1. Zareh.F.MD

2. All bleeding during pregnancy should be investigated by examination and imaging studies

3. 1/4 of women who bleed at 14-26 w had pp or ap. 1/3 of pregnancy with vag bleeding after 26 w had poor outcome. Unexplained vag.bleeding at term must be considered for delivery.

4. etiologies Placenta previa Placenta abruption Vasa previa Cervical lesions (carcinoma,polyps) Vaginal laceration (trauma,carcinoma) Uterine rupture or dehiscence

6. Placenta previa incidece 0.5-1% of all pregnancies Fatal 0.03% of cases Incidence in multipar :1/20 Incidence in nulipar : 1/1500

7. difinition Dillated cervix: complete previa partial previa marginal previa low lying Closed cervix: complete partial / marginal 2 cm from int.os

12. pathophysiology Abnormal endometrial tissue less favorable location for implantation: poor vascularization thinner myometrium Uterine trauma from c/s (6 fold)

13. Risk factors Perior c/s Black, minority Older women >35 y High gravidity & parity Cigarette smoking 2.6-4.4 fold Previous abortion

14. diagnosis Abdominal sonography misdiagnosis : full distended bladder lower ut segment contraction pp in 2nd trimester 90-95% resolved by the 3rd trimester(but no central) 3 dimensional scanning transvaginal scan Transperineal scan Double set up examination MSAFP>2 MoM

15. Clinical features Asymptomatic Vaginal bleeding variable intermittent red to brownish maternal origin the fetus usually not in jeopardy

16. complication Hospital stay c/s Abruptio placenta Malpresentation Post partum hemorrhage Growth restriction Placenta accreta pp+previous c/s10-35% +multiple c/s 60-65% Coagulation defect

17. Other complications A.T.N Sheehan syndrome Maternal mortality<1% Perinatal mortality <5%

18. outcome IUGR ? Preterm birth Congenital anomaly Respiratory distress syndrome Anemia Recurrence rate 2-3%(6-8 fold)

19. management no bleeding 2nd trimester intercourse avoid usual activity repeat sonography 3rd trimester decrease physical activity travel away from home prolonged bed rest

20. management with Bleeding Evaluation of the patient Fetal status IV fluid Blood cross match RHoGam if necessary Steroid if 24-34 W Delivery after 34-36W

21. management Severe hemorrhage Medical team for immediate delivery 2 large bore IV line Blood cross match Foley catheter Coagulation panel Continuous Fetal monitoring delivery

23. Premature separation of placenta. 0.5-1% of deliveries Perinatal mortality is 20-25% Preterm birth is 40% Cause of 15% of stillbirth

24. Definition Preplacental or subamniotic

27. retroplacental

28. Risk factors Socioeconomic: High parity low education infertility

29. Risk factors Uterine: ut.malformation ut.septum Myoma

30. Risk factors Medical: Diabete pregestational Hypertension _chronic&gestational PROM with chorioamnionitis

31. Risk factors Thrombophilias Antiphospholipid syndrome Prothrombin 20210A mutation Hyperhomocysteinemia Factor V leiden mutation Activated protein C resistance Protein C and S deficiency dysfibrinogenemia

32. Risk factor iatrogenic Sudden decompression(amniocentesis) External cephalic version Cigarette smoking Cocaine abuse Blant trauma Heavy physical activity

33. pathophysiology Blunt trauma : forceful shearing effort Majority of other case : cell death (apoptosis) induced through ischemia,hypoxia. Thrombophilia : thrombose in decidua basalis Chorioamnionitis: infectious agents (lipopolysacharids & endotoxins) cytokines,superoxide ischemia and hypoixia

34. Pathophysiology cont. Nicotine(cigarete) and cocaine vasoconstriction ischemia placental lesions(infarction,oxidative stress,appoptosis and necrosis) Circumvalate placenta(chorion leave don’t insert at the edge of placenta) A.P,IUGR,PROM,preterm labor

35. diagnosis Clinically vaginal bleeding Uterine pain tetanic contraction fetal heart abnormality sinusoidal pattern

36. diagnosis Paraclinic Ultrasound MRI Doppler Biochemical test Unexplained elevated of MSAFP AP>10 fold Preterm labor+AFP>2MoM = AP (67%) Preterm labor+AFP>2MoM+bleeding= AP (100%) HCG Inhibin A Fetal Hb

38. management Marginal Abruptio hospitalize a patient with any bleeding after fetal viability Large retroplacental usually require acute & aggressive management

39. Large bleeding Continues fetal monitoring Foley catheter Frequent maternal v/s Steroid therapy (24-34w, membrane intact) Folic acid 1mg,vit B12,vit B6

40. discharge Mild bleeding : 2-5 days without any further bleeding Large bleeding :decision is difficult with any bleeding, pain, contraction no discharge

41. Tocolytic use Now become acceptable to consider a short course of tocolytic therapy for: stable patient, limited abruptio, established fetal well being, preterm G.age

42. Which tocolytic B mimetics (terbut,ritod): mask cardiovascular response to volume depletion Ca channel blockers (nifidipine): reduce BP Mgso4 : most acceptable agents

43. delivery Vaginal or c/s Depending on the: Degree of bleeding Presence or absence of: Active labor Fetal distress

44. complications c/s 50% of case Shock DIC Renal failure Couvelaire uterus Recurrence : 10 fold

45. Fetal outcome Mortality: term babies 25 fold Prematurity: 40%

46. Thrombophilia defects Anticardiolipin antibodies Lupus anticoagulant Pr c, Pr s and antithrombin 3 deficiencies Factor v leiden “activated pr c resistance” Metilentetrahydrofulate reductase gene mutation Prothrombin 20210A gene mutation Congenital dysfibrinogenemia

47. Factor V leiden Activated protein C resistance Most common genetic factor predisposing to thrombosis Most common identifiable causes Substitution of adenine for guanine “ Amino acid arginine for glutamine Increased tendency to form clots

48. hyperhomocysteinemia Methionine metabolise homocysteine damage vascular Remethylate MTHFR endothelium folate vit.B 12, vit. B 6 Methionine