Late pregnancy bleeding.pptx
Transcript of Late pregnancy bleeding.pptx
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LATE-PREGNANCY BLEEDING
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ETIOLOGY
The most common cause of late-pregnancy bleeding is aproblem with the PLACENTA : Placenta Praevia
Abruptio Placentae Vasa Praevia
Less common causes of late-pregnancy bleeding include : Uterine Rupture
Injuries or lesions of the CERVIX and VAGINA,
Polyps, cancer, and Varicose
Inherited bleeding problems, such as : HEMOPHILIA, are very rare, occurring in 1 in 10,000 women.
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PLACENTA PRAEVIA The placenta, can PARTIALLY or COMPLETELYcover the
cervical opening
Late in pregnancy called the cervix, THINS ANDDILATES (widens) in preparation for labor, some blood
vessels of the placenta stretch and rupture. This causes about 20% OF THIRD-TRIMESTER
BLEEDING and happens in about 1 in 200 pregnancies.
Risk factors for placenta previa include these
conditions: Multiple pregnancies
Prior placenta previa
Prior Cesarean delivery
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CLASSIFICATION
COMPLETE PLACENTA PREVIArefers to the situation in which the placentacompletely covers the opening from the womb to the cervix.
PARTIAL PLACENTA PREVIArefers to the placenta that partially covers thecervical opening (since the cervical opening is not dilated until time fordelivery approaches, this type of placenta previa occurs after the cervix
has begin to dilate). MARGINAL PLACENTA PREVIA refers to a placenta that is located adjacent
to, but not covering, the cervical opening.
The term LOW-LYING PLACENTA or LOW PLACENTAhas been used to referboth to placenta previa and marginal placenta previa.
The terms ANTERIOR PLACENTA PREVIA and POSTERIOR PLACENTA PREVIAare sometimes used after ULTRASOUND EXAMINATION to further define theexact position of the placenta within the uterine cavity.
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PLACENTA
PREVIA
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PLACENTA PREVIA SYMPTOMS
VAGINAL BLEEDING after the 20th week of gestation is the primary
symptom of placenta previa. Although the bleeding is typically PAINLESS and
Recurrent and the more intense
Can be associated with other complications of pregnancy including:
PLACENTA ACCRETA occurs when the placental tissues grows too deeplyinto the womb, attaching to the muscle layer,
Can cause LIFE-THREATENING BLEEDING and commonly requires
HISTERECTOMY.
Placenta accrete occurs in 5% to 10% of women with placenta previa.
PRETERM PREMATURE RUPTURE OF THE MEMBRANES (PPROM)
Other abnormalities of the placenta or umbilical cord
BREECH or ABNORMAL PRESENTATION OF THE FETUS.
a REDUCTION IN FETAL GROWTH associated with placenta previa.
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PLACENTAL ABRUPTION
A normal placenta separates from the wall of
the uterus prematurely and blood collects
between the placenta and the uterus. Such separation occurs in 1 in 200 of all
pregnancies.
The cause is unknown.
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CLASSIFICATION OF PLACENTAL ABRUPTION
Classification of placental abruption is based on :
EXTENT OF SEPARATION (ie, partial vs complete) and
LOCATION OF SEPARATION (ie, marginal vs central).
Clinical classification is as follows: Class 0 - Asymptomatic
Class 1 - MILD (represents approximately 48% of all cases)
Class 2 - MODERATE (represents approximately 27% of all
cases) Class 3 - SEVERE (represents approximately 24% of all
cases)
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DIFFERENTIAL DIAGNOSIS
ABDOMINAL TRAUMA
ACUTE APPENDICITIS
DISSEMINATED INTRAVASCULAR
COAGULATION
TORSION OVARIAN CYST
PLACENTA PREVIA
ECTOPIC PREGNANCY
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A DIAGNOSIS OF CLASS 0 IS MADERETROSPECTIVELY BY FINDING AN:
ORGANIZED BLOOD CLOT OR A
DEPRESSED AREA
ON A DELIVERED PLACENTA.
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CLASS 1 : MILD
CHARACTERISTICS
1. No vaginal bleeding to mild vaginal bleeding
2. Slightly tender uterus
3. Normal maternal BP and heart rate
4. No coagulopathy
5. No fetal distress
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CLASS 2 : MODERATE
CHARACTERISTICS
1. No vaginal bleeding to moderate vaginal
bleeding2. Moderate to severe uterine tenderness with
possible tetanic contractions
3. Maternal tachycardia with orthostatic changes in
BP and heart rate
4. Fetal distress
5. Hypofibrinogenemia (ie, 50-250 mg/dL)
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CLASS 3 : SEVERE
CHARACTERISTICS
No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, < 150 mg/dL)
Coagulopathy
Fetal death
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A. CONCEALED BLEEDING B. REVEALED BLEEDING C.MIXED BLEEEDING
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COMPLICATION
Potential MATERNAL COMPLICATIONS include thefollowing:
1. Hemorrhagic shock
2. Coagulopathy/disseminated intravascularcoagulation (DIC)
3. Uterine rupture
4. Renal failure5. Ischemic necrosis of distal organs (eg, hepatic,
adrenal, pituitary)
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COMPLICATION
Potential FETAL COMPLICATIONS include the
following:
1. Hypoxia
2. Anemia
3. Growth retardation
4. CNS anomalies5. Fetal death
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LAB STUDIES IN
ABRUPTIO PLACENTAE
Hemoglobin
Hematocrit
Platelets Prothrombin time/activated partial
thromboplastin time
Fibrinogen Fibrin/fibrinogen degradation products
Blood type
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ULTRASONOGRAPHY and MRI
Ultrasonography helps to determine the location of the placenta inorder to EXCLUDE PLACENTA PREVIA.
