Tashkent Medical Academy Department of Obstetrics and Gynecology for 4-5 courses Practical lesson №12 Bleeding in late pregnancy: Placenta previa and abruptio placentae.

Placenta previ a Placenta previa is called its attachment in the lower uterine segment, that is the way the fetus is born.

There are three types of placenta previa. At full placenta previa internal os is fully closed. A variety of complete previa consider central placenta previa when its center is located on the inner throat. In case of partial placenta previa covered only part of the internal os. Thus for the inner throat along with placental tissue determined fetal membranes. At low placenta its location is near the edge of the internal os (within 2 cm).

Risk factors age (in pregnant women aged 35 placenta previa occurs 3 times more often than at the age of 25 years). a large amount of labor. scar on the uterus. placenta previa in history. smoking. multiple pregnancy.

The clinical picture sudden painless bleeding from the genital tract bleeding yourself stops later - resumes one-third of patients have wrong position and fetal presentation

Diagnosis abdominal and transvaginal ultrasound Vaginal examination in cases where after ultrasound diagnosis is unclear, but the woman does not stop bleeding from the genital tract. Because of the risk of major bleeding study produced in the operating room, in the presence of a sufficient amount of blood products.

Clinical management Outpatient treatment is possible in the following cases. Pregnant aware of the severity of their condition. at home possible compliance of the above restrictions. pregnant is under constant supervision, it is possible to quickly take her to hospital. upon reaching the 36th week of pregnancy regularly evaluate fetal lung maturity. delivery is carried out immediately after receiving a positive test result.

Clinical management If immature fetal lungs or gestational age less than 36 weeks and there is no bleeding, conservative treatment is carried out: Limitation of physical activity. Abstinence from sexual activity and douching. Maintaining hemoglobin level of at least 100 g / l. The administration of anti-Rh0 (D) -immunoglobulin women with Rh-negative blood. Tocolytic therapy (performed with caution). The drug of choice - magnesium sulfate. Harvesting of blood products.

Clinical management When severe bleeding that threatens the mother's life, regardless of the duration of pregnancy carried out an emergency cesarean delivery. In the absence of severe bleeding and gestational age 36 weeks or more after the confirmation of fetal lung maturity delivery is carried out in a planned manner.

Complications hemorrhagic shock. complications of cesarean section. complications of transfusion therapy. placenta previa can be observed its increment.

Premature detachment of the normal situated placenta Premature detachment of the placenta called the partial or complete separation of placenta from the uterine wall, which occurred before the birth of the fetus - during pregnancy or childbirth.

Risk factors pre-eclampsia and hypertension. premature detachment of the placenta in the history of (risk of recurrence is 10%). a large amount of labor. age (risk increases with age). injury. smoking. addiction, especially cocainism. alcohol. premature rupture of membranes. rapid discharge of amniotic fluid at birth and rapid polyhydramnios first fetus in twins. hysteromyoma, especially at the location of the node in the placental site

Clinical classification of placental abruption Light (40% of cases). Blood loss from the genital tract does not exceed 100 ml. In the formation of retroplacental hematoma is no external bleeding. Uterine tone slightly elevated. Fetal heart rate within the normal range. Pregnant condition is satisfactory. Basic physiological parameters and indices of coagulation system in the normal range.

Clinical classification of placental abruption Moderate (45% of cases). Blood loss from the genital tract of ml. In the formation of retroplacental hematoma is no external bleeding. Increased uterine tone. Can uterine tenderness on palpation. The character of the fetal heart. Showing signs of intrauterine hypoxia, sometimes - no heartbeat. A pregnant marked tachycardia, orthostatic hypotension, and low pulse pressure. Possible decrease in fibrinogen levels to mg%.

Clinical classification of placental abruption Heavy (15%). Blood loss from the genital tract than 500 ml. When retroplacental hematoma external bleeding may be absent. Uterus dramatically tense and painful on palpation. Fetus usually dies. A pregnant developing hemorrhagic shock. Often joins DIC.

Clinical manifestations Vaginal bleeding is observed in 80% of cases of placental abruption, in 20% of cases formed retroplacental hematoma. Pain. In most cases, it appears suddenly, is constant, localized in the lower abdomen and lower back. Soreness and tension of the uterus is usually seen in more severe cases. In the formation of retroplacental hematoma uterus increases. It is possible to identify when re-measured waist circumference and height standing uterus. Amniotic fluid can be stained with blood. May develop hemorrhagic shock. Often there are signs of fetal hypoxia. Premature detachment of the placenta can cause premature birth.

Clinical management Easy premature detachment of the placenta When a satisfactory condition pregnant woman and fetus conduct a thorough observation. At the slightest deterioration pregnant or fetus shown immediate delivery. Provide round the clock monitoring of the fetus. Conduct monitoring coagulation system, in case of violations immediately begin their treatment. If the fetus is immature, prescribed tocolytic therapy.

Clinical management Moderate and severe premature detachment of the placenta Conduct a thorough monitoring of the pregnant woman and the fetus. shock treatment Treat DIC. Heparin is contraindicated. After delivery, the content of clotting factors generally normal after 24 hr, and the content of platelets - for 4 days. Carried oxygen inhalation. For the control of diuresis establish a urinary catheter.

Timing and methods of delivery 1 In light of premature detachment of the placenta, if the state of pregnant stable, allowed distinct genera. In other cases, requires an emergency delivery. 2 If the premature detachment of the placenta occurred in childbirth, the mother and the fetus condition is satisfactory, BCC made ​​ up and delivery proceeds normally, accelerate their course is not required. 3 For stimulation of delivery and reduce income in blood thromboplastin produce amniotomy. 4 In some cases delivery stimulate oxytocin. 5 There is preferred vaginal delivery path. 6 Caesarean section is performed in the following cases. a. Intrauterine hypoxia in the absence of conditions for rapid delivery vaginally. b. Severe premature detachment of the placenta from the threat to the life of the mother.

Complications 1 Hemorrhagic shock. 2 DIC. 3 An extensive hemorrhage into the wall of the uterus - the uterus of Kuveler (developed in 8% of cases). 4 Ischemic necrosis of the internal organs (hypovolemia), acute tubular necrosis, necrosis of the liver, pituitary gland, lung, kidney cortex and the adrenal glands.