LatePregnancyBleeding晚期妊娠流血课件

1、LatePregnancyBleeding晚期妊娠流血第一页，共二十九页。LatePregnancyBleeding晚期妊娠流血第二页，共二十九页。LatePregnancyBleeding晚期妊娠流血Importance Maternal Risks Acute hemorrhage Operative delivery Fetal Risks Uteroplacental insufficiency Premature birth Key Points Identify the cause Timely intervention第三页，共二十九页。LatePregnancyBleeding

2、晚期妊娠流血Initial Assessment History Amount of bleeding, recent intercourse or digital exam, severity of pain, trauma Physical exam Vital signs, speculum, digital only if no placenta previa, may note cervicitis/ polyp/cancer Ultrasound Evaluation for placenta previa Period of observation第四页，共二十九页。LatePr

3、egnancyBleeding晚期妊娠流血Initial Management of Significant Bleeding Hemodynamic instability Hypotension Tachycardia IV fluids Consider blood products/transfusion Lab tests Hematocrit, platelets, fibrinogen, coagulation, blood type, and antibody screen Continuous fetal monitoring Consider emergent cesare

4、an section第五页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placenta 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 os第六页，共二十九页。LatePregnancyBleeding晚期妊娠流血第七页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placenta Previa (con

5、tinued) 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 deliveries第八页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placenta Previa (continued) Presentation “painl

6、ess bleeding” Often “sentinel bleed” in the late 2nd or early 3rd trimester Often after sexual intercourse第九页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placenta Previa (continued) Management Goal is to promote fetal lung maturity Admit to hospital initially Administer steroids if 24-34 weeks gestation Consid

7、er tocolytics Outpatient management in selected situations Serial ultrasounds If does not resolve, cesarean delivery at term第十页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placenta Previa (continued)Mode of delivery If unstable, immediate cesarean delivery If stable, ultrasound at 36 weeks If placental edge 2c

8、m from os, vaginal delivery If placental edge 1-2cm from os, may attempt vaginal delivery if 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/hyster

9、ectomy第十一页，共二十九页。LatePregnancyBleeding晚期妊娠流血第十二页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placental 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 gestation第十三页，共二十九页。LatePregna

10、ncyBleeding晚期妊娠流血第十四页，共二十九页。LatePregnancyBleeding晚期妊娠流血第十五页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placental Abruption (continued) Risk factors Smoking tobacco Cocaine use Chronic hypertension Preeclampsia Thrombophilias Abdominal trauma History of abruption in previous pregnancy第十六页，共二十九页。LatePregnancyBl

11、eeding晚期妊娠流血Placental Abruption (continued) Clinical Presentation Bleeding Uterine tenderness or back pain Fetal distress Preterm labor Intrauterine fetal death Disseminated intravascular coagulation Recurrent bleeding, pain, contractions第十七页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placental Abruption (con

12、tinued) Management Stabilize the mother Assess fetal well-being Ultrasound is not reliable Serial labs (Hct and coagulation studies) Rarely, administer corticosteroids RAPID DELIVERY!第十八页，共二十九页。LatePregnancyBleeding晚期妊娠流血Placental Abruption (continued) Prevention No tobacco use No illegal drug use P

13、roper management of HTN in pregnancy第十九页，共二十九页。LatePregnancyBleeding晚期妊娠流血第二十页，共二十九页。LatePregnancyBleeding晚期妊娠流血Vasa Previa Insertion of the umbilical cord into the amniotic membranes in the lower uterine segment Results in fetal vessels between the cervix and the presenting part 1 in 2500 births 33

14、 to 100 percent perinatal mortality第二十一页，共二十九页。LatePregnancyBleeding晚期妊娠流血第二十二页，共二十九页。LatePregnancyBleeding晚期妊娠流血第二十三页，共二十九页。LatePregnancyBleeding晚期妊娠流血Vasa Previa (continued) Risk factors In vitro fertilization Placenta previa Multi-lobed placentas第二十四页，共二十九页。LatePregnancyBleeding晚期妊娠流血Vasa Previa

15、(continued) Presentation Hemorrhage at the time of amniotomy or spontaneous rupture of membranes Exsanguination of fetal blood can occur rapidly第二十五页，共二十九页。LatePregnancyBleeding晚期妊娠流血Vasa 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 performed第二十六页，共二十九页。LatePregnancyBleeding晚期妊娠流血第二十七页，共二十九页。LatePregnancyBleeding晚期妊娠流血ReferencesSakornbut, E, Leema