Ultrasonography is NOT VERY USEFUL in diagnosing placentalabruption (and normal ultrasonographic findings do not exclude the
condition).[4]
RETROPLACENTAL HEMATOMA may be recognized in 2-25% of allabruptions.
This recognition depends on the degree of hematoma and on theoperator's skill level.
MRI is DIAGNOSTICALLY EFFECTIVE and can ACCURATELY depictplacental abruption. Consider using MRI in cases where ultrasonography findings in the
presence of late pregnancy bleeding are negative, but positivediagnosis of abruption would change patient management.[7]
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MANAGEMENT
Initial Management of Abruptio Placentae
1. Begin continuous external fetal monitoring for thefetal heart rate and contractions.
2. Obtain intravenous access using 2 large-boreintravenous lines.
3. Institute crystalloid fluid resuscitation for the patient.
4. Type and crossmatch blood.
5. Begin a transfusion if the patient is hemodynamicallyunstable after fluid resuscitation.
6. Correct coagulopathy, if present.
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VAGINAL DELIVERY
This is the preferred method of delivery for afetus that has DIED secondary to placentalabruption.
The ability of the patient to undergo vaginaldelivery depends on her remainingHEMODYNAMICALLY STABLE.
Delivery is USUALLY RAPID in these patientssecondary to increased uterine tone andcontractions.
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CESAREAN DELIVERY
Is often necessary for fetal and maternal stabilization.
While cesarean delivery facilitates rapid delivery and direct access to the
uterus and its vasculature, it can be complicated by the patient's coagulation
status.
Because of this, a vertical skin incision, which has been associated with less blood loss, is
often used when the patient appears to have DIC.
The type of uterine incision is dictated by the GESTATIONAL AGE of the fetus, with a vertical
or classic uterine incision often being necessary in the preterm patient.
If hemorrhage cannot be controlled after delivery, a CESAREAN
HYSTERECTOMY may be required to save the patient's life.
Before proceeding to hysterectomy, other procedures, including correction of coagulopathy,
ligation of the uterine artery,
administration of uterotonics (if atony is present),
packing of the uterus, and
other techniques to control hemorrhage,
may be attempted.
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UTERINE RUPTURE
An abnormal splitting open of the uterus, causing the baby to be partially
or completely expelled into the abdomen.
About 40% of women who have uterine rupture had prior surgery on their
uterus, including Cesarean delivery.
The rupture may occur before or during labor or at the time of delivery. Other risk factors for uterine rupture are these conditions:
More than four pregnancies (MULTIPARITY)
Trauma
Excessive use of OXYTOCIN (Pitocin), a medicine that helps strengthen
contractions A baby in any position other than head down
Having the baby's shoulder get caught on the pubic bone during labor
Certain types of forceps deliveries
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FETAL VESSEL RUPTURE
Occurs in about 1 of every 1,000 pregnancies.
The baby's blood vessels from the umbilical
cord may attach to the membranes instead ofthe placenta.
The baby's blood vessels pass over the
entrance to the birth canal. This is called VASA PREVIA and occurs in 1 in
5,000 pregnancies
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PLACENTA BILOBATA
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PLACENTA SUCCENTERIATA
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DIAGNOSIS
The classic triad of the vasa praevia is:
Membrane rupture,
Painless vaginal bleeding and
Fetal bradycardia. This is rarely confirmed before delivery but may be suspected when
antenatal sono-gram with color-flow Doppler reveals a vesselcrossing the membranes over the internal cervical os.[2][3]
The diagnosis is usually confirmed after delivery on examination ofthe placenta and fetal membranes
MOST OFTEN THE FETUS IS ALREADY DEAD when the diagnosis ismade; because the blood loss (say 300ml) constitutes a major bulkof blood volume of the fetus (80-100ml/kg i.e. 300ml approx for a3kg fetus)[citation needed].
http://en.wikipedia.org/wiki/Vasa_praeviahttp://en.wikipedia.org/wiki/Vasa_praeviahttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Wikipedia:Citation_neededhttp://en.wikipedia.org/wiki/Vasa_praevia -
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THANK YOU
dr.Bambang Widjanarko, Sp OGDept.Obstetri Gynecology
School of Medicine & Health
Muhammdiyah University of Jakarta