Please enable JavaScript.
Coggle requires JavaScript to display documents.
Obstetrics hemorrhage :<3: (:crossed_flags: Placental previa (…
Obstetrics hemorrhage :<3:
:timer_clock:
Timings
& cause
1st trimester bleeding
Spontaneous abortion
Ectopic preg
Normal preg
3rd trimester bleeding
(occurs 3-4% of pregnancies)
Obstetric causes / Non-obstetric causes :grapes:
Antepartum / Postpartum
Antepartum major causes
Placenta abruption (30%)
Placenta previa (20%)
:red_flag:
Placental Abruption
:
(
รกลอกตัวก่อนกำหนด)
1/3 causes of 2nd to 3rd tri bleeding
Etio & Associated factors
Age, parity, race & familial factors
HT
PROM and Preterm delivery
Smoking
Cocaine
Thrombophilia
Traumatic abortion
Leiomyomas
:four_leaf_clover:
S&S
Hx
30% of Placental seperation — small ➯ asymp. Only found out after delivery
Painful uterine bleeding
classic presentation — 3rd Vx bleeding assoc with Severe abd pain and/or freq, strong contractions
PE
Vx bleeding + Firm, tender Uterus
Tocometer: small frequent contractions usu seen along tetanic contactions
Fetal monitoring: Nonreassuring fetal heart tracing secondary to Hypoxia
Classic
sign that only seen the time of C/S ➯
Couvelaire uterus
— life threatening condition :fire:
Additional clinical findings
Hypovolemic shock
Consumptive coagulopathy
Types
Concealed
รกลอกหมดทั้งแผ่น
ยกเว้น
ตรงกลาง
เลือดซัดเฉยๆ -> + coag fac ต่างๆ -> DIC
ท้องใหญ่, ตึง, tenderness, BP drops, HT
Revealed
Chronic placental abruption -> blood mom & fetus mix -> fetal distress -> death
:evergreen_tree:
Mx
Ajarn prayooks
± Tocolysis
Timing
Can’t wait anymore → C/S
Cx dilate → Vx delivery
Amniotomy → helps :arrow_down: duration of เลือดเซาะ
Oxytocin
Preterm preg: expectant mx
Depends on GA and status of mom and fetus
Delivery
Vx delivery preferred as long as: controlled bleeeding + no signs of fetal distress
:zap:
Def
: Premature separation of normally implanted placenta fr uterine wall
➯ Hemorrhafe between uterine wall and placenta
:male-factory-worker::skin-tone-3:
Facts
50% of this occur
before labor and after GA 30 wks
15% occurs
during labor
30% only identified in Placental inspection after delivery
Large Placental separations may ➯ Premature delivery, Uterine tetany, DIC and hypovolemic Shock
:gear:
Pathogenesis
Unknown primary cause of Placental abruption
Initial point of seperation — nonclotted blood courses fr injury site ➯
enlarging collection of blood
causes further seperation of placenta
20% — confined within uterine cavity ➯
Concealed hemorrhage
80% of Placental seperation — Dissects downward toward Cx ➯
Revealed/External hemorrhage
Predisposing & precipitating factors
:grapes:
:earth_americas:
Epidemiology
High mortality due to its strong assoc. with Preterm birth
0.5-1.5%. of preg
30% cases of 3rd tri bleeding
15% of perinatal bleeding
Incidence of this inc. with no. of gestations (triplets > twins > singletons), Perinatal mortality is greatest among singletons then twin then triplets
M/C factor associated with :arrow_up: incidence of this is
HT
(whether fr Chronic, Result of preeclampsia, Maternal ingestion of cocaine or methamphetamine)
Incidence severe enough to cause fetal death
50% due to HT
(25% chronic HT and 25% fr preeclampsia)
Risk of abruption in future pregnancy: 10% after 1 abruption ➯ 25% after two prior abruptions
:dango:
Dx
Primarily
clinical
U/S are use to R/O tho negative findings
doesn’t rule out placenta abruption
Confirmed
by inspection of placenta at delivery — presence of
retroplacental clot
with overlying placental destruction
:crossed_flags:
Placental previa
:four_leaf_clover:
S&S
Hx
Sudden, profuse
Painless vaginal bleeding
(1st epic of bleeding —
Sentinel bleed
usu occurs after GA 28 wks ➯ LUS develops and thins
➯ disrupts Placental attachements ➯ Bleeding)
PE
PV is C/I
(PV can cause further placenta seperation ➯ trigger catastrophic hemorrhage)
U/S*
to dx
Speculum examination or palpated: Notable varicoses in LUS or Cx (fr increased vascularity)
:dango:
Dx
U/S
For location
Upper/lower
:star:
Transvaginal U/S*
accuracy & superiority in Dx > Transabd U/S
Alternative:
Translabial U/S
— better than TAUS in locates placenta
Questioning TVUS
safety
?
