张华-Obstetrical Hemorrhage.docVIP

Obstetrical Hemorrhage Antepartum/Intrapartum/Postpartum Bleeding Placenta previa Placenta abruption Vasa previa Ectopic pregnancy Hydatidiform mole Abortion Cervical or vaginal neoplasm, cervicitis Genital tract trauma Placenta Previa definition: the placenta is located over or very near the internal cervical os. ( after 28 wks, extends below the presenting part of the fetus) Incidence: 0.5% or 1:250 births Types of Previa Total or completely : Partial: Marginal: Low-lying: implanted over the lower uterine segment, the edge actually does not reach the os, but is in close proximity to it Etiology (1) The exact etiology of placenta previa is unknown. Multiparity and advancing age increase the risk of placenta previa;35y 0.5%;40y 1%; 20~29y 1/400 Etiology (2) Prior cesarean delivery or induced abortion (threefold); uterine insult; Defective decidual vascularization: inflammatory or atrophic changes; Smoking and cocaine user( twofold) Etiology (3) Large placenta; Succenturiate placenta; Multipregnancy; Placental tumors; Implanted delay; Clinical presentation: Vaginal bleeding(1) has its onset without warning; presenting without pain; usually it ceases spontaneously; Bleeding usually is bright red; Vaginal bleeding(2) The first bleed occurs (on average) at 27-32 weeks gestation; Initial bleeding usually is not profuse enough to cause the mother death; Contractions may or may not occur simultaneously with the bleeding The cause of hemorrhage the formation of the lower uterine segment ; the dilatation of internal os; the inability of the myometrial fibers of the lower uterine segment; Physical exam (1) Profuse hemorrhage ; Hypotension ; Tachycardia; Soft and nontender uterus ; Sometimes uterine irritability ; Physical exam (2) Normal fetal heart tones (usually); Fetal Malpresentation: 25- 33% ; Breech and t-lie presentation equal in frequency;  vaginal and rectal exam Do not perform these examinations Perfo