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

2. Placental Abruption
Placenta Previa

4. The First Section
Placental Abruption

5. 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

6. Syllabus Introduction Clinical Diagnosis & Differentials Complications
Treatment

7. 1、INTRODUCTION Background & Definition Mortality & Morbidity Etiology
Pathophysiology

8. 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.

9. 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%.

10. 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 % of all cases

11. 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

12. 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.

18. 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.

19. 2、CLINICAL History & Clinical Menifestation Classification
Accessory Examination

20. 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%

21. Classification extent of separation location of separation partial
complete
central
marginal

22. In China
Classification
Grasp
Slight Type
Heavy Type

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

24. 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 mg/dL)
Coagulopathy
Fetal distress or death
Maternal tachycardia with orthostatic changes in BP and heart rate

25. Accessory Examination
Lab
Studies
Imaging
Studies

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

27. 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.

28. 3 、 Diagnosis & Differentials
History & Clinical Menifestation
Diagnosis
Accessory Examination
Grasp
Placenta Previa:no painful
hemorrhage
Differentials
threatened rupture of uterus:

29. 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

30. 4-2、 Complications Hypoxia Anemia Growth retardation CNS anomalies
Know
4-2、 Complications
Hypoxia
Anemia
Growth retardation
CNS anomalies
Fetal death
Fetal
complications

31. 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

32. 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

33. 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.

34. 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

35. 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

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

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

38. 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

40. The more English,The better!