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1、If you are a doctor,In the midnight,the pregnant women awakens to find that they have to sleep in a pool of blood,How to diagnosis？How to management？,You,Antepartum Hemorrhage,Obstetrics&Gynecology Hospital of Fudan UniversityXu Huan,Rationale(why we care),4-5%of pregnancies complicated by 3rd trime
2、ster bleedingImmediate evaluation neededSignificant threat to mother&fetus(consider physiologic increase in uterine blood flow)Consider causes of maternal&fetal deathPriorities in management(triage!),Objectives,We will be able to:Describe the approach to the patient with third-trimester bleedingComp
3、are symptoms,physical findings,and diagnostic methods that differentiate bleeding etiologiesDescribe management and delivery options for 3rd trimester bleeding etiologiesDescribe potential maternal and fetal morbidity&mortality Describe management of postpartum hemorrhageApply knowledge in the discu
4、ssion of clinical case scenarios,Vaginal Bleeding:Differential diagnosis,Common:Abruption,previa,preterm labor,laborLess common:Uterine rupture,fetal vessel rupture,lacerations/lesions,cervical ectropion,polyps,vasa previa,bleeding disordersUnknownNOT vaginal bleeding!(happens more than you think!),
5、Other Etiologies,Cervicitisinfection Cervical erosion Trauma Cervical cancer Foreign body Bloody show/labor,Perinatal mortality and morbidity,PreviaDecreased mortality from 30%to 1%over last 60 yearsNow emergent cesarean delivery often possibleRisk of preterm deliveryAbruptionPerinatal mortality rat
6、e 35%Accounts for 15%of 3rd trimester stillbirthsRisk of preterm deliveryMost common cause of DIC in pregnancyMassive hemorrhage-risk of acute renal failure,Sheehans,etc.,Placenta previa,Definition,After 28 pregnant weeks placental implantation over the cervical os or in the lower uterine segmentIt
7、constitutes an obstruction of descent of the presenting partMain cause of obstetrical hemorrhage(20%)Incidence 0.24%-1.57%(our country).,Risk factors,Prior cesarean delivery/myomectomyPrior previa(4-8%recurrence risk)Previous abortion Increased parity Multiple pregnancyAdvanced maternal age Abnormal
8、 presentation Smoking,Etiology,CausesEndometrial abnormalityScared or poorly vascularized endometrium in the corpus.Curettage,Delivery,CS and infection of endometriumPlacental abnormality Large placenta(multiple pregnancy),succenturiate lobeDelayed development of trophoblast,Classification,Complete
9、placenta previa,Partrial placenta previa,Marginal placenta previa,Classification,Symptoms(1),Painless vaginal bleeding(70%)Spontaneous,After coitusThe most characteristic symptomlate pregnancy(after the 28th week)and deliveryCharacteristics:sudden,painless and profuseContractionsNo symptomsRoutine u
10、ltrasound findingThe mean gestational age of first bleed:30 wks1/3 before 30 weeks,Symptoms(2),Anemia or shock repeated bleeding anemia heavy bleeding shockAbnormal fetal position a high presenting part breech presentation(often),Physical Findings,Bleeding on speculum examCervical dilationAbnormal p
11、osition/lieNon-reassuring fetal status If significant bleeding:Tachycardia Postural hypertensionShock,Diagnosis(1),HistoryPainless hemorrhageAt late pregnancy or deliveryHistory of curettage or CS,Diagnosis(2),SignsAbdominal findingsUterus is soft,relaxed and nontender.Contraction may be palpated.A
12、high presenting part cant be pressed into the pelvic inlet.(Breech presentation)Fetal heart tones maybe disappear(shock or abruption),Diagnosis(3),Speculum examination Rule out local causes of bleeding,such as cervical erosion or polyp or cancer.Limited vaginal examination(seldom used)Palpation of t
13、he vaginal fornices to learn if there is an intervening bogginess between the fornix and presenting part.Rectal examination is useless and dangerous,Limited vaginal examination,Diagnosis(4),Ultrasoundabdominal 95%accurate to detecttransvaginal(TVUS)will detect almost allconsider what placental locat
14、ion a TVUS may find that was missed on abdominalMRICheck the placenta and membrane after deliveryremember:no digital exams unless previa RULED OUT!,Diagnosis(5),Before 20 weeks gestation,4-6%have some degree of placenta previa on ultrasonic examination90%of these resolving by the third trimesterOnly
