1、第一页，共二十九页。,第二页，共二十九页。,Importance,Maternal RisksAcute hemorrhageOperative deliveryFetal RisksUteroplacental insufficiencyPremature birthKey PointsIdentify the causeTimely intervention,第三页，共二十九页。,Initial Assessment,HistoryAmount of bleeding,recent intercourse or digital exam,severity of pain,traumaPhy
2、sical examVital signs,speculum,digital only if no placenta previa,may note cervicitis/polyp/cancerUltrasoundEvaluation for placenta previaPeriod of observation,第四页，共二十九页。,Initial Management of Significant Bleeding,Hemodynamic instabilityHypotensionTachycardiaIV fluidsConsider blood products/transfus
3、ionLab testsHematocrit,platelets,fibrinogen,coagulation,blood type,and antibody screenContinuous fetal monitoringConsider emergent cesarean section,第五页，共二十九页。,Placenta Previa,CompleteCovers the internal cervical osMarginalEdge lies within 2cm of internal cervical osLow lyingEdge lies 2 3.5cm from th
4、e internal os,第六页，共二十九页。,第七页，共二十九页。,Placenta Previa(continued),Noted in mid-pregnancy in 40/1000 pregnanciesAt term,only 4/1000Best visualized with transvaginal ultrasoundRisk factorsIncreased ageIncreased parityTobacco useIncreasing number of cesarean deliveries,第八页，共二十九页。,Placenta Previa(continued
5、),Presentation“painless bleeding”Often“sentinel bleed”in the late 2nd or early 3rd trimesterOften after sexual intercourse,第九页，共二十九页。,Placenta Previa(continued),ManagementGoal is to promote fetal lung maturityAdmit to hospital initiallyAdminister steroids if 24-34 weeks gestationConsider tocolyticsO
6、utpatient management in selected situationsSerial ultrasoundsIf does not resolve,cesarean delivery at term,第十页，共二十九页。,Placenta Previa(continued),Mode of deliveryIf unstable,immediate cesarean deliveryIf stable,ultrasound at 36 weeksIf placental edge 2cm from os,vaginal deliveryIf placental edge 1-2c
7、m from os,may attempt vaginal delivery if operating room near byIf fetal lungs are mature,cesarean for complete previaIf history of cesarean,evaluate for invasive placentaColor flow DopplerMRIIf confirmed,prepare for possible cesarean/hysterectomy,第十一页，共二十九页。,第十二页，共二十九页。,Placental Abruption,Separati
8、on of placenta from uterine wallMost common cause of serious bleeding1%of pregnanciesNeonatal mortality is 10-30%50%of abruptions occur prior to 36 weeks gestation,第十三页，共二十九页。,第十四页，共二十九页。,第十五页，共二十九页。,Placental Abruption(continued),Risk factorsSmoking tobaccoCocaine useChronic hypertensionPreeclampsi
9、aThrombophiliasAbdominal traumaHistory of abruption in previous pregnancy,第十六页，共二十九页。,Placental Abruption(continued),Clinical PresentationBleedingUterine tenderness or back painFetal distressPreterm laborIntrauterine fetal deathDisseminated intravascular coagulationRecurrent bleeding,pain,contractio
10、ns,第十七页，共二十九页。,Placental Abruption(continued),ManagementStabilize the motherAssess fetal well-beingUltrasound is not reliableSerial labs(Hct and coagulation studies)Rarely,administer corticosteroidsRAPID DELIVERY!,第十八页，共二十九页。,Placental Abruption(continued),PreventionNo tobacco useNo illegal drug use
11、Proper management of HTN in pregnancy,第十九页，共二十九页。,第二十页，共二十九页。,Vasa Previa,Insertion of the umbilical cord into the amniotic membranes in the lower uterine segmentResults in fetal vessels between the cervix and the presenting part1 in 2500 births33 to 100 percent perinatal mortality,第二十一页，共二十九页。,第二十二
12、页，共二十九页。,第二十三页，共二十九页。,Vasa Previa(continued),Risk factorsIn vitro fertilizationPlacenta previaMulti-lobed placentas,第二十四页，共二十九页。,Vasa Previa(continued),PresentationHemorrhage at the time of amniotomy or spontaneous rupture of membranesExsanguination of fetal blood can occur rapidly,第二十五页，共二十九页。,Vasa
13、 Previa(continued),ManagementIf fetal well-being is not reassuring,or if hemorrhage is severe,RAPID DELIVERY!If fetal heart tones are reassuring,APT test can be performed,第二十六页，共二十九页。,第二十七页，共二十九页。,References,Sakornbut,E,Leeman,L,Fontaine,P“Late Pregnancy Bleeding”American Family Physician,Vol 75,No 8,April 15th,2007.,第二十八页，共二十九页。,内容(nirng)总结,Importance。Consider blood products/transfusion。Image:http:/Previa(continued)。Image:http:/,第二十九页，共二十九页。,