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Importance•MaternalRisks–Acutehemorrhage–Operativedelivery•FetalRisks–Uteroplacentalinsufficiency–Prematurebirth•KeyPoints–Identifythecause–TimelyinterventionInitialAssessment•History–Amountofbleeding,recentintercourseordigitalexam,severityofpain,trauma•Physicalexam–Vitalsigns,speculum,digitalonlyifnoplacentaprevia,maynotecervicitis/polyp/cancer•Ultrasound–Evaluationforplacentaprevia•PeriodofobservationInitialManagementofSignificantBleeding•Hemodynamicinstability–Hypotension–Tachycardia•IVfluids•Considerbloodproducts/transfusion•Labtests–Hematocrit,platelets,fibrinogen,coagulation,bloodtype,andantibodyscreen•Continuousfetalmonitoring•ConsideremergentcesareansectionPlacentaPrevia•Complete–Coverstheinternalcervicalos•Marginal–Edgelieswithin2cmofinternalcervicalos•Lowlying–Edgelies2–3.5cmfromtheinternalosImage:http://midwifemuse.files.wordpress.com/2008/02/previa.gifPlacentaPrevia(continued)•Notedinmid-pregnancyin40/1000pregnancies•Atterm,only4/1000•Bestvisualizedwithtransvaginalultrasound•Riskfactors–Increasedage–Increasedparity–Tobaccouse–IncreasingnumberofcesareandeliveriesPlacentaPrevia(continued)•Presentation–“painlessbleeding”–Often“sentinelbleed”inthelate2ndorearly3rdtrimester–OftenaftersexualintercoursePlacentaPrevia(continued)•Management–Goalistopromotefetallungmaturity–Admittohospitalinitially–Administersteroidsif24-34weeksgestation–Considertocolytics–Outpatientmanagementinselectedsituations–Serialultrasounds–Ifdoesnotresolve,cesareandeliveryattermPlacentaPrevia(continued)•Modeofdelivery–Ifunstable,immediatecesareandelivery–Ifstable,ultrasoundat36weeks•Ifplacentaledge>2cmfromos,vaginaldelivery•Ifplacentaledge1-2cmfromos,mayattemptvaginaldeliveryifoperatingroomnearby•Iffetallungsaremature,cesareanforcompleteprevia–Ifhistoryofcesarean,evaluateforinvasiveplacenta•ColorflowDoppler•MRI•Ifconfirmed,prepareforpossiblecesarean/hysterectomyPlacentalAbruption•Separationofplacentafromuterinewall•Mostcommoncauseofseriousbleeding•1%ofpregnancies•Neonatalmortalityis10-30%•50%ofabruptionsoccurpriorto36weeksgestationImage:http://www.dkimages.com/discover/previews/817/95012674.JPGPlacentalAbruption(continued)•Riskfactors–Smokingtobacco–Cocaineuse–Chronichypertension–Preeclampsia–Thrombophilias–Abdominaltrauma–HistoryofabruptioninpreviouspregnancyPlacentalAbruption(continued)•ClinicalPresentation–Bleeding–Uterinetendernessorbackpain–Fetaldistress–Pretermlabor–Intrauterinefetaldeath–Disseminatedintravascularcoagulation–Recurrentbleeding,pain,contractionsPlacentalAbruption(continued)•Management–Stabilizethemother–Assessfetalwell-being–Ultrasoundisnotreliable–Seriallabs(Hctandcoagulationstudies)–Rarely,administercorticosteroids–RAPIDDELIVERY!PlacentalAbruption(continued)•Prevention–Notobaccouse–Noillegaldruguse–PropermanagementofHTNinpregnancyVasaPrevia•Insertionoftheumbilicalcordintotheamnioticmembranesintheloweruterinesegment•Resultsinfetalvesselsbetweenthecervixandthepresentingpart•1in2500births•33to100percentperinatalmortalityImage:http://www.soliris.net/images/sec1.2.gifVasaPrevia(continued)•Riskfactors–Invitrofertilization–Placentaprevia–Multi-lobedplacentasVasaPrevia(continued)•Presentation–Hemorrhageatthetimeofamniotomyorspontaneousruptureofmembranes–ExsanguinationoffetalbloodcanoccurrapidlyVasaPrevia(continued)•Management–Iffetalwell-beingisnotreassuring,orifhemorrhageissevere,RAPIDDELIVERY!–Iffetalhearttonesarereassuring,APTtestcanbeperformedReferences•Sakornbut,E,Leeman,L,Fontaine,P“LatePregnancyBleeding”AmericanFamilyPhysician,Vol75,No8,April15th,2007.