或接近足月，应迅速分娩。对于胎儿心率令人安心的稳定早产患者，轻度早剥可在医院内期待治疗，使用 corticosteroids 并密切监护。异位妊娠：停经、一侧下腹痛、点滴出血，若破裂则出现牵涉性肩痛和休克；未破裂且稳定时用 methotrexate 治疗，或进行手术。自然流产：妊娠 20 周前出血和痉挛性疼痛；数卫生巾的数量，保存组织，对 Rh 阴性患者给予 Rh 免疫球蛋白（自 2024 年起，ACOG 建议在 12 周前不必常规给予）。妊娠滋养细胞疾病（葡萄胎）：深褐色出血、子宫大于孕周、hCG 非常高；之后随访连续 hCG 水平，并在整个监测期间使用可靠的避孕方法，监测可持续长达一年。

PLACENTA PREVIA: the placenta covers or lies near the cervix, causing PAINLESS, bright red vaginal bleeding, usually after 20 weeks, with a soft, non-tender uterus. NO VAGINAL EXAMS, which can tear the placenta; diagnose by ultrasound, maintain pelvic rest (no intercourse, douching or tampons) with activity limitation (bed rest while actively bleeding) and fetal monitoring, and plan a cesarean birth, done urgently at any gestational age if bleeding is heavy or continuous. ABRUPTIO PLACENTAE: the placenta separates early, causing PAINFUL, often dark bleeding (which may be concealed), a rigid, board-like, tender uterus, and signs of shock out of proportion to visible blood; risk factors include hypertension, trauma, cocaine use and smoking; it can cause fetal distress and disseminated intravascular coagulation. Treat as an emergency: large-bore IV access, oxygen, continuous fetal monitoring, labs including coagulation studies, and blood products as needed. Deliver promptly if the abruption is severe, the mother is unstable, the fetus shows distress, or the pregnancy is at or near term. A mild abruption in a stable preterm client with a reassuring fetal heart rate may be managed expectantly in the hospital with corticosteroids and close monitoring. ECTOPIC PREGNANCY: a missed period, one-sided lower abdominal pain, spotting, and, if ruptured, referred shoulder pain and shock; treated with methotrexate if unruptured and stable, or surgery. SPONTANEOUS ABORTION: bleeding and cramping before 20 weeks; count pads, save tissue, give Rh immune globulin to Rh-negative clients (since 2024 ACOG suggests forgoing it routinely before 12 weeks). GESTATIONAL TROPHOBLASTIC DISEASE (molar pregnancy): dark brown bleeding, a uterus larger than dates, very high hCG; follow serial hCG levels afterward and use reliable contraception throughout monitoring, which can last up to a year.

🏥 真实场景

🚫 一名妊娠 32 周的患者因无痛的鲜红色出血入院。一名学生伸手拿手套准备检查宫颈扩张。护士拦住了她：对于原因不明的出血，阴道检查可能扰动前置胎盘并引起大出血。先做超声检查。在这里，考试的错误答案是那个看起来像全面评估的选项。

🚫 A client at 32 weeks arrives with painless bright red bleeding. A student reaches for gloves to check cervical dilation. The nurse stops her: with bleeding of unknown cause, a vaginal exam can disrupt a placenta previa and cause a hemorrhage. Ultrasound first. The exam's wrong answer here is the one that looks like thorough assessment.

📌 要点总结

• 无痛的鲜红色出血：前置胎盘；禁止阴道检查Painless bright red bleeding: previa; no vaginal exam
• 疼痛、僵硬的腹部伴深色或隐匿性出血：胎盘早剥；有 DIC 风险Painful rigid abdomen with dark or hidden bleeding: abruption; DIC risk
• 异位妊娠破裂：一侧疼痛、肩痛、休克Ectopic rupture: one-sided pain, shoulder pain, shock

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