1 / 55

If you are a doctor

If you are a doctor. In the midnight, awakens to find that they have to sleep in a pool of blood. How to diagnosis ? How to management ?. You. Antepartum Hemorrhage. Obstetrics & Gynecology Hospital of Fudan University Xu Huan. Rationale (why we care…).

Télécharger la présentation

If you are a doctor

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. If you are a doctor • In the midnight, awakens to find that they have to sleep in a pool of blood

  2. How to diagnosis? How to management? You

  3. Antepartum Hemorrhage Obstetrics & Gynecology Hospital of Fudan University Xu Huan

  4. Rationale (why we care…) • 4-5% of pregnancies complicated by 3rd trimester bleeding • Immediate evaluation needed • Significant threat to mother & fetus (consider physiologic increase in uterine blood flow) • Consider causes of maternal & fetal death • Priorities in management (triage!)

  5. Objectives • We will be able to: • Describe the approach to the patient with third-trimester bleeding • Compare symptoms, physical findings, and diagnostic methods that differentiate bleeding etiologies • Describe management and delivery options for 3rd trimester bleeding etiologies • Describe potential maternal and fetal morbidity & mortality • Describe management of postpartum hemorrhage • Apply knowledge in the discussion of clinical case scenarios

  6. Vaginal Bleeding: Differential diagnosis • Common: • Abruption, previa, preterm labor, labor • Less common: • Uterine rupture, fetal vessel rupture, lacerations/lesions, cervical ectropion, polyps, vasa previa, bleeding disorders • Unknown • NOT vaginal bleeding!!! (happens more than you think!)

  7. Other Etiologies • Cervicitis • infection • Cervical erosion • Trauma • Cervical cancer • Foreign body • Bloody show/labor

  8. Perinatal mortality and morbidity • Previa • Decreased mortality from 30% to 1% over last 60 years • Now emergent cesarean delivery often possible • Risk of preterm delivery • Abruption • Perinatal mortality rate 35% • Accounts for 15% of 3rd trimester stillbirths • Risk of preterm delivery • Most common cause of DIC in pregnancy • Massive hemorrhage --> risk of ARF, Sheehan’s, etc.

  9. Placenta previa

  10. Definition • After 28 pregnant weeks placental implantation over the cervical os or in the lower uterine segment • It constitutes an obstruction of descent of the presenting part • Main cause of obstetrical hemorrhage(20%) • Incidence 0.24%-1.57% (our country).

  11. Risk factors & Associations • Prior cesarean delivery/myomectomy • Prior previa (4-8% recurrence risk) • Previous abortion • Increased parity • Multiple pregnancy • Advanced maternal age • Abnormal presentation • Smoking

  12. Etiology • Causes • Endometrial abnormality • Scared or poorly vascularized endometrium in the corpus. • Curettage, Delivery, CS and infection of endometrium • Placental abnormality Large placenta (multiple pregnancy), succenturiate lobe • Delayed development of trophoblast

  13. Classification Complete placenta previa Partrial placenta previa Marginal placenta previa

  14. Manifestation(1) Symptoms • Painless vaginal bleeding (70%) • Spontaneous,After coitus • The most characteristic symptom • late pregnancy (after the 28th week) and delivery • Characteristics: sudden, painless and profuse • Contractions • No symptoms • Routine ultrasound finding • The mean gestational age of first bleed: 30 wks • 1/3 before 30 weeks

  15. Manifestation(2) • Anemia or shock repeated bleeding→ anemia heavy bleeding→ shock • Abnormal fetal position a high presenting part breech presentation (often)

  16. Physical Findings • Bleeding on speculum exam • Cervical dilation • Bleeding a sx related to PTL/normal labor • Abnormal position/lie • Non-reassuring fetal status • If significant bleeding: • Tachycardia • Postural hypertension • Shock

  17. Diagnosis(1) • History • Painless hemorrhage • At late pregnancy or delivery • History of curettage or CS

  18. Diagnosis(1) • Signs • Abdominal findings • Uterus is soft, relaxed and nontender. • Contraction may be palpated. • A high presenting part can’t be pressed into the pelvic inlet. Breech presentation • Fetal heart tones maybe disappear (shock or abruption)

  19. Diagnosis • Speculum examination Rule out local causes of bleeding, such as cervical erosion or polyp or cancer. • Limited vaginal examination (seldom used) Palpation of the vaginal fornices to learn if there is an intervening bogginess between the fornix and presenting part. • Rectal examination is useless and dangerous

  20. Limited vaginal examination

  21. Diagnosis(1) • Ultrasound • abdominal 95% accurate to detect • transvaginal (TVUS) will detect almost all • consider what placental location a TVUS may find that was missed on abdominal • MRI • Check the placenta and membrane after delivery • remember: no digital exams unless previa RULED OUT!