Vx probe introduced at angle that places it against Ant. fornix and Ant. Lip of Cx
Optimal distance for visualization of Cx: 2-3 cm away fr Cx ➯ so Not advanced sufficiently to make contact with placenta (anw TVUS should performed by Experienced personnel as to avoid putting probe in Cx)
MRI
:deciduous_tree:
Mx
*should early detect and then refer to รพ. ศูนย์
Anterior placenta and overlies C/S scars ➯ I/C for
Close surveillance
IPD or OPD Mx remains controversy
Unstoppable labor, Fetal distress & Life threatening hemorrhage ➯
I/C for Immediate C/S
regardless of GA
GA
Preterm preg + Not bleed profusely ➯ Agressive expectant Mx
Delivery at GA 34 - 37 wks with minimal benefit fr fetal lung maturity determination
Course of action when Vx bleeding suspected placenta previa
Stabilize pt
(EFM, 2 large bore IV, Lab (suspected bleeding or coagulopathy — PT, PTT, D-diner, and fibrinogen), type and cross,
Prepare for catastrophic hemorrhage
(Expectant Mx: Hosp, Bed rest, Hct monitoring, Limit any oral intake, 2 or more units of blood typing + cross-matched + made available
Prepare for Preterm delivery
GA 24 - 34 wks ➯ Corticosteroid
Hx of C/S or Uterine Sx ➯ Detailed U/S to exclude placenta accreta
Try to prolong preg until more than GA 34 wks
:zap:
Def
: Abnormal implantation of placenta over Internal Cx Os
Types
Complete previa
: placenta
completely
cover Internal Os
Partial previa:
placenta covers
portion
of Internal Os
Marginal previa
: edge of placenta reaches the margin of Os
Low lying placenta
: implanted in LUS in close proximity
but not extend into Internal os
Rarely found
Vasa previa
: Fetal vss lie over the Cx
:gear:
Pathogenesis :
Still unclear why some placentas implant in LUS rather than Fundus (Fundus - where is better vascularized)
As preg progresses: 90% of low-lying placentas identified early in preg will move out of Cx and out of LUS
due
to aparent movement of placenta by to develop of LUS
Placenta that lies over
less vascularized Cx
➯ Placenta atrophy
Some cases of atrophy ➯ leaves
vessels
running thru membranes
unsupported by Placental tissue or Umbilical cord
Occurs over Cx:
Vasa previa
Incomplete atropjy ➯ Placental lobe discrete fr the rest of placenta:
Succenturiate lobe
:explode:
Other fetal risks asso. placenta previa
:grapes:
:bomb:
Complications
Placenta accreta (placenta previa accreta)
:male-factory-worker::skin-tone-5:
Facts
2/3 women with Placenta previa + assoc. Placenta accreta ➯
requires
Hysterectomy at the time of delivery
(Peripartum hysterectomy)
:warning:
Caution
DO NOT PV
unless alrdy R/O by U/S
Viable fetus c bleeding
must always R/O this
:earth_americas:
Epidemiology
0.5% of preg (1:200 births)
~20% of all Antepartum hemorrhage
1-4% of women with Prior C/S
Found Placenta previa accreta (placenta previa complicated by placenta accreta) ~5% of cases
Due to Routine OB U/S ➯ Marginal previa or Low-lying placenta — commonly Dx in 2nd tri
➯ LUS develops during 3rd tri — Placenta moves up and away fr Cx ➯ mostly resolve
The later in preg that Placenta previa is Dx, the higher the likelihood of persistence to Delivery
Predisposing factors
:grapes:
:flags:
Placenta accreta, increta & percreta
:warning:
Percreta
may involve UB which need to consult Uro and Onco to resect UB
:evergreen_tree:
Mx
Preoperative arterial catheter placement
Placenta delivery
Mx outcomes
Considerations for suspected placenta accreta/increta/percreta
Plan for total abdominal hysterectomy at the time of C/S
Schedule GA 34-37 wks delivery for
elective peripartum hysterectomy
(as less blood loss than Emer peripartum hysterectomy)
Plan ahead and hv backup available
(Type and crossed blood products available + Urology, Urogynecology and/or gynecologic oncology should aware)
:zap:
Def
Placenta accreta
: Superficial attachment of placenta to uterine myometrium
Placenta increta
: Placenta
invades myometrium
Placenta percreta
: Placenta invades thru myometrium to
uterine serosa
:gear:
Mechs
Inability of placenta to properly separate fr uterine wall after fetal delivery ➯ Profuse hemorrhage & shock with
substantial maternal mortality and morbidity
Need for hysterectomy
Surgical injury to ureters, bladder and other viscera
Adult respiratory distress syndrome
Renal failure
Coagulopathy
Death
:female-factory-worker::skin-tone-3:
Facts
Average blood loss at delivery with placenta accreta
= 3000 - 5000 mL
History: Most frequent I/C for peripartum hysterectomy - Uterine atony
Now — abn placentation :arrow_up: ➯ more common reason for peripartum hysterectomy
Rarely — may led to Spontaneous uterine rupture in 2nd or 3rd trimester ➯ intraperitoneal hemorrhage
life threatening emer
Minor degrees of placenta accreta ➯ Slightly heavier bleeding
:earth_americas:
Epidemiology
Increased risk in Placenta previa in setting of prior C/S
(ยิ่ง C/S หลายรอบ ➯ ความเสี่ยง accreta สูงขึ้นเรื่อยๆ)
:leaves:
S&S
Hx
Usu. Asymptomatic
Rare — found Hematuria or Rectal bleeding (if percreta into bladder or rectum)
PE