15、 10%of complete placenta,Differential Diagnosis,Placental abruption vagina bleeding with pain,tenderness of uterus.vasa previa In cases of velamentous cord insertion fetal vessels cover cervical osAbnormality of cervix cervical erosion or polyp or cancer,vasa previa,Velamentous placenta,vasa previa,
16、Effects,obstetrical hemorrhagePlacenta accreta,increta,and percreta Anemia and infectionPremature labor or fetal death or fetal distress,Abnormally adherent placentation.A.Placenta accreta.B.Placenta increta.C.Placenta percreta,A,B,C,Management(1),Less than 36 wks gestation-expectant management if s
17、table,reassuringRest:keep the bed No vaginal exams(not negotiable)Steroids for lung maturation(32 wks)Controlling the contraction:MgSO4Treatment of anemia Preventing infection70%will have recurrent vaginal bleeding before 36 completed weeks requiring emergent cesarean,Management(2),Initial evaluatio
18、n/diagnosisObserve/admit to Labor&DeliveryIntravenous access,routine(maybe serial)labs Continuous electronic fetal monitoringContinuous at least initallyMay re-evaluate later if stable,no further bleeding Delivery?,Management,Termination of pregnancyCStotal placenta previa(36th week),Partial placent
19、a previa(37th week)and heavy bleeding with shockPreventing postpartum hemorrhage:pitocin and PGHysterectomy:Placenta accreta or uncontroled bleeding,Cesarean hysterectomy specimens with placenta percreta.,Cesarean hysterectomy specimens with placenta percreta.(Lateral fundal percreta caused hemoperi
20、toneum in late pregnancy),Management,36+weeks gestationCesarean delivery if positive fetal lung maturity by amniocentesisDelivery vs expectant management if fetal lung immaturitySchedule cesarean delivery at 37 weeksDiscussion/counseling regarding cesarean hysterectomyNote:given stable maternal and
21、reassuring fetal status,none of these management guidelines are absolute(this is why Obstetrics is so much fun!),Other Considerations,Placenta accreta,increta,percretaCesarean delivery may be necessaryHistory of uterine surgery increases riskMust consider these diagnoses if previa presentCould requi
22、re further evaluation,imaging(MRI considered now)NOT the delivery you want to do at 2 am,Management,Vaginal delivery Marginal placenta previa(2cm)Vaginal bleeding is limited,Placental abruption,Definition,abruptio placentae or placental abruption:placental separation from its implantation site befor
23、e delivery(the normally implanted placenta)Incidence complicates 0.5-1.5%of all pregnancies recurrence risk 10%after 1st episode 25%after 2nd episode,Risk factors&Associations,Cocainematernal hypertensionabdominal trauma smoking prior abruptionpreeclampsiamultiple gestation,prolonged PROMuterine dec
24、ompressionshort umbilical cordchorioamnionitismultiparity,Pathology,Placental separation is initiated by hemorrhage into the decidua basalis with formation of a decidual hematomaConcealed hemorrhageRevealed hemorrhage,revealed hemorrhage,concealed hemorrhage,mixed hemorrhage,Total placental abruptio
25、n with concealed hemorrhage and fetal death,Maternal-fetal risk,perinatal mortality:35%DIChypovolemic shockacute renal failureSheehans syndrome,Symptoms,Vaginal bleeding Abdominal or back painUterine contractions Uterine tenderness,Physical Findings,Vaginal bleedingUterine contractions Hypertonus Te
26、tanic contractions Non-reassuring fetal status or demiseCan be concealed hemorrhage,Laboratory Findings,Anemiamay be out of proportion to observed blood loss DICCan occur in up to 10%(30%if“severe”)First,increase in fibrin split products Followed by decrease in fibrinogen,Diagnosis,Clinical scenario
27、Physical examNot digital pelvic exams until rule out previaCareful speculum examUltrasoundCan evaluate previaNot accurate to diagnose abruption,Management,Physical examContinuous electronic fetal monitoring UltrasoundAssess viability,gestational age,previa,fetal position/lieExpectant managementvagin
28、al vs cesarean deliveryAvailable anesthesia,OR team for cesarean delivery,Partial placental abruption with adhered clot,Couvelaire Uterus,腹壁子宫按摩法,腹部-阴道双手压迫子宫法,A bimanual compression,Packing the uterine cavity,Flash,B-lynch/Bind suture,Cho/patch suture,Ligation of the utering arteries,Management,Careful maternal hemodynamic monitoringFetal monitoring Serial evaluation of the hematocrit,coagulation profile,deliveryBlood products for replacementA large-bore intravenous line,
