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1、PlacetalPrevia LongXiaoyu龙晓宇XuanWuHospital宣武医院 Case 1 30G3P2at32weeks gestation painlessvaginalbleeding Fourweeksago postcoitalvaginalspotting2 BP 110 70mmHg abdomenissoftuterusnontender FHR 140 150bpm Case1 Whatismostlikelydiagnosis Whatisyournextstep Long termmanagementofthispatient Whatarethemost
2、commoncausesofAntepartumHemorrhage COMMONCAUSES PlacentaPreviaPlacentalAbruptionPretermlabor UNCOMMONCAUSES UterineruptureFetal chorionic vesselruptureCervicalorvaginallacerationsCervicalorvaginallesions includingcancerCongenitalbleedingdisorderUnknown byexclusionoftheabove PlacentalPrevia Understan
3、dthatplacentapreviaandplacentalabruptionaremajorcausesofantepartumhemorrhageKnowthepainlessvaginalbleedingisconsistentwithplacentapreviaUnderstandthattheultrasoundexaminationisagoodmethodforassessingplacentallocation Objectives Definedastheinferioredgeofplacentaloadattheloweruterinesegment orevenrea
4、chtheinternalcervicalosafter28weeksgestation Incidencerate Internal 0 24 1 57 International 0 5 0 9 PlacentalPrevia theplacentaoverlyingtheinternalosofthecervix Classification Classification Complete central placentapreviaPartialplacentapreviaMarginalplacentapreviaLow lyingplacentaprevia Whatarether
5、iskfactorsforplacentalPrevia Question ETIOLOGY IncreasedmaternalageUterinefactors PreviousCSInstrumentationoftheuterinecavity DandCformiscarriagesorInducedAbortions Placentalfactors MultiparityMultiplegestationPriorplacentaprevia ETIOLOGY ManifestationItcharacteristicallypresentswithunprovokedandrep
6、eatedpainlessvaginalbleeding ClinicalPresentation Manifestation Theclassificationofpreviaplacentasometimesdeterminestheoccurrenceperiodandthevolumeoflosingblood TotalplacentapreviaEarly 20 28wks LargeamountSeveraltimes PartialplacentapreviaBetweentotalandmarginal Bleedingtimeandvolume Centralplacent
7、apreviaEarly 20 28wks LargeamountSeveraltimes PartialplacentapreviaBetweentotalandmarginal MarginalplacentapreviaLate 37 40WKSorinlabor Lessbleeding symptom Severebloodlosingleadstoseveralshocksigns suchaspaleness weakandquickpulseandhypotension Malpresentationmaybeexists andfloatingpresentationcoul
8、dbefoundduringlategestationalweeks Complicationofmotherandfetus BleedingatorpostpartumImplantationofplacentaAnemiaandpuerperalinfectionPrematuredelivery HowtodiagnosetheplacentalPrevia Question PatientHistory PlacentaPrevia Painlessbleeding2ndor3rdtrimester orattermOftenfollowingintercourseMayhavepr
9、etermcontractions Sentinelbleed PhysicalExam PlacentaPrevia TheuterusisusuallysoftandrelaxedAnomalyoffetalconditionFetusisusuallyaliveandwellPervaginaexaminationNOdigitalvaginalexamunlessplacentallocationknown Auxiliaryexamination B ultrasoundexaminationUltrasoundistheeasiest mostreliablewaytodiagno
10、se 95 98 accuracy Falsepositive ultrasoundwithdistendedbladderTransvaginalortransperinealoftensuperiortotransabdominalmethodsMRIPosteriorpreviaHighcostLimitedavailability Laboratory PlacentaPrevia HematocritorcompletebloodcountBloodtypeandRhCoagulationtestsWhilewaiting serumclottubetapedtowall Diffe
11、rentiationdiagnosis PlacentalabruptionvesselPreviaCervicalpolypusCervicalerosionCervicalcarcinoma Management Expectantdeliveryaimatachievingamixmumfetalmaturitypossiblewhileminimizingtherisktobothmotherandfetus Management expectanttreatmentIndication FewervaginalbleedingPatient sconditionstabilizati
12、on 36weeksgestation fetalweight 2300gManagement LyinginbedtotakearestInhibitionofuterinecontractionTreatmentaimatsymptomsPromotedevelopmentoffetusPreventionofinfection TerminationofpregnancyCStotalplacentaprevia 36thweek Partialplacentaprevia 37thweek andheavybleedingwithshockPreventingpostpartumhem
13、orrhage pitocinandPGHysterectomy Placentaaccretaoruncontroledbleeding Management VaginaldeliveryMarginalplacentapreviaVaginalbleedingislimited Management AdmittohospitalNOVAGINALEXAMINATIONIVaccessPlacentallocalizationCesareandeliveryisnecessaryinpracticallyallwomenwithplacentalprevia Management Pla
14、centaPreviaManagement Severebleeding Caesareansection Moderatebleeding Gestation 34 34 ResuscitateSteroids Unstable Stable Resuscitate Mildbleeding Gestation 36 Conservativecare 36 Management Managementofplacentaprevia IndividualizedbasedonGestationalageAmountofbleedingFetalconditionandpresentation
15、Ultrasoundexamination Placentaprevia Expectantmanagementaslongasthebleedingisnotexcessive Cesareandeliveryat36to37weeks gestation Eachofthefollowingisariskfactorofplacentapreviaexcept A Priorcesareansection B Hypertension C Multiplegestation D Prioruterinecurettage Exercise1 B Eachofthefollowingisat
16、ypicalfeatureofplacentapreviaexcept A Painlessbleeding B Commonlyassociatedwithcoagulopathy C Firstepisodeofbleedingisusuallyself limited D Associatedwithpostcoitalspotting Exercise2 B A33 year oldwomanat37week sgestation confirmedbyfirsttrimestersonography presentswithmoderatedlyseverevaginalbleeding Sheisnotedonsonographytohaveaplacentaprevia Whichofthefollowingisthebestmanagementforthispatient A Inductionoflabor B Tocolysisoflabor C Cesareandelivery D ExpectantmanagementE Intrauterinetransfus
