第一页，共二十九页。第二页，共二十九页。Importance•MaternalRisks–Acutehemorrhage–Operativedelivery•FetalRisks–Uteroplacentalinsufficiency–Prematurebirth•KeyPoints–Identifythecause–Timelyintervention第三页，共二十九页。InitialAssessment•History–Amountofbleeding,recentintercourseordigitalexam,severityofpain,trauma•Physicalexam–Vitalsigns,speculum,digitalonlyifnoplacentaprevia,maynotecervicitis/polyp/cancer•Ultrasound–Evaluationforplacentaprevia•Periodofobservation第四页，共二十九页。InitialManagementofSignificantBleeding•Hemodynamicinstability–Hypotension–Tachycardia•IVfluids•Considerbloodproducts/transfusion•Labtests–Hematocrit,platelets,fibrinogen,coagulation,bloodtype,andantibodyscreen•Continuousfetalmonitoring•Consideremergentcesareansection第五页，共二十九页。PlacentaPrevia•Complete–Coverstheinternalcervicalos•Marginal–Edgelieswithin2cmofinternalcervicalos•Lowlying–Edgelies2–3.5cmfromtheinternalos第六页，共二十九页。Image:://midwifemuse.files.wordpress/2022/02/previa.gif第七页，共二十九页。PlacentaPrevia(continued)•Notedinmid-pregnancyin40/1000pregnancies•Atterm,only4/1000•Bestvisualizedwithtransvaginalultrasound•Riskfactors–Increasedage–Increasedparity–Tobaccouse–Increasingnumberofcesareandeliveries第八页，共二十九页。PlacentaPrevia(continued)•Presentation•“painlessbleeding〞•Often“sentinelbleed〞inthelate2ndorearly3rdtrimester•Oftenaftersexualintercourse第九页，共二十九页。PlacentaPrevia(continued)•Management–Goalistopromotefetallungmaturity–Admittohospitalinitially–Administersteroidsif24-34weeksgestation–Considertocolytics–Outpatientmanagementinselectedsituations–Serialultrasounds–Ifdoesnotresolve,cesareandeliveryatterm第十页，共二十九页。PlacentaPrevia(continued)•Modeofdelivery–Ifunstable,immediatecesareandelivery–Ifstable,ultrasoundat36weeks•Ifplacentaledge>2cmfromos,vaginaldelivery•Ifplacentaledge1-2cmfromos,mayattemptvaginaldeliveryifoperatingroomnearby•Iffetallungsaremature,cesareanforcompleteprevia–Ifhistoryofcesarean,evaluateforinvasiveplacenta•ColorflowDoppler•MRI•Ifconfirmed,prepareforpossiblecesarean/hysterectomy第十一页，共二十九页。第十二页，共二十九页。PlacentalAbruption•Separationofplacentafromuterinewall•Mostcommoncauseofseriousbleeding•1%ofpregnancies•Neonatalmortalityis10-30%•50%ofabruptionsoccurpriorto36weeksgestation第十三页，共二十九页。Image:://dkimages/discover/previews/817/95012674.JPG第十四页，共二十九页。第十五页，共二十九页。PlacentalAbruption(continued)•Riskfactors–Smokingtobacco–Cocaineuse–Chronichypertension–Preeclampsia–Thrombophilias–Abdominaltrauma–Historyofabruptioninpreviouspregnancy第十六页，共二十九页。PlacentalAbruption(continued)•ClinicalPresentation–Bleeding–Uterinetendernessorbackpain–Fetaldistress–Pretermlabor–Intrauterinefetaldeath–Disseminatedintravascularcoagulation–Recurrentbleeding,pain,contractions第十七页，共二十九页。PlacentalAbruption(continued)•Management–Stabilizethemother–Assessfetalwell-being–Ultrasoundisnotreliable–Seriallabs(Hctandcoagulationstudies)–Rarely,administercorticosteroids–RAPIDDELIVERY!第十八页，共二十九页。PlacentalAbruption(continued)•Prevention–Notobaccouse–Noillegaldruguse–PropermanagementofHTNinpregnancy第十九页，共二十九页。第二十页，共二十九页。VasaPrevia•Insertionoftheumbilicalcordintotheamnioticmembranesintheloweruterinesegment•Resultsinfetalvesselsbetweenthecervixandthepresentingpart•1in2500births•33to100percentperinatalmortality第二十一页，共二十九页。Image:://soliris.net/images/sec1.2.gif第二十二页，共二十九页。第二十三页，共二十九页。VasaPrevia(continued)•Riskfactors–Invitrofertilization–Placentaprevia–Multi-lobedplacentas第二十四页，共二十九页。VasaPrevia(continued)•Presentation–Hemorrhageatthetimeofamniotomyorspontaneousruptureofmembranes–Exsanguinationoffetalbloodcanoccurrapidly第二十五页，共二十九页。VasaPrevia(continued)•Management–Iffetalwell-beingisnotreassuring,orifhemorrhageissevere,RAPIDDELIVERY!–Iffetalhearttonesarereassuring,APTtestcanbeperformed第二十六页，共二十九页。第二十七页，共二十九页。References•Sakornbut,E,Leeman,L,Fontaine,P“LatePregnancyBleeding〞AmericanFamilyPhysician,Vol75,No8,April15th,2007.第二十八页，共二十九页。内容总结Importance。Considerbloodproducts/transfusion。PlacentalAbruption(continued)。Stabilizethemother。Rarely,administercorticosteroids。VasaPrevia(continued)。References第二十九页，共二十九页。
