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PlacetalPreviaPlacetalPrevia1Case1.30G3P2at32weeks’gestation,painlessvaginalbleeding.Fourweeksago,postcoitalvaginalspotting2.BP:110/70mmHg,abdomenissoftuterusnontender,FHR:140-150bpmCase1Case1.30G3P2at32weeks2Whatismostlikelydiagnosis?Whatisyournextstep?Long-termmanagementofthispatient?Whatismostlikelydiagnosis?3《前置胎盤英文》課件4《前置胎盤英文》課件5Whatarethemostcommoncausesof
AntepartumHemorrhage?Whatarethemostcommoncause6COMMONCAUSESPlacentaPreviaPlacentalAbruptionPretermlaborUNCOMMONCAUSES
Uterinerupture
Fetal(chorionic)vesselrupture
Cervicalorvaginallacerations
Cervicalorvaginallesions,includingcancer
Congenitalbleedingdisorder
Unknown(byexclusionoftheabove)COMMONCAUSESPlacentaPreviaUN7PlacentalPreviaPlacentalPrevia8UnderstandthatplacentapreviaandplacentalabruptionaremajorcausesofantepartumhemorrhageKnowthepainlessvaginalbleedingisconsistentwithplacentapreviaUnderstandthattheultrasoundexaminationisagoodmethodforassessingplacentallocationObjectivesUnderstandthatplacentaprev9Definedastheinferioredgeofplacentaloadattheloweruterinesegment,orevenreachtheinternalcervicalosafter28weeksgestation.Incidencerate:Internal：0.24%~1.57%；
International：0.5%~0.9%。PlacentalPreviaDefinedastheinferioredgeo10“theplacentaoverlyingtheinternalosofthecervix”“theplacentaoverlyingthei11ClassificationClassification12ClassificationComplete(central)placentapreviaPartialplacentapreviaMarginalplacentapreviaLow-lyingplacentapreviaClassificationComplete(central13WhataretheriskfactorsforplacentalPrevia?Question
Whataretheriskfactorsfor14ETIOLOGYIncreasedmaternalageUterinefactors:PreviousCSInstrumentationoftheuterinecavity(DandCformiscarriagesorInducedAbortions)Placentalfactors:MultiparityMultiplegestationPriorplacentapreviaETIOLOGYETIOLOGYIncreasedmaternalage15ManifestationItcharacteristicallypresentswithunprovokedandrepeatedpainlessvaginalbleeding.ClinicalPresentationManifestationClinicalPresenta16Manifestation
Theclassificationofpreviaplacentasometimesdeterminestheoccurrenceperiodandthevolumeoflosingblood.ManifestationTheclass17TotalplacentapreviaEarly(20-28wks)LargeamountSeveraltimesPartialplacentaprevia
BetweentotalandmarginalBleedingtimeandvolumeCentralplacentapreviaEarly(20-28wks)LargeamountSeveraltimesPartialplacentaprevia
BetweentotalandmarginalMarginalplacentaprevia
Late(37-40WKSorinlabor)LessbleedingTotalplacentapreviaPartialp18
symptom
Severebloodlosingleadstoseveralshocksigns,suchaspaleness,weakandquickpulseandhypotension.