  22. Diagnosis • Before 20 weeks’ gestation,4-6% have some degree of placenta previa on ultrasonic examination • 90% of these resolving by the third trimester • Only 10% of complete placenta

  23. Differential Diagnosis • Placental abruption vagina bleeding with pain, tenderness of uterus. • vasa previa In cases of velamentous cord insertion fetal vessels cover cervical os • Abnormality of cervix cervical erosion or polyp or cancer

  24. vasa previa

  25. Effects • obstetrical hemorrhage • Placenta accreta, increta, and percreta • Anemia and infection • Premature labor or fetal death or fetal distress

  26. Treatments • Expectant therapy • Rest: keep the bed • Controlling the contraction: MgSO4 • Treatment of anemia • Preventing infection

  27. Treatments • Termination of pregnancy • CS • total placenta previa (36th week), Partial placenta previa (37th week) and heavy bleeding with shock • Preventing postpartum hemorrhage: pitocin and PG • Hysterectomy: Placenta accreta or uncontroled bleeding

  28. Treatments • Vaginal delivery Marginal placenta previa Vaginal bleeding is limited

  29. Management • Initial evaluation/diagnosis • Observe/admit to L&D • IV access, routine (maybe serial) labs • Continuous electronic fetal monitoring • Continuous at least initally • May re-evaluate later if stable, no further bleeding • Delivery???

  30. Management • Less than 36 wks gestation -expectant management if stable, reassuring • Bed rest (negotiable) • No vaginal exams (not negotiable) • Steroids for lung maturation (<32 wks) • Possible mgmt at home after 1st bleed • 70% will have recurrent vaginal bleeding before 36 completed weeks requiring emergent cesarean

  31. Management • 36+ weeks gestation • Cesarean delivery if positive fetal lung maturity by amniocentesis • Delivery vs expectant mgmt if fetal lung immaturity • Schedule cesarean delivery at 37 weeks • Discussion/counseling regarding cesarean hysterectomy • Note: given stable maternal and reassuring fetal status, none of these management guidelines are absolute (this is why Obstetrics is so much fun!)

  32. Other Considerations • Placenta accreta, increta, percreta • Cesarean delivery may be necessary • History of uterine surgery increases risk • Must consider these diagnoses if previa present • Could require further evaluation, imaging (MRI considered now) • NOT the delivery you want to do at 2 am

  33. A B Abnormally adherent placentation. A. Placenta accreta. B. Placenta increta. C. Placenta percreta C

  34. Cesarean hysterectomy specimens with placenta percreta.

  35. Cesarean hysterectomy specimens with placenta percreta.

  36. Placental abruption

  37. Definition • abruptio placentae or placental abruption: placental separation from its implantation site before delivery (the normally implanted placenta ) • Incidence • complicates 0.5-1.5% of all pregnancies • recurrence risk • 10% after 1st episode • 25% after 2nd episode

  38. Cocaine maternal hypertension abdominal trauma smoking prior abruption preeclampsia multiple gestation prolonged PROM uterine decompression short umbilical cord chorioamnionitis multiparity Risk factors & Associations

  39. Pathology • Placental separation is initiated by hemorrhage into the decidua basalis with formation of a decidual hematoma • Concealed hemorrhage • Revealed hemorrhage

  40. revealed hemorrhage concealed hemorrhage

  41. Total placental abruption with concealed hemorrhage and fetal death

  42. Maternal-fetal risk • perinatal mortality: 35% • DIC • hypovolemic shock • acute renal failure • Sheehan’s syndrome

  43. Symptoms • Vaginal bleeding • Abdominal or back pain • Uterine contractions • Uterine tenderness

  44. Physical Findings • Vaginal bleeding • Uterine contractions • Hypertonus • Tetanic contractions • Non-reassuring fetal status or demise • Can be concealed hemorrhage

  45. Laboratory Findings • Anemia • may be out of proportion to observed blood loss • DIC • Can occur in up to 10% (30% if “severe”) • First, increase in fibrin split products • Followed by decrease in fibrinogen

  46. Diagnosis • Clinical scenario • Physical exam • Not digital pelvic exams until rule out previa • Careful speculum exam • Ultrasound • Can evaluate previa • Not accurate to diagnose abruption

More Related