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* * * * 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 Management Physical exam Continuous electronic fetal monitoring Ultrasound Assess viability, gestational age, previa, fetal position/lie Expectant management vaginal vs cesarean delivery Available anesthesia, OR team for cesarean delivery Partial placental abruption with adhered clot Couvelaire Uterus 腹壁子宫按摩法 腹部-阴道双手压迫子宫法 A bimanual compression Packing the uterine cavity 正面观 背面观 正面观 Flash B-lynch/Bind suture Cho/patch suture Ligation of the utering arteries Management Careful maternal hemodynamic monitoring Fetal monitoring Serial evaluation of the hematocrit, coagulation profile,delivery Blood products for replacement A large-bore intravenous line * * * A. Total placenta previa with percreta involving the lower uterine segment and cervical canal. Black arrows show the invading line of the placenta through the myometrium * B. Lateral fundal percreta caused hemoperitoneum in late pregnancy. * * * * * * * * * * * * * * * Diagnosis(3) 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 Limited vaginal examination Diagnosis(4) 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! Diagnosis(5) 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 Differential Diagnosis Placental abruption vagina
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