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Placenta previa. Placental abruption. (Placental abruption (Due to…
Placenta previa.
Placental abruption.
Bleeding in the second and third trimester
Vaginal bleeding after 24 weeks of pregnancy and before beginning of labour.
Frequency: 4-5% of all pregnancies
Causes
Placenta previa (20%)
Preterm placental abruptio (30%)
Uterine rupture in advanced pregnancy (rare)
Vasa previa (rare)
Other reasons (50%): beginning of labour, birth canal trauma, cervical polyps, erosions
Placental abruption
Preterm separation of normally localised placental tissue after 20 weeks of gestation, correlated to abnormal placental vascularization
Due to
hemorrhage
heart insufficiency
renal insufficiency
Significant coagulopathy develops in 10% of patients – the most frequent cause of DIC during pregnancy
Risk factors
before labour
PIH, HA, Advanced maternal age, Multiparity,
Preterm rupturę of membranes
Rapid loose of large amount of amniotic fluid
Short umbilical cord
Anatomic abnormalities of uterus
Aspirin use
Mechanical trauma of abdomen
Compression of inferior vena cava
Placental abruptio in history (recurrence in 10% after one and 25% after two abruptions)
during labour
Delivery of one fetus in multiple pregnancy
Strong uterine contraction in feto-maternal incompatibility
Stimulation of uterine contractions with Oxytocin
Induction of labour with prostaglandines
Symptoms
Abdominal pain - 90%
Increased uterine tone – 34%
Uterine contractions – 35%
Vaginal bleeding – 78-80%
Hypotension
Hypovolemic shock
DIC – 20% (depends on size of the retroplacental hematoma, speed of placental separation, gesational age)
Hypofibrinogenemia, afibrinogenemia – 30% of caces complicated with DIC
Fetal distress – 50% (bradycardia, fetal demise)
Latent: bleeding to the uterine cavity, wide ligaments, uterine cavity with unruptured membranes
Uterine flow in term pregnancy – 600-700ml/min.
In uterine cavity 4-5l of blood may collect.
Diagnosis
Ultrasound scans – visualization of hematomas over 300ml
Kleihauer-Betke test may confirm abruption (Quantifies fetal cells in the maternal circulation)
Management
Depending on gestational age, blood loss and maternal and fetal wellbeing:
small area of placental abruptio, pregnancy before term – expectant management (amniocentesis for fetal lung maturation assessment, steroids, magnesium, US, CTG, tocolysis in chosen cases)
term pregnancy – delivery
Fetal distress and/or hemodynamic disturbancies in the mother – cesarean section independently from gestational age
Placenta previa
The placenta is attached to the lower uterine segment.
Placenta is lower than fetus.
Cause of 1/3 af all bleedings in the 3rd trimester, 20% in pre-delivery period
Types
Total: internal os completely covered – 47%.
Partial: internal os partially covered - 29%
Marginal: edge of placenta at the margin of internal os – 24%
Low lying placenta
Risk factors
Chronic hypertension
Multiparity (second or succeeding pregnancy)
Multiple gestations (i.e., twins, etc.)
Older maternal age
Previous cesarean delivery
Smoking
Prior uterine curettage
Diagnosis
painless
vaginal bleeding with bright-red blood (maternal, may be after sexual intercourse or vainal examination, be related to uterine contractions), usually recurrent, at the beginning slight
abnormal fetal lie and position
US scan confirms diagnosis
Only 5% od placenta praevia diagnosed in the 2nd trimester remains so at term
Management
During pregnancy
Usually bleeding does not threaten mother nor child – expectant management is possible
Outpatient management after first light bleeding
Heavy bleeding or fetal distress – urgent cesarean section
At the time of labour
Elective cxesarean section at 36 weeks
Vaginal delivery is rare possible, advisable when: advanced delivery with engaged fetal head and sloght bleeding, fetal demise, lethal fetal malformations
Gynecological examination – at the readiness of opertatign theater
complications
Maternal
mortality rate – 10%
placenta accreta – 5-15% (25% if patient had previously cesarean section and 60% after 2 cesarean sections).
Fetal
mortality rate – 25-35%, prematurity, fetal asphyxia, abnormal lie and presentation
Bleeding assessment
Blood character: bright or dark, clots, hemolysis
Blood volume: spotting, bleeding, hemorrhage
Blood origin: vagina, uterine cervix, cervical canal, uterine cavity