LatePregnancyBleeding晚期妊娠流血

LatePregnancyBleeding晚期妊娠流血第1页/共28页ImportanceMaternalRisksAcutehemorrhageOperativedeliveryFetalRisksUteroplacentalinsufficiencyPrematurebirthKeyPointsIdentifythecauseTimelyintervention第2页/共28页InitialAssessmentHistoryAmountofbleeding,recentintercourseordigitalexam,severityofpain,traumaPhysicalexamVitalsigns,speculum,digitalonlyifnoplacentaprevia,maynotecervicitis/polyp/cancerUltrasoundEvaluationforplacentapreviaPeriodofobservation第3页/共28页InitialManagementofSignificantBleedingHemodynamicinstabilityHypotensionTachycardiaIVfluidsConsiderbloodproducts/transfusionLabtestsHematocrit,platelets,fibrinogen,coagulation,bloodtype,andantibodyscreenContinuousfetalmonitoringConsideremergentcesareansection第4页/共28页PlacentaPreviaCompleteCoverstheinternalcervicalosMarginalEdgelieswithin2cmofinternalcervicalosLowlyingEdgelies2–3.5cmfromtheinternalos第5页/共28页Image:/2008/02/previa.gif第6页/共28页PlacentaPrevia(continued)Notedinmid-pregnancyin40/1000pregnanciesAtterm,only4/1000BestvisualizedwithtransvaginalultrasoundRiskfactorsIncreasedageIncreasedparityTobaccouseIncreasingnumberofcesareandeliveries第7页/共28页PlacentaPrevia(continued)Presentation“painlessbleeding”Often“sentinelbleed”inthelate2ndorearly3rdtrimesterOftenaftersexualintercourse第8页/共28页PlacentaPrevia(continued)ManagementGoalistopromotefetallungmaturityAdmittohospitalinitiallyAdministersteroidsif24-34weeksgestationConsidertocolyticsOutpatientmanagementinselectedsituationsSerialultrasoundsIfdoesnotresolve,cesareandeliveryatterm第9页/共28页PlacentaPrevia(continued)ModeofdeliveryIfunstable,immediatecesareandeliveryIfstable,ultrasoundat36weeksIfplacentaledge>2cmfromos,vaginaldeliveryIfplacentaledge1-2cmfromos,mayattemptvaginaldeliveryifoperatingroomnearbyIffetallungsaremature,cesareanforcompletepreviaIfhistoryofcesarean,evaluateforinvasiveplacentaColorflowDopplerMRIIfconfirmed,prepareforpossiblecesarean/hysterectomy第10页/共28页第11页/共28页PlacentalAbruptionSeparationofplacentafromuterinewallMostcommoncauseofseriousbleeding1%ofpregnanciesNeonatalmortalityis10-30%50%ofabruptionsoccurpriorto36weeksgestation第12页/共28页Image:/discover/previews/817/95012674.JPG第13页/共28页第14页/共28页PlacentalAbruption(continued)RiskfactorsSmokingtobaccoCocaineuseChronichypertensionPreeclampsiaThrombophiliasAbdominaltraumaHistoryofabruptioninpreviouspregnancy第15页/共28页PlacentalAbruption(continued)ClinicalPresentationBleedingUterinetendernessorbackpainFetaldistressPretermlaborIntrauterinefetaldeathDisseminatedintravascularcoagulationRecurrentbleeding,pain,contractions第16页/共28页PlacentalAbruption(continued)ManagementStabilizethemotherAssessfetalwell-beingUltrasoundisnotreliableSeriallabs(Hctandcoagulationstudies)Rarely,administercorticosteroidsRAPIDDELIVERY!第17页/共28页PlacentalAbruption(continued)PreventionNotobaccouseNoillegaldrugusePropermanagementofHTNinpregnancy第18页/共28页第19页/共28页VasaPreviaInsertionoftheumbilicalcordintotheamnioticmembranesintheloweruterinesegmentResultsinfetalvesselsbetweenthecervixandthepresentingpart1in2500births33to100percentperinatalmortality第20页/共28页Image:/images/sec1.2.gif第21页/共28页第22页/共28页VasaPrevia(continued)RiskfactorsInvitrofertilizationPlacentapreviaMulti-lobedplacentas第23页/共28页VasaPrevia(continued)PresentationHemorrhageatthetimeofamniotomyorspontaneousruptureofmembranesExsanguinationoffetalbloodcanoccurrapidly第24页/共28页VasaPrevia(continued)ManagementIffetalwell-beingisnotreassuring,orifhemorrhageissevere,RAPIDDELIVERY!Iffetalhearttonesarereassuring,APTtestcanbepe