1. Placenta previa Placental abruption
Women’s Hospital School of Medicine
Zhejiang University
Wang Zhengping

2. Antepartum Hemorrhage
Third-trimester bleeding
Obstetric: Placental separation
Placental Previa
Placenta Abruption
Uterine Rupture
vasa previa : Fetal Vessel Rupture
No obstetric: Acute vaginitis/cervicitis, Cervical polyp, Cervical cancer, Trauma

3. Placenta previa

4. Definition Placenta previa:
The inferior edge of placenta load at the lower uterine segment, or even reach the internal cervical os after 28 weeks gestation.
Incidence rate:
Internal：0.24%~1.57%；
International：0.5%~0.9%。

5. Etiology High-risk group Initial etiologic agnet Multipara
Age of gravida>35
Multipara
Pregnancy women used to tobacco or dope
Initial etiologic agnet
Damage of endometria
Development of the trophoblastic layer of
fertilized ovum delayed
Anomaly of placenta
Cicatricial uterus due to cesarean section ,e.g.

6. Classification
Classified according to the relationship between the edge of placenta and the internal cervical os :
complete ( central ) placenta previa
partial placenta previa
marginal placenta previa
Time to determine classification : the last examination before managed

7. (1) complete placenta previa
(2) partial placenta previa
(3) marginal placenta previa

8. Classification
Types of placenta previa.

9. Clinical Features
Painless 、recurrent vaginal bleeding in the second or third trimester of pregnancy
Anemia,shock or even death corresponded to the volume of vaginal bleeding
The uterus is usually soft and relaxed
Anomaly of fetal condition
Per vagina examination

10. Bleeding time and volume
Central placenta previa
Early(20-28wks)
Large amount
Several times
Total placenta previa
Early(20-28wks)
Large amount
Several times
Partial placenta previa
Between total and marginal
Partial placenta previa
Between total and marginal
Marginal placenta previa
Late(37-40WKS or in labor )
Less bleeding
Marginal placenta previa
Late(37-40WKS or in labor )
Less bleeding
Bleeding time and volume

11. Auxiliary examination
B-ultrasound examination
Placenta examination post partum <7cm
MRI

12. marginal placenta previa

13. partial placenta previa

14. central placenta previa

15. Differential diagnosis
Placental abruption
Disruption of vasa previa
Cervical polyp or erosion
Cancer of cervix

16. Complication of mother and fetus
Bleeding at or post partum
Implantation of placenta
Anemia and puerperal infection
Premature delivery

17. Implantation of placenta

18. Management expectant treatment Indication: Fewer vaginal bleeding
Patient’s condition stabilization
<36 weeks gestation,
fetal weight<2300g
Management: Lying in bed to take a rest
Inhibition of uterine contraction
Treatment aim at symptoms
Promote development of fetus
Prevention of infection

19. Termination of pregnancy
Indication: 1.Severe vaginal bleeding
2.Gestation age >36 weeks, or fetal
lung function been matured
Mode of labor:According to the type of placenta
previa,volume of vaginal bleeding
and condition of gravia, et al.
Cesarean delivery is necessary in practically all women with placental previa

21. Transport in emergency condition
In the neighborhood
Initiatory management

22. Placental abruption

23. Definition
Placental abruption: placenta in normal site strip from the uterine parietal partially or completely before the fetus expulsion,after 20 weeks gestation or in the delivery procedure.
Incidence rate: 0.46%~2.1%
Neonatal mortality: 200‰~428‰

24. Etiology Angiopathy of vasa basalis Mechanical agent
Venous pressure of uterus elevated abruptly
Volume of uterus deflated abruptly
Others: Age of gravida>35,multipara,
tobacco,dope

25. Classification Classify according to vaginal bleeding or nor:
Dominant/Recessive/Mixed
Classify according to severity degree:
Light type ＜1/3
Severe type ＞1/3; ＞ 1/2, Dead fetus

26. Uteroplacental apoplexy:
widespread extravasation of blood into the uterine musculature and beneath the uterine serosa

27. Clinical Features
Abruptly,persistent abdominal pain with vaginal bleeding
Maternal compromise/ shock(Volume of vaginal bleeding not correspond to patient condition)
Anomaly of fetal condition
The uterus touched hard with pain
The size of uterus is bigger than it should be in that gestation age

28. Auxiliary examination
Diagnotic examination:
B-ultrasound examination
Placenta examination post partum
Blood Rt,Blood coagulation,blood examination of hepatic and renal function

29. Sonography

30. Differential diagnosis
Placental previa
Uterus rupture

31. Complications DIC,dysfunction of coagulation
Post partum hemorrhagic/shock
Amniotic fluid embolism
Acute renal failure
Fetal death

32. Management Treatment depends on: Condition of the mother and fetus
Gestational age of the fetus
Cervical examination
Principle:
If diagnosed,fetus will be deliveried immediately

33. Management Mature fetus Deliver Compromised mother Deliver
Immature fetus
Expectant, if mother stable

34. Expectant Management Bed rest Ongoing maternal monitoring
Fetal assessment: age, growth, well being
Deliver if recurrent signs / symptoms
Deliver at fetal maturation

35. Severe placental abruption:
Resuscitation
Evaluate and treat coagulation defect
Deliver the fetus: Cesarean section
Prevention of PPH
Monitor renal status closely

36. THANKS