6.Late Pregnancy Bleeding晚期妊娠流血.ppt

* Picture of abruption * Picture of vasa previa * Picture of vasa previa Importance Maternal Risks Acute hemorrhage Operative delivery Fetal Risks Uteroplacental insufficiency Premature birth Key Points Identify the cause Timely intervention Initial Assessment History Amount of bleeding, recent intercourse or digital exam, severity of pain, trauma Physical exam Vital signs, speculum, digital only if no placenta previa, may note cervicitis/ polyp/cancer Ultrasound Evaluation for placenta previa Period of observation Initial Management of Significant Bleeding Hemodynamic instability Hypotension Tachycardia IV fluids Consider blood products/transfusion Lab tests Hematocrit, platelets, fibrinogen, coagulation, blood type, and antibody screen Continuous fetal monitoring Consider emergent cesarean section Placenta Previa Complete Covers the internal cervical os Marginal Edge lies within 2cm of internal cervical os Low lying Edge lies 2 – 3.5cm from the internal os Image: /2008/02/previa.gif Placenta Previa (continued) Noted in mid-pregnancy in 40/1000 pregnancies At term, only 4/1000 Best visualized with transvaginal ultrasound Risk factors Increased age Increased parity Tobacco use Increasing number of cesarean deliveries Placenta Previa (continued) Presentation “painless bleeding” Often “sentinel bleed” in the late 2nd or early 3rd trimester Often after sexual intercourse Placenta Previa (continued) Management Goal is to promote fetal lung maturity Admit to hospital initially Administer steroids if 24-34 weeks gestation Consider tocolytics Outpatient management in selected situations Serial ultrasounds If does not resolve, cesarean delivery at term Placenta Previa (continued) Mode of delivery If unstable, immediate cesarean delivery If stable, ultrasound at 36 weeks If placental edge 2cm from os, vaginal delivery If placental edge 1-2cm from os, may attempt vaginal delivery if operating room near by If fetal lungs are mature, cesarean for complete previa If history of