Zareh.F.MD
description
Transcript of Zareh.F.MD
![Page 1: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/1.jpg)
Zareh.F.MD
![Page 2: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/2.jpg)
All bleeding during
pregnancy should be
investigated by examination
and imaging studies
![Page 3: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/3.jpg)
• 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.
![Page 4: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/4.jpg)
etiologies
• Placenta previa• Placenta abruption• Vasa previa• Cervical lesions (carcinoma,polyps)• Vaginal laceration
(trauma,carcinoma)• Uterine rupture or dehiscence
![Page 5: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/5.jpg)
![Page 6: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/6.jpg)
Placenta previaincidece
• 0.5-1% of all pregnancies
• Fatal 0.03% of cases
• Incidence in multipar :1/20
• Incidence in nulipar : 1/1500
![Page 7: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/7.jpg)
difinition• Dillated cervix:
complete previa partial previa
marginal previa low lying
• Closed cervix:complete
partial / marginal<1 cm from int.os1-2 cm from int.os>2 cm from int.os
![Page 8: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/8.jpg)
![Page 9: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/9.jpg)
![Page 10: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/10.jpg)
![Page 11: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/11.jpg)
![Page 12: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/12.jpg)
pathophysiology
• Abnormal endometrial tissue less favorable location for implantation: poor vascularization thinner myometrium
• Uterine trauma from c/s (6 fold)
![Page 13: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/13.jpg)
Risk factors• Perior c/s
• Black , minority
• Older women >35 y
• High gravidity & parity
• Cigarette smoking 2.6-4.4 fold
• Previous abortion
![Page 14: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/14.jpg)
diagnosis
• Abdominal sonographymisdiagnosis :
full distended bladderlower 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
![Page 15: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/15.jpg)
Clinical features
• Asymptomatic
• Vaginal bleedingvariableintermittentred to brownish
maternal origin
• the fetus usually not in jeopardy
![Page 16: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/16.jpg)
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
![Page 17: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/17.jpg)
Other complications
• A.T.N• Sheehan syndrome• Maternal mortality<1% • Perinatal mortality <5%
![Page 18: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/18.jpg)
outcome• IUGR ?
• Preterm birth
• Congenital anomaly
• Respiratory distress syndrome
• Anemia
• Recurrence rate 2-3%(6-8 fold)
![Page 19: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/19.jpg)
management
no bleeding• 2nd trimester
intercourse avoidusual activityrepeat sonography
• 3rd trimester decrease physical activity travel away from home
prolonged bed rest
![Page 20: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/20.jpg)
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
![Page 21: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/21.jpg)
management
Severe hemorrhage• Medical team for immediate
delivery• 2 large bore IV line• Blood cross match• Foley catheter• Coagulation panel• Continuous Fetal monitoring• delivery
![Page 22: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/22.jpg)
![Page 23: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/23.jpg)
Premature separation of placenta.
• 0.5-1% of deliveries
• Perinatal mortality is 20-25%
• Preterm birth is 40%
• Cause of 15% of stillbirth
![Page 24: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/24.jpg)
Definition
Preplacental or subamniotic
![Page 25: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/25.jpg)
![Page 26: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/26.jpg)
![Page 27: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/27.jpg)
retroplacental
![Page 28: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/28.jpg)
Risk factors
Socioeconomic:• High parity
• low education
• infertility
![Page 29: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/29.jpg)
Risk factors
Uterine:• ut.malformation
• ut.septum
• Myoma
![Page 30: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/30.jpg)
Risk factors
Medical:• Diabete pregestational
• Hypertension _chronic&gestational
• PROM with chorioamnionitis
![Page 31: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/31.jpg)
Risk factorsThrombophilias
• Antiphospholipid syndrome
• Prothrombin 20210A mutation
• Hyperhomocysteinemia
• Factor V leiden mutation
• Activated protein C resistance
• Protein C and S deficiency
• dysfibrinogenemia
![Page 32: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/32.jpg)
Risk factor iatrogenic• Sudden decompression(amniocentesis)
• External cephalic version
• Cigarette smoking
• Cocaine abuse
• Blant trauma
• Heavy physical activity
![Page 33: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/33.jpg)
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
![Page 34: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/34.jpg)
Pathophysiologycont.
• 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
![Page 35: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/35.jpg)
diagnosis Clinically• vaginal bleeding
• Uterine pain• tetanic contraction
• fetal heart abnormality
sinusoidal pattern
![Page 36: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/36.jpg)
diagnosis Paraclinic• Ultrasound • MRI• Doppler • Biochemical testUnexplained elevated of MSAFP AP>10
foldPreterm labor+AFP>2MoM = AP (67%)Preterm labor+AFP>2MoM+bleeding= AP
(100%) HCG Inhibin A Fetal Hb
![Page 37: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/37.jpg)
![Page 38: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/38.jpg)
management• Marginal Abruptio
hospitalize a patient with any bleeding after fetal viability
• Large retroplacentalusually require acute &
aggressive management
![Page 39: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/39.jpg)
Large bleeding
• Continues fetal monitoring
• Foley catheter
• Frequent maternal v/s
• Steroid therapy (24-34w , membrane intact)
• Folic acid 1mg ,vit B12 ,vit B6
![Page 40: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/40.jpg)
discharge• Mild bleeding : 2-5 days without any further bleeding
• Large bleeding :decision is difficult
with any bleeding , pain , contraction no discharge
![Page 41: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/41.jpg)
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
![Page 42: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/42.jpg)
Which tocolytic
• B mimetics (terbut,ritod): mask cardiovascular response to volume depletion
• Ca channel blockers (nifidipine): reduce BP
• Mgso4 : most acceptable agents
![Page 43: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/43.jpg)
delivery
Vaginal or c/s Depending on the: Degree of bleeding Presence or absence of: Active labor Fetal distress
![Page 44: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/44.jpg)
complications
• c/s 50% of case
• Shock
• DIC
• Renal failure
• Couvelaire uterus
• Recurrence : 10 fold
![Page 45: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/45.jpg)
Fetal outcome
• Mortality: term babies 25 fold
• Prematurity: 40%
![Page 46: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/46.jpg)
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
![Page 47: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/47.jpg)
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
![Page 48: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/48.jpg)
hyperhomocysteinemia
Methionine metabolise
homocysteine damage
vascular Remethylate MTHFR endothelium
folate vit.B12 , vit. B6
Methionine
![Page 49: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/49.jpg)
![Page 50: Zareh.F.MD](https://reader036.fdocuments.us/reader036/viewer/2022062422/56813d54550346895da711bf/html5/thumbnails/50.jpg)