Bleeding in Pregnancy: Third Trimester Hemorrhage Anita Department of Gynaecology and Obstetrics

Placental Abruption Placenta Previa

The First Section Placental Abruption

Learning Objectives ＆ Desire To grasp the classification, clinical manifestation or presentation, diagnosis and principle of management To be familiar with the etiology To know the complications and preventive measure

Syllabus Introduction Clinical Diagnosis & Differentials Complications Treatment

1、INTRODUCTION Background & Definition Mortality & Morbidity Etiology Pathophysiology

Background & Definition Grasp Background & Definition refers to separation of the normally located placenta after the 20th week of gestation and prior to birth, and is one of the most important complications in third trimester pregnancy.

Frequency Mortality/Morbidity Internationally: occurs in about 1% of all pregnancies throughout the world. Mortality/Morbidity Know Maternal and fetal death may occur because of hemorrhage and coagulopathy. The fetal perinatal mortality rate is approximately 15%.

Be familiar Etiology The pathological changes of blood vessels in gravida:Maternal hypertension - occurring in approximately 44% of all cases Mechanical factors: Maternal trauma- striking, the sexual life ,motor vehicle accidents [MVA], assaults, falls, which causes 1.5-9.4% of all cases

Ascending of venous pressure of the uterus: Idiopathic (probable abnormalities of uterine blood vessels and decidua) Others: pluripura, cigarette smoking, alcohol consumption, cocaine use, short umbilical cord, sudden decompression of the uterus (eg, premature rupture of membranes, delivery of first twin), retroplacental fibromyoma, retroplacental bleeding from needle puncture (ie, postamniocentesis), advanced maternal age

Be familiar Pathophysiology Bleeding into the decidua basalis leads to separation of the placenta. Hematoma formation further separates the placenta from the uterine wall, causing compression of these structures and compromise of blood supply to the fetus.

Uteroplacental apoplexy Grasp Uteroplacental apoplexy Retroplacental blood may penetrate through the thickness of the uterine wall into the peritoneal cavity, a phenomenon known as Couvelaire uterus.

2、CLINICAL History & Clinical Menifestation Classification Accessory Examination

History & Clinical Menifestation Grasp History & Clinical Menifestation Vaginal bleeding - 80% Abdominal or back pain and uterine tenderness - 70% Fetal distress - 60% Abnormal uterine contractions (eg, hypertonic, high frequency) - 35% Idiopathic premature labor - 25% Fetal death - 15%

Classification extent of separation location of separation partial complete central marginal

In China Classification Grasp Slight Type Heavy Type

Slight Type: mild Characteristics include the following: mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress

Heavy Type: severe Moderate vaginal bleeding to heavy vaginal bleeding Moderate-to-severe uterine tenderness with possible tetanic contractions or very painful tetanic uterus Maternal shock Hypofibrinogenemia (ie, <150 mg/dL or 50-250 mg/dL) Coagulopathy Fetal distress or death Maternal tachycardia with orthostatic changes in BP and heart rate

Accessory Examination Lab Studies Imaging Studies

Lab Studies Hemoglobin Hematocrit Platelets Prothrombin time/activated partial thromboplastin time Fibrinogen Fibrin/fibrinogen degradation products D-dimer Blood type

Imaging Studies Ultrasonography helps determine the location of the placenta. (Location is used to exclude previa.) Retroplacental hematoma may be recognized in 2-25% of all abruptions. Recognition of retroplacental hematoma depends on the degree of hematoma and on the operator's skill level.

3 、 Diagnosis & Differentials History & Clinical Menifestation Diagnosis Accessory Examination Grasp Placenta Previa:no painful hemorrhage Differentials threatened rupture of uterus:

4-1、 Complications Hemorrhagic shock DIC Uterine rupture Renal failure Know 4-1、 Complications Hemorrhagic shock DIC Uterine rupture Renal failure Ischemic necrosis of distal organs (eg, hepatic, adrenal, pituitary) Maternal complications

4-2、 Complications Hypoxia Anemia Growth retardation CNS anomalies Know 4-2、 Complications Hypoxia Anemia Growth retardation CNS anomalies Fetal death Fetal complications

5、TREATMENT Treatment of hemorrhagic shock Grasp 5、TREATMENT Treatment of hemorrhagic shock Closely perform fetal monitoring Termination of pregnancy immediately The treatment to dysfunction of blood coagulation To prevent the renal failure Follow-up, pre-hospital care

Treatment of hemorrhagic shock If needed, Administer supplemental oxygen Administer IV fluids Perform aggressive fluid resuscitation to maintain adequate perfusion, if needed Transfuse, if necessary. Crossmatch 4 units of packed red blood cells

Closely perform fetal monitoring Monitor vital signs and urine output. Closely observe the patient Perform amniotomy to decrease intrauterine pressure, extravasation of blood into the myometrium, and entry of thromboplastic substances into the circulation.

Termination of pregnancy immediately cesarean delivery :Immediately deliver the fetus by cesarean delivery if the mother or fetus becomes unstable. vaginal delivery: to be adapted to the slight type

The treatment to dysfunction of blood coagulation (DIC) To renew the blood volume and blood clotting factor To apply the heparin To resist the fibrin dissolution To prevent the renal failure: mannitol as like

Further Inpatient Care Deterrence/Prevention Know Follow-up, pre-hospital care Further Inpatient Care Deterrence/Prevention

Further Inpatient Care Labor, delivery, and postpartum care Further management of the complications of abruptio placentae

Deterrence/Prevention Know Deterrence/Prevention Treat maternal hypertension. Prevent maternal trauma/domestic violence. Prevent smoking and substance abuse. Diagnose placental abruption at an early stage in high-risk groups

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