Malpresentationmaybeexists,andfloatingpresentationcouldbefoundduringlategestationalweeks.symptomSeverebloodl19Complicationofmother
andfetus
BleedingatorpostpartumImplantationofplacentaAnemiaandpuerperalinfectionPrematuredeliveryComplicationofmother
20HowtodiagnosetheplacentalPrevia?Question
Howtodiagnosetheplacental21PatientHistory–PlacentaPreviaPainlessbleeding2ndor3rdtrimester,orattermOftenfollowingintercourseMayhavepretermcontractions“Sentinelbleed”PatientHistory–PlacentaPre22PhysicalExam–PlacentaPrevia
TheuterusisusuallysoftandrelaxedAnomalyoffetalconditionFetusisusuallyaliveandwellPervaginaexaminationNOdigitalvaginalexamunlessplacentallocationknownPhysicalExam–PlacentaPrevi23AuxiliaryexaminationB-ultrasoundexaminationUltrasoundistheeasiest,mostreliablewaytodiagnose(95-98+%accuracy)Falsepositive-ultrasoundwithdistendedbladderTransvaginalortransperinealoftensuperiortotransabdominalmethodsMRI
PosteriorpreviaHighcostLimitedavailabilityAuxiliaryexaminationB-ultr24《前置胎盤英文》課件25Laboratory–PlacentaPreviaHematocritorcompletebloodcountBloodtypeandRhCoagulationtestsWhilewaiting–serumclottubetapedtowallLaboratory–PlacentaPreviaHe26Differentiation
diagnosisPlacentalabruption
vesselPreviaCervicalpolypusCervicalerosionCervicalcarcinoma
DifferentiationdiagnosisPlace27《前置胎盤英文》課件28Management
Expectantdelivery
aimat
achievingamixmumfetalmaturitypossiblewhileminimizingtherisktobothmotherandfetus.ManagementExpectantdelivery29Management
expectanttreatment
Indication:
FewervaginalbleedingPatient’sconditionstabilization<36weeksgestation,fetalweight<2300g
Management:LyinginbedtotakearestInhibitionofuterinecontractionTreatmentaimatsymptomsPromotedevelopmentoffetusPreventionofinfectionManagementexpectanttreatmen30TerminationofpregnancyCStotalplacentaprevia(36thweek),Partialplacentaprevia(37thweek)andheavybleedingwithshockPreventingpostpartumhemorrhage:pitocinandPGHysterectomy:PlacentaaccretaoruncontroledbleedingManagement
TerminationofpregnancyManage31《前置胎盤英文》課件32Vaginaldelivery
Marginalplacentaprevia
VaginalbleedingislimitedManagement
VaginaldeliveryManagement33AdmittohospitalNOVAGINALEXAMINATIONIVaccessPlacentallocalizationCesareandeliveryisnecessaryinpracticallyallwomenwithplacentalpreviaManagement
Management34PlacentaPrevia
ManagementSeverebleedingCaesareansectionModeratebleedingGestation>34<34ResuscitateSteroidsUnstableStableResuscitateMildbleedingGestation<36Conservativecare>36Management
PlacentaPrevia
ManagementSeve35Managementofplacentaprevia?IndividualizedbasedonGestationalageAmountofbleedingFetalconditionandpresentationManagementofplacentaprevia?36UltrasoundexaminationPlacenta
previaExpectantmanagementaslongasthebleedingisnotexcessive.Cesareandeliveryat36to37weeks’gestationUltrasoundexaminationPlacent37Eachofthefollowingisariskfactorofplacentapreviaexcept:A)Priorcesareansection;B)Hypertension;C)Multiplegestation;D)PrioruterinecurettageExercise1BEachofthefollowingisaris38Eachofthefollowingisatypicalfeatureofplacentapreviaexcept:A)Painlessbleeding;B)Commonlyassociatedwithcoagulopathy;C)Firstepisodeofbleedingisusuallyself-limited;D)AssociatedwithpostcoitalspottingExercise2BEachofthefollowingisaty39A33-year-oldwomanat37week’sgestation,confirmedbyfirsttrimestersonography,presentswithmoderatedlyseverevaginalbleeding.Sheisnotedonsonographytohaveaplacentaprevia.Whichofthefollowingisthebestmanagementforthispatient?A)Inductionoflabor;B)Tocolysisoflabor;C)Cesareandelivery;D)ExpectantmanagementE)IntrauterinetransfusionExercise3CA33-year-oldwomanat37wee40A22-year-oldG1P0womanat34week’sgestationpresentswithmoderatevaginalbleedingandnouterinecontractions.Whichofthefollowingsequenceofexaminationsismostappropriate?A)Speculumexamination,ultrasoundexamination,digitalexamination;B)Ultrasoundexamination,digitalexamination,speculumexamination;C)Digitalexamination,ultrasoundexamination,speculumexamination;D)Ultrasoundexamination,speculumexamination,digitalexamination;Exercise4DA22-year-oldG1P0womanat3441An18-yeas-oldwomanisnotedtohaveamarginalplacentapreviaonanultrasoundexaminationat22week’sgestation.Whichofthefollowingisthemostappropriatemanagement?A)Schedulecesareandeliveryat39weeks;B)Scheduleanamniocentesisat36weeksanddeliverbycesareanifthefetallungsaremature;C)ScheduleanMRIexaminationat35weekstoassessforpossiblepercretainvolvingthebladder;D)Reassessplacentalpositionat32weeksE)RecommendterminationofpregnancyExercise5DAn18-yeas-oldwomanisnoted42UnderstandthatplacentapreviaandplacentalabruptionaremajorcausesofantepartumhemorrhageKnowthepainlessvaginalbleedingisconsistentwithplacentapreviaUnderstandthattheultrasoundexaminationisagoodmethodforassessingplacentallocationObjectivesUnderstandthatplacentaprev43《前置胎盤英文》課件44PlacetalPreviaPlacetalPrevia45Case1.30G3P2at32weeks’gestation,painlessvaginalbleeding.Fourweeksago,postcoitalvaginalspotting2.BP:110/70mmHg,abdomenissoftuterusnontender,FHR:140-150bpmCase1Case1.30G3P2at32weeks46Whatismostlikelydiagnosis?Whatisyournextstep?Long-termmanagementofthispatient?Whatismostlikelydiagnosis?47《前置胎盤英文》課件48《前置胎盤英文》課件49Whatarethemostcommoncausesof
AntepartumHemorrhage?Whatarethemostcommoncause50COMMONCAUSESPlacentaPreviaPlacentalAbruptionPretermlaborUNCOMMONCAUSES
Uterinerupture
Fetal(chorionic)vesselrupture
Cervicalorvaginallacerations
Cervicalorvaginallesions,includingcancer
Congenitalbleedingdisorder
Unknown(byexclusionoftheabove)COMMONCAUSESPlacentaPreviaUN51PlacentalPreviaPlacentalPrevia52UnderstandthatplacentapreviaandplacentalabruptionaremajorcausesofantepartumhemorrhageKnowthepainlessvaginalbleedingisconsistentwithplacentapreviaUnderstandthattheultrasoundexaminationisagoodmethodforassessingplacentallocationObjectivesUnderstandthatplacentaprev53Definedastheinferioredgeofplacentaloadattheloweruterinesegment,orevenreachtheinternalcervicalosafter28weeksgestation.Incidencerate:Internal：0.24%~1.57%；
International：0.5%~0.9%。PlacentalPreviaDefinedastheinferioredgeo54“theplacentaoverlyingtheinternalosofthecervix”“theplacentaoverlyingthei55ClassificationClassification56ClassificationComplete(central)placentapreviaPartialplacentapreviaMarginalplacentapreviaLow-lyingplacentapreviaClassificationComplete(central57WhataretheriskfactorsforplacentalPrevia?Question
Whataretheriskfactorsfor58ETIOLOGYIncreasedmaternalageUterinefactors:PreviousCSInstrumentationoftheuterinecavity(DandCformiscarriagesorInducedAbortions)Placentalfactors:MultiparityMultiplegestationPriorplacentapreviaETIOLOGYETIOLOGYIncreasedmaternalage59ManifestationItcharacteristicallypresentswithunprovokedandrepeatedpainlessvaginalbleeding.ClinicalPresentationManifestationClinicalPresenta60Manifestation
Theclassificationofpreviaplacentasometimesdeterminestheoccurrenceperiodandthevolumeoflosingblood.ManifestationTheclass61TotalplacentapreviaEarly(20-28wks)LargeamountSeveraltimesPartialplacentaprevia
BetweentotalandmarginalBleedingtimeandvolumeCentralplacentapreviaEarly(20-28wks)LargeamountSeveraltimesPartialplacentaprevia
BetweentotalandmarginalMarginalplacentaprevia
Late(37-40WKSorinlabor)LessbleedingTotalplacentapreviaPartialp62
symptom
Severebloodlosingleadstoseveralshocksigns,suchaspaleness,weakandquickpulseandhypotension.
Malpresentationmaybeexists,andfloatingpresentationcouldbefoundduringlategestationalweeks.symptomSeverebloodl63Complicationofmother
andfetus
BleedingatorpostpartumImplantationofplacentaAnemiaandpuerperalinfectionPrematuredeliveryComplicationofmother
64HowtodiagnosetheplacentalPrevia?Question
Howtodiagnosetheplacental65PatientHistory–PlacentaPreviaPainlessbleeding2ndor3rdtrimester,orattermOftenfollowingintercourseMayhavepretermcontractions“Sentinelbleed”PatientHistory–PlacentaPre66PhysicalExam–PlacentaPrevia
TheuterusisusuallysoftandrelaxedAnomalyoffetalconditionFetusisusuallyaliveandwellPervaginaexaminationNOdigitalvaginalexamunlessplacentallocationknownPhysicalExam–PlacentaPrevi67AuxiliaryexaminationB-ultrasoundexaminationUltrasoundistheeasiest,mostreliablewaytodiagnose(95-98+%accuracy)Falsepositive-ultrasoundwithdistendedbladderTransvaginalortransperinealoftensuperiortotransabdominalmethodsMRI
PosteriorpreviaHighcostLimitedavailabilityAuxiliaryexaminationB-ultr68《前置胎盤英文》課件69Laboratory–PlacentaPreviaHematocritorcompletebloodcountBloodtypeandRhCoagulationtestsWhilewaiting–serumclottubetapedtowallLaboratory–PlacentaPreviaHe70Differentiation
diagnosisPlacentalabruption
vesselPreviaCervicalpolypusCervicalerosionCervicalcarcinoma
DifferentiationdiagnosisPlace71《前置胎盤英文》課件72Management
Expectantdelivery
aimat
achievingamixmumfetalmaturitypossiblewhileminimizingtherisktobothmotherandfetus.ManagementExpectantdelivery73Management
expectanttreatment
Indication:
FewervaginalbleedingPatient’sconditionstabilization<36weeksgestation,fetalweight<2300g
Management:LyinginbedtotakearestInhibitionofuterinecontractionTreatmentaimatsymptomsPromotedevelopmentoffetusPreventionofinfectionManagementexpectanttreatmen74TerminationofpregnancyCStotalplacentaprevia(36thweek),Partialplacentaprevia(37thweek)andheavybleedingwithshockPreventingpostpartumhemorrhage:pitocinandPGHysterectomy:PlacentaaccretaoruncontroledbleedingManagement
TerminationofpregnancyManage75《前置胎盤英文》課件76Vaginaldelivery
Marginalplacentaprevia
VaginalbleedingislimitedManagement
VaginaldeliveryManagement77AdmittohospitalNOVAGINALEXAMINATIONIVaccessPlacentallocalizationCesareandeliveryisnecessaryinpracticallyallwomenwithplacentalpreviaManagement
Management78PlacentaPrevia
ManagementSeverebleedingCaesareansectionModeratebleedingGestation>34<34ResuscitateSteroidsUnstableStableResuscitateMildbleedingGestation<36Conservativecare>36Management
PlacentaPrevia
ManagementSeve79Managementofplacentaprevia?IndividualizedbasedonGestationalageAmountofbleedingFetalconditionandpresentationManagementofplacentaprevia?80UltrasoundexaminationPlacenta
previaExpectantmanagementaslongasthebleedingisnotexcessive.Cesareandeliveryat36to37weeks’gestationUltrasoundexaminationPlacent81Eachofthefollowingisariskfactorofplacentapreviaexcept:A)Priorcesareansection;B)Hypertension;C)Multiplegestation;D)PrioruterinecurettageExercise1BEachofthefollowingisaris82Eachofthefollowingisatypicalfeatureofplacentapreviaexcept:A)Painlessbleeding;B)Commonlyassociatedwithcoagulopathy;C)Firstepisodeofbleedingisusuallyself-limited;D)AssociatedwithpostcoitalspottingExercise2BEachofthefollowingisaty83A33-year-oldwomanat37week
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