醫(yī)學(xué)專題-LatePregnancyBleeding晚期妊娠流血

第一頁，共二十九頁。編輯課件第二頁，共二十九頁。編輯課件ImportanceMaternalRisksAcutehemorrhageOperativedeliveryFetalRisksUteroplacentalinsufficiencyