LatePregnancyBleeding晚期妊娠流血

1、Importance Maternal Risks Acute hemorrhage Operative delivery Fetal Risks Uteroplacental insufficiency Premature birth Key Points Identify the cause Timely interventionInitial Assessment History Amount of bleeding, recent intercourse or digital exam, severity of pain, trauma Physical exam Vital sign

2、s, speculum, digital only if no placenta previa, may note cervicitis/ polyp/cancer Ultrasound Evaluation for placenta previa Period of observationInitial Management of Significant Bleeding Hemodynamic instability Hypotension Tachycardia IV fluids Consider blood products/transfusion Lab tests Hematoc

3、rit, platelets, fibrinogen, coagulation, blood type, and antibody screen Continuous fetal monitoring Consider emergent cesarean sectionPlacenta 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 osImage:

4、 http:/ 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 deliveriesPlacenta Previa (continued) Presentation “painless bleeding” Ofte

5、n “sentinel bleed” in the late 2nd or early 3rd trimester Often after sexual intercoursePlacenta 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 situati

6、ons Serial ultrasounds If does not resolve, cesarean delivery at termPlacenta 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 i

7、f operating room 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/hysterectomyPlacental Abruption Separation of placenta from uterine wall Most common cause of ser

8、ious bleeding 1% of pregnancies Neonatal mortality is 10-30% 50% of abruptions occur prior to 36 weeks gestationImage: http:/ Abruption (continued) Risk factors Smoking tobacco Cocaine use Chronic hypertension Preeclampsia Thrombophilias Abdominal trauma History of abruption in previous pregnancyPla

9、cental Abruption (continued) Clinical Presentation Bleeding Uterine tenderness or back pain Fetal distress Preterm labor Intrauterine fetal death Disseminated intravascular coagulation Recurrent bleeding, pain, contractionsPlacental Abruption (continued) Management Stabilize the mother Assess fetal

10、well-being Ultrasound 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 pregnancyVasa Previa Insertion of the umbilical cord into the am

11、niotic membranes in the lower uterine segment Results in fetal vessels between the cervix and the presenting part 1 in 2500 births 33 to 100 percent perinatal mortalityImage: http:/ Previa (continued) Risk factors In vitro fertilization Placenta previa Multi-lobed placentasVasa Previa (continued) Pr

12、esentation Hemorrhage at the time of amniotomy or spontaneous rupture of membranes Exsanguination of fetal blood can occur rapidlyVasa 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

13、 performedReferences Sakornbut, E, Leeman, L, Fontaine, P “Late Pregnancy Bleeding” American Family Physician, Vol 75, No 8, April 15th, 2007.Importance Maternal Risks Acute hemorrhage Operative delivery Fetal Risks Uteroplacental insufficiency Premature birth Key Points Identify the cause Timely in

14、terventionPlacental Abruption Separation of placenta from uterine wall Most common cause of serious bleeding 1% of pregnancies Neonatal mortality is 10-30% 50% of abruptions occur prior to 36 weeks gestationPlacental Abruption (continued) Management Stabilize the mother Assess fetal well-being Ultrasound is not reliable Seria