1、Importance Maternal Risks Acute hemorrhage Operative delivery Fetal Risks Uteroplacental insufficiency Premature birth Key Points Identify the cause Timely intervention Initial Assessment History Amount of bleeding,recent intercourse or digital exam,severity of pain,trauma Physical exam Vital signs,
2、speculum,digital only if no placenta previa,may note cervicitis/polyp/cancer Ultrasound Evaluation for placenta previa Period of observation Initial Management of Significant Bleeding Hemodynamic instability Hypotension Tachycardia IV fluids Consider blood products/transfusion Lab tests Hematocrit,p
3、latelets,fibrinogen,coagulation,blood type,and antibody screen Continuous fetal monitoring Consider emergent cesarean section Placenta Previa Complete Covers the internal cervical os Marginal Edge lies within 2cm of internal cervical os Low lying Edge lies 2 3.5cm from the internal os Image:http:/ P
4、lacenta Previa(continued)Noted in mid-pregnancy in 40/1000 pregnancies At term,only 4/1000 Best visualized with transvaginal ultrasound Risk factors Increased age Increased parity Tobacco use Increasing number of cesarean deliveries Placenta Previa(continued)Presentation “painless bleeding”Often“sen
5、tinel bleed”in the late 2nd or early 3rd trimester Often after sexual intercourse Placenta Previa(continued)Management Goal is to promote fetal lung maturity Admit to hospital initially Administer steroids if 24-34 weeks gestation Consider tocolytics Outpatient management in selected situations Seri
6、al ultrasounds If does not resolve,cesarean delivery at term Placenta Previa(continued)Mode of delivery If unstable,immediate cesarean delivery If stable,ultrasound at 36 weeks If placental edge 2cm from os,vaginal delivery If placental edge 1-2cm from os,may attempt vaginal delivery if operating ro
7、om near by If fetal lungs are mature,cesarean for complete previa If history of cesarean,evaluate for invasive placenta Color flow Doppler MRI If confirmed,prepare for possible cesarean/hysterectomy Placental Abruption Separation of placenta from uterine wall Most common cause of serious bleeding 1%
8、of pregnancies Neonatal mortality is 10-30%50%of abruptions occur prior to 36 weeks gestation Image:http:/ Placental Abruption(continued)Risk factors Smoking tobacco Cocaine use Chronic hypertension Preeclampsia Thrombophilias Abdominal trauma History of abruption in previous pregnancy Placental Abr
9、uption(continued)Clinical Presentation Bleeding Uterine tenderness or back pain Fetal distress Preterm labor Intrauterine fetal death Disseminated intravascular coagulation Recurrent bleeding,pain,contractions Placental Abruption(continued)Management Stabilize the mother Assess fetal well-being Ultr
10、asound is not reliable Serial labs(Hct and coagulation studies)Rarely,administer corticosteroids RAPID DELIVERY!Placental Abruption(continued)Prevention No tobacco use No illegal drug use Proper management of HTN in pregnancy Vasa Previa Insertion of the umbilical cord into the amniotic membranes in
11、 the lower uterine segment Results in fetal vessels between the cervix and the presenting part 1 in 2500 births 33 to 100 percent perinatal mortality Image:http:/ Vasa Previa(continued)Risk factors In vitro fertilization Placenta previa Multi-lobed placentas Vasa Previa(continued)Presentation Hemorr
12、hage at the time of amniotomy or spontaneous rupture of membranes Exsanguination of fetal blood can occur rapidly Vasa Previa(continued)Management If fetal well-being is not reassuring,or if hemorrhage is severe,RAPID DELIVERY!If fetal heart tones are reassuring,APT test can be performed References Sakornbut,E,Leeman,L,Fontaine,P“Late Pregnancy Bleeding”American Family Physician,Vol 75,No 8,April 15th,2007.
