2022年醫(yī)學專題-LatePregnancyBleeding晚期妊娠流血

1、第一頁，共二十九頁。第二頁，共二十九頁。ImportanceMaternal RisksAcute hemorrhageOperative deliveryFetal RisksUteroplacental insufficiencyPremature birthKey PointsIdentify the causeTimely intervention第三頁，共二十九頁。Initial AssessmentHistoryAmount of bleeding, recent intercourse or digital exam, severity of pain, traumaPhysic

2、al examVital signs, speculum, digital only if no placenta previa, may note cervicitis/ polyp/cancerUltrasoundEvaluation for placenta previaPeriod of observation第四頁，共二十九頁。Initial Management of Significant BleedingHemodynamic instabilityHypotensionTachycardiaIV fluidsConsider blood products/transfusio

3、nLab testsHematocrit, platelets, fibrinogen, coagulation, blood type, and antibody screenContinuous fetal monitoringConsider emergent cesarean section第五頁，共二十九頁。Placenta PreviaCompleteCovers the internal cervical osMarginalEdge lies within 2cm of internal cervical osLow lyingEdge lies 2 3.5cm from th

4、e internal os第六頁，共二十九頁。第七頁，共二十九頁。Placenta Previa (continued)Noted in mid-pregnancy in 40/1000 pregnanciesAt term, only 4/1000Best visualized with transvaginal ultrasoundRisk factorsIncreased ageIncreased parityTobacco useIncreasing number of cesarean deliveries第八頁，共二十九頁。Placenta Previa (continued)Pr

5、esentation“painless bleeding”O(jiān)ften “sentinel bleed” in the late 2nd or early 3rd trimesterOften after sexual intercourse第九頁，共二十九頁。Placenta Previa (continued)ManagementGoal is to promote fetal lung maturityAdmit to hospital initiallyAdminister steroids if 24-34 weeks gestationConsider tocolyticsOutpa

6、tient management in selected situationsSerial ultrasoundsIf does not resolve, cesarean delivery at term第十頁，共二十九頁。Placenta Previa (continued)Mode of deliveryIf unstable, immediate cesarean deliveryIf stable, ultrasound at 36 weeksIf placental edge 2cm from os, vaginal deliveryIf placental edge 1-2cm

7、from os, may attempt vaginal delivery if operating room near byIf fetal lungs are mature, cesarean for complete previaIf history of cesarean, evaluate for invasive placentaColor flow DopplerMRIIf confirmed, prepare for possible cesarean/hysterectomy第十一頁，共二十九頁。第十二頁，共二十九頁。Placental AbruptionSeparation

8、 of placenta from uterine wallMost common cause of serious bleeding1% of pregnanciesNeonatal mortality is 10-30%50% of abruptions occur prior to 36 weeks gestation第十三頁，共二十九頁。第十四頁，共二十九頁。第十五頁，共二十九頁。Placental Abruption (continued)Risk factorsSmoking tobaccoCocaine useChronic hypertensionPreeclampsiaThr

9、ombophiliasAbdominal traumaHistory of abruption in previous pregnancy第十六頁，共二十九頁。Placental Abruption (continued)Clinical PresentationBleedingUterine tenderness or back painFetal distressPreterm laborIntrauterine fetal deathDisseminated intravascular coagulationRecurrent bleeding, pain, contractions第十

10、七頁，共二十九頁。Placental Abruption (continued)ManagementStabilize the motherAssess fetal well-beingUltrasound is not reliableSerial labs (Hct and coagulation studies)Rarely, administer corticosteroidsRAPID DELIVERY!第十八頁，共二十九頁。Placental Abruption (continued)PreventionNo tobacco useNo illegal drug useProper

11、 management of HTN in pregnancy第十九頁，共二十九頁。第二十頁，共二十九頁。Vasa PreviaInsertion of the umbilical cord into the amniotic membranes in the lower uterine segmentResults in fetal vessels between the cervix and the presenting part1 in 2500 births33 to 100 percent perinatal mortality第二十一頁，共二十九頁。第二十二頁，共二十九頁。第二十三

12、頁，共二十九頁。Vasa Previa (continued)Risk factorsIn vitro fertilizationPlacenta previaMulti-lobed placentas第二十四頁，共二十九頁。Vasa Previa (continued)PresentationHemorrhage at the time of amniotomy or spontaneous rupture of membranesExsanguination of fetal blood can occur rapidly第二十五頁，共二十九頁。Vasa Previa (continued)ManagementIf fetal well-being is not reassuring, or if hemorrhage is severe, RAPID DELIVERY!If fetal heart tones are reassuring, APT test can be performed第二十六頁，共二十九頁。第二十七頁，共二十九頁。ReferencesSakornbut, E, Leeman, L, Fontaine, P “Late Pregnancy Bleeding” American Family Physician,