妊娠出血

Bleeding in Pregnancy:Third Trimester Hemorrhage Department of Gynaecology and ObstetricsAnitaPlacenta PreviaPlacental AbruptionPlacenta PreviaThe Second SectionLearning Objectives DesireTo grasp the classification, clinical menifestation, diagnosis and principle of managementTo be familiar with the etiologyTo know the effect on the mother and fetus and preventive measureSyllabus Clinical Diagnosis it spontaneously ceases, only to recur later.vThe first bleed occurs (on average) at 27-32 weeks gestation.vContractions may or may not occur simultaneously with the bleeding.vTotal placenta previa occurs when the internal cervical os is completely covered by the placenta. vPartial placenta previa occurs when the internal os is partially covered by the placenta. vMarginal placenta previa occurs when the placenta is at the margin of the internal os. ClassificationGraspAccessory ExaminationLab Studies Imaging Studies OtherTests Lab Studies Beta-human chorionic gonadotropin (beta-hCG) subunitRh compatibilityFibrin split products (FSP) and fibrinogen levelsProthrombin time (PT)/activated partial thromboplastin time (aPTT)Type and hold for at least 4 unitsImaging Studies Transabdominal ultrasonographyv A simple, precise, and safe method to visualize the placenta, this ultrasonography has an accuracy of 93-98%.v False-positive results can occur secondary to focal uterine contractions or bladder distention. Transvaginal ultrasonographyv Recent studies have shown that the transvaginal method is safer and more accurate than the transabdominal method.v The angle between the transvaginal probe and the cervical canal is such that the probe does not enter the cervical canal.Other Tests Kleihauer-Betke test, if concerned about fetal-maternal transfusionBedside clot test vComplete blood cell count (CBC)vApt test to determine fetal origin of blood (as in the case of vasa previa)vWright stain applied to a slide smear of vaginal blood, looking for nucleated red blood cells (RBCs), not adult bloodvLecithin/sphingomyelin (L/S) ratio for fetal maturity, if needed vTransperineal ultrasonography: Transperineal ultrasonography has been suggested as an alternate method, especially when instrumentation of the vaginal canal with a probe is a concern; however, further study is required.vMagnetic resonance imaging (MRI): MRI has been suggested as a safe and alternate method, but further investigation is required. 3 、 Diagnosis & DifferentialsHistory & Clinical MenifestationAccessory ExaminationDifferentialsDiagnosisGraspAbruptio Placentae DICPregnancy, Delivery Physical Profuse hemorrhageHypotensionTachycardiaSoft and nontender uterusNormal fetal heart tones (usually)Vaginal and rectal examinationsv Do not perform these examinations in the ED because they may provoke uncontrollable bleeding.v Perform examinations in the operating room under double set-up conditions (ie, ready for emergent cesarean delivery). Procedures If the location of the placenta is unknown and sonography is not available, a double set-up bimanual examination under anesthesia (EUA) may be performed in the operating room 4、 Effectsv Hemorrhage in delivery & postpart