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  1. 1. Antepartum haemorrhage Qu Quanxin Tianjin First Centre Hospital
  2. 2. Definition and Classification Definition The volume of bleeding from vagina occurs at any time of pregnancy and before the birth of the child. Classification Placenta praevia Abruptio placenta
  3. 3. Causes of 763 Pregnancy-related Deaths Due to Hemorrhage   32 (4) Retained placenta 44 (6) Placenta accreta/increta/percreta 47 (6) Uterine bleeding 50 (7) Placenta previa 108 (14) Coagulopathies 115 (15) Uterine atony 125 (16) Laceration/uterine rupture 141 (19) Placental abruption Number (%) Causes of Hemorrhage
  4. 4. Placenta Praevia
  5. 5. Definition The condition that the placenta is wholly or partly attached to the lower uterine segment Classification Type I Type II Type III Type IV
  6. 10. Etiology <ul><li>Advancing maternal age </li></ul><ul><li>Multiparity </li></ul><ul><li>Prior cesarean section </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Smoking </li></ul>
  7. 11. Pathology The incidence of placenta praevia is 0.5%, bleeding from a placenta praevia is about 20% of all cases of antepartum hemorrhage . <ul><li>Maternal influence </li></ul><ul><li>Haemorrhage </li></ul><ul><li>Shock </li></ul><ul><li>Anemia </li></ul><ul><li>Fetal influence </li></ul><ul><li>Distress or death </li></ul><ul><li>IUGR </li></ul><ul><li>Premature </li></ul><ul><li>Neonatal death </li></ul>
  8. 12. Signs and symptoms During the trimester of pregnancy Slight or severe bleeding from the vagina without evident cause and without any pain on the abdomen. During delivery Severe haemorrhage is inevitable as the cervix dilates, especially in type I and type II. During the third stage of labour Postpartum haemorrhage
  9. 13. <ul><li>Diagnosis </li></ul><ul><li>History </li></ul><ul><li>Signs and symptoms Repeated bleeding from vagina without pain. There is no tenderness on the abdomen. The fetal heart sounds are present and normal. </li></ul><ul><li>Examination The vaginal examination must be avoided. Ultrosonograph. </li></ul><ul><li>Inspect after vaginal delivery (The distance from the ruptured situs of membranes to the edge of the placenta < 7cm) </li></ul>
  10. 14. <ul><li>Therapy </li></ul><ul><li>The appropriate treatment for the placenta praevia should depend on the type and the gestational age of the fetus. </li></ul><ul><li>Type I Caesarean section </li></ul><ul><li>Type II Caesarean section </li></ul><ul><li>Type III Delivery from vagina </li></ul><ul><li>Type IV Delivery from vagina </li></ul>
  11. 15. Abruptio placentae
  12. 16. Definition and Classification Definition The separation of the placenta from its site of implantation before delivery has been variously called placental abruption, or abruptio placentae Classification Revealed Hemorrhage Concealed Hemorrhage
  13. 17. Frequency <ul><li>The frequency for placental abruption averages about 1 in 200 deliveries. </li></ul>
  14. 18. Significance <ul><li>Maternal The maternal mortality may exceed 10% in severe cases. The chief causes are DIC, shock and renal function failure </li></ul><ul><li>Fetus The perinatal mortality is over 50%. The chief causes are asphyxia caused by placental separation and preterm delivery. </li></ul><ul><li>Infant adverse sequence such as neurological deficits (cerebral palsy ) </li></ul>
  15. 19. Etiology Hypertension Proteinuria Folic acid deficiency Trauma
  16. 20. Risk Factors for Placental Abruption 10-25 Prior abruption 37 Thrombophilias 1.4-1.9 Cigarette smoking 2.0 Hydramnios 2.1 Multifetal gestation 2.4-4.9 Preterm ruptured membranes 1.8-3.0 Chronic hypertension 2.1-4.0 Preeclampsia 1.3-1.5 Increased age and parity Relative Risk Risk Factor
  17. 21. Pathology Revealed hemorrhage The bleeding may track down between the membrane and the wall of the uterus and escape at the cervix Concealed hemorrhage The blood remain inside the uterine cavity
  18. 23. CONCEALED HEMORRHAGE <ul><li>There is an effusion of blood behind the placenta but its margins still remain adherent </li></ul><ul><li>The placenta is completely separated yet the membranes retain their attachment to the uterine wall </li></ul><ul><li>Blood gains access to the amnionic cavity after breaking through the membranes </li></ul><ul><li>The fetal head is so closely applied to the lower uterine segment that the blood cannot make its way past it </li></ul><ul><li>Most often, however, the membranes are gradually dissected off the uterine wall, and blood sooner or later escapes. </li></ul>
  19. 24. Signs and symptoms Revealed hemorrhage The patients often appear bleeding from the vagina without any obvious signs and symptoms or just slight abdominal discomfort and tenderness over the placental site. The size of uterus is accordant with the period of gestation reached.
  20. 25. Concealed hemorrhage The patient often complains of a sudden attack of abdominal pain and at the same time feels faint and suffers from nausea. When abdominal examination is done, the uterine tenderness is discovered. In severe cases, shock often occurs and the degree of shock is out of all proportion to the external loss. The uterus may be larger than would be expected for the period of gestation. The fetal outline cannot be made out and the fetal heart sounds become inaudible, even cannot be heard.
  21. 26. Diagnosis Revealed hemorrhage The history, signs and symptoms and ultrasound investigation help diagnosis. If the case is questionable, the vaginal examination must not be done in order to avoid severe bleeding. Concealed hemorrhage Ultrasound investigation of the uterus can provide invaluable in the diagnosis of concealed accidental hemorrhage since the retroplacental clot can often be visualized.
  22. 27. <ul><li>Prognosis </li></ul><ul><li>Maternal The maternal mortality may exceed 10% in severe cases. The chief causes are DIC, shock and renal function failure </li></ul><ul><li>Fetus The perinatal mortality is over 50%. The chief causes are asphyxia caused by placental separation and preterm delivery. </li></ul>
  23. 28. <ul><li>Treatment </li></ul><ul><li>Revealed haemorrhage </li></ul><ul><li>Concealed haemorrhage </li></ul><ul><li>Treatment after the labour </li></ul>Vigorous transfusion and prompt delivery
  24. 29. Differentiate between abruptio placenta and placenta praevia The distance <7cm The old clotting behind the placenta Ultrasonography   No Normal or abnormal No   Often exist, especially on the lesion site Often abnormal or disappear Obviously on the site of placenta bleeding Signs and symptoms Pain on abdomen   Fetal heart rate Tenderness Multiparity, multiple gestation, prior cesarean section Hypertension, Trauma History Placenta praevia Abruptio placenta
  25. 30. Questions <ul><li>About definition placenta previa, abruptio placenta </li></ul><ul><li>What are the clinical characteristics of placenta previa, abruptio placenta? </li></ul><ul><li>How to differentiate between placenta previa and abruptio placenta? </li></ul><ul><li>What are the principle of treatment for these two diseases? </li></ul>
  26. 31. Questions <ul><li>A pregnant client who reports painless vaginal bleeding at 28 weeks’gestation is diagnosed with placenta previa. The placenta edge reaches the internal os. This type of placenta previa is known as which of the following </li></ul><ul><li>A.Low-lying placenta previa </li></ul><ul><li>B.Marginal placenta previa </li></ul><ul><li>C.Partial placenta previa </li></ul><ul><li>D.Total placenta previa </li></ul>
  27. 32. Questions <ul><li>A pregnant client complaints slightly vaginal bleeding at 32 weeks’gestation with severe abdominal pain. Ultrosound shows the placenta locates at the fundus of the uterus. Then the diagnosed may be </li></ul><ul><li>A.Low-lying placenta previa </li></ul><ul><li>B.Marginal placenta previa </li></ul><ul><li>C.Partial placenta previa </li></ul><ul><li>D.Abruptio placenta </li></ul>