Transcript Slide 1
Dr. Mostajeran
Obstetrical hemorrhage
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Antepartum hemorrhage
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Placental abroption
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placental previa
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vasaprevia
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Bloody show
Post partum hemorrhage
Third stage Uterine atony Retained placental P- accreta increta precreta Inversion Laceration Hematomas Rapture uterus
Pregnancy – related deaths due to hemorrhage
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p – abroption 19%
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laceration – rupture 16%
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U- atony 15%
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Coagulopathies 14%
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P.previa 7%
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U-bleeding 6%
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Accreta – increta –p 6%
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Retained p – 4%
Antepartum hemorrhage
Placental abroption, abraptio placenta, p-abruption definition separation p. sit implantation before delivery premature separation → differentiates p.p
External hemorrhage Concealed hemo . (DIC . Extent H not appreciated late diagnosis Partial - total
Prenatal morbidity and mortality 1994 12% still birth due to p. abruption 15% infant does survive first year of life neurological deficits
Etiology
Frequency different criteria
1.200 1.185 1.830
Recurrent abruption Severe abruption 1.8 pregnancy's 1 to 3 weeks earlier than firs abruption
Pathology
Initiated hemorrhage into decidua basalis Decidua splits thin layer adherent to myometrium hematoma destruction of p adjacent.
In early stage no clinical symptoms depression few centimeters maternal surface covered dark clothed blood (several minutes) in some case decidual spiral artery ruptures
Fetal to maternal hemorrhage Non truvmatic 20% F.M- Hemor < 10 ml
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Concealed hemorrhage
Margin still remain adhevent Memberan retain their attachment Blood gain access to A.F
Fetal head closely applied lower uterine
Clinical diagnosis
Signs and symptoms vary Ex – bleeding ± DIC Back pain U.S 25% confirmed clinical diagnosis Shock Thromboplactin (DIC Af embolism)
D.D
Severe P.ab diagnosis obvious Milder more common forms difficalt Nither lab test nor diagnostic methods No pain previa pretermlabor
Consumptive coagulopathy
Most common p.ab
Hypophibrinogenemia (<15-mg/dl) ↑ FDP ↑ D-dimer ↓ other coagulation f in 30% p.ab
A hypofibrinogenemia ± thrombocytopenia
Renal failure
In severe p.ab (hypovolemia delayed or incomplete) 32% pregnancy with R-F had p.ab
75% ATN reversible Even p.ab complicated → severe DIC Vigorous Prompt treatment By blood crystalloid solution prevents renal dysfunction proteinuria in severe p.ab?
Couvelaire uterus
1900 uteroplacental apoplexy extravasation blood into uterine mosculature Seldom interfere with uterine contraction
Management
Depending on gestational age Status mother –fetus Most clinicians live, mature fetus V.D not imminent C.S
If diagnosis uncertain fetus alive Without evidence f-compromise close observation
Expectant management in PT
Delaying delivery may prove beneficial (tacolytic) Very early abrubtion frequently oligohydraminios.
With or without PROM Lack of ominous deceleration not guarantee safety intrauterine enviroment any period of time farther separation compromise or kill F C.S F. distress F. death bleeding or other obstetrical Complication to prevent V.D
Vaginal delivery
Amniotomy mature DIC Oxytocin Hypertonus characterizes myo-function If no rhytmic uterin contraction → oxytocin
Placenta previa
Placenta previa
Placenta located over or near in – os 1. Total p.previa
2. Partial p.previa
3. Marginal p.p edge of p at margin of in – os 4. Low – lying placenta p.edge does not reach in –as but close Vasa previa p.vessels course through membranes and present at cervical os
Incidence 1.300
Prenatal morbidity and mortality
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Preterm delivery Neonatal mortality rate three fold high 500000 singleton births relationship previa FGR PTL found L - Birth weight is due to PT and lesser to found G - impairment
Etiology
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Advance M-age 1.1500 19 years of age 1.100 older than 35
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Multiparity para 5 or greather
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Prior cesarean delivery With two prior c.delivery 1.9% With three or more c. delivery 4.1
Para>4 >4 cesareans > 8 fold previa Repeat c+ previa →c.hysterectomy 25% Primary cesarean + previa → c.hysterectomy 6% * Smoking ↑ Two fold
Clinical finding
Painless hemorrhage near end second trimester or later Without warning Initialy bleeding rarely so profuse Cause hemorrhage formation L.U.Segment, dilatation in-os
Placenta accreta, increta, and precreta Poorly development deciduas in L-segment (7%) Coagulation defects Is rare with p.previa
Thromboplastin escapes cervical canal
Diagnosis
U. Bleeding later half of pregnancy P. Previa seldom establish clinical exam V.E finger pass cervix → p.palpated → torrential Hemorr Planned delivery Doubel set up
Automibile accidents
1_3% pregnant woman Fetal injury and death direct fetal placental injury M_ shock pelvic fracture Maternal head injury hypoxia
Fetal death
→trauma
82% motor vehicle crashes 50% placenta injury 4% uterine rupture
Placental abruption and uterine rupture and placental tear traumatic placental abruption 1-6% minor injuries some degree of abruption 50% major injury
Management
1. Fetus preterm no indication for delivery 2. Fetus reasonably mature 3. Those in labor 4. Hemorrhage so severe
Preterm fetus no active bleeding Close observation Her family must fully appreciate problem P.P
Delivery C.S All women with P.P
Most often transverse U-incision Sometimes vertical incision