Placenta previa:前置胎盘.ppt
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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
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