课件：前置胎盘英文课件.pptx

Placetal Previa,Long Xiaoyu 龙晓宇 XuanWu Hospital 宣武医院,Case,1. 30 G3P2 at 32 weeks gestation, painless vaginal bleeding. Four weeks ago , postcoital vaginal spotting 2. BP:110/70mmHg ,abdomen is soft uterus nontender , FHR :140-150bpm,Case 1,What is most likely diagnosis?,What is your next step?,Long-term management of this patient?,What are the most common causes of Antepartum Hemorrhage ?,COMMON CAUSES,Placenta Previa Placental Abruption Preterm labor,UNCOMMON CAUSES,Uterine rupture Fetal(chorionic ) vessel rupture Cervical or vaginal lacerations Cervical or vaginal lesions, including cancer Congenital bleeding disorder Unknown ( by exclusion of the above),Placental Previa,Understand that placenta previa and placental abruption are major causes of antepartum hemorrhage Know the painless vaginal bleeding is consistent with placenta previa Understand that the ultrasound examination is a good method for assessing placental location,Objectives,Defined as the inferior edge of placenta load at the lower uterine segment, or even reach the internal cervical os after 28 weeks gestation. Incidence rate: Internal：0.24%1.57%； International：0.5%0.9%。,Placental Previa,“ the placenta overlying the internal os of the cervix”,Classification,Classification,Complete(central ) placenta previa Partial placenta previa Marginal placenta previa Low-lying placenta previa,What are the risk factors for placental Previa?,Question,ETIOLOGY,Increased maternal age Uterine factors: Previous CS Instrumentation of the uterine cavity (D and C for miscarriages or Induced Abortions) Placental factors: Multiparity Multiple gestation Prior placenta previa,ETIOLOGY,Manifestation It characteristically presents with unprovoked and repeated painless vaginal bleeding.,Clinical Presentation,Manifestation,The classification of previa placenta sometimes determines the occurrence period and the volume of losing blood.,Total placenta previa Early(20-28wks) Large amount Several times,Partial placenta previa Between total and marginal,Bleeding time and volume,Central placenta previa Early(20-28wks) Large amount Several times,Partial placenta previa Between total and marginal,Marginal placenta previa Late(37-40WKS or in labor ) Less bleeding,symptom,Severe blood losing leads to several shock signs ,such as paleness ,weak and quick pulse and hypotension. Malpresentation maybe exists, and floating presentation could be found during late gestational weeks.,Complication of mother and fetus,Bleeding at or post partum Implantation of placenta Anemia and puerperal infection Premature delivery,How to diagnose the placental Previa?,Question,Patient History Placenta Previa,Painless bleeding 2nd or 3rd trimester, or at term Often following intercourse May have preterm contractions “Sentinel bleed”,Physical Exam Placenta Previa,The uterus is usually soft and relaxed Anomaly of fetal condition Fetus is usually alive and well Per vagina examination NO digital vaginal exam unless placental location known,Auxiliary examination,B-ultrasound examination Ultrasound is the easiest, most reliable way to diagnose (95-98+% accuracy) False positive- ultrasound with distended bladder Transvaginal or transperineal often superior to transabdominal methods MRI Posterior previa High cost Limited availability,Laboratory Placenta Previa,Hematocrit or complete blood count Blood type and Rh Coagulation tests While waiting serum clot tube taped to wall,Differentiation diagnosis,Placental abruption vessel Previa Cervical polypus Cervical erosion Cervical carcinoma,Management,Expectant delivery aim at achieving amixmum fetal maturity possible while minimizing the risk to both mother and fetus.,Management,expectant treatment Indication: Fewer vaginal bleeding Patients condition stabilization 36 weeks gestation, fetal weight2300g Management: Lying in bed to take a rest Inhibition of uterine contraction Treatment aim at symptoms Promote development of fetus Prevention of infection,Termination of pregnancy CS total placenta previa (36th week), Partial placenta previa (37th week) and heavy bleeding with shock Preventing postpartum hemorrhage: pitocin and PG Hysterectomy: Placenta accreta or uncontroled bleeding,Management,Vaginal delivery Marginal placenta previa Vaginal bleeding is limited,Management,Admit to hospital NO VAGINAL EXAMINATION IV access Placental localization Cesarean delivery is necessary in practically all women with placental previa,Management,Placenta Previa Management,Severe bleeding,Caesarean section,Moderate bleeding,Gestation,34,34,Resuscitate Steroids,Unstable,Stable,Resuscitate,Mild bleeding,Gestation,36,Conservative care,36,Management,Management of placenta previa?,Individualized based on Gestational age Amount of bleeding Fetal condition and presentation,Ultrasound examination,Placenta previa,Expectant management as long as the bleeding is not excessive. Cesarean delivery at 36 to 37 weeks gestation,Each of the following is a risk factor of placenta previa except: A ) Prior cesarean section; B ) Hypertension; C ) Multiple gestation; D ) Prior uterine curettage,Exercise 1,B,Each of the following is a typical feature of placenta previa except: A ) Painless bleeding; B ) Commonly associated with coagulopathy; C ) First episode of bleeding is usually self-limited; D ) Associated with postcoital spotting,Exercise 2,B,A 33-year-old woman at 37 weeks gestation, confirmed by first trimester sonography, presents with moderatedly severe vaginal bleeding. She is noted on sonography to have a placenta previa. Which of the following is the best management for this patient? A ) Induction of labor; B ) Tocolysis of labor; C ) Cesarean delivery; D ) Expectant management E ) Intrauterine transfusion,Exercise 3,C,A 22-year-old G1P0 woman at 34 weeks gestation presents with moderate vaginal bleeding and no uterine contractions. Which of the following sequence of examinations is most appropriate ? A ) Speculum examination, ultrasound examination, digital examination; B ) Ultrasound examination, digital examination, speculum examination; C ) Digital examination, ultrasound examination, speculum examination; D ) Ultrasound examination, speculum examination, digital examination;,Exercise 4,D,An 18-yeas-old woman is noted to have a marginal placenta previa on an ultrasound examination at 22 weeks gestation. Which of the following is the most appropriate management? A ) Schedule cesarean delivery at 39 weeks; B ) Schedule an amniocentesis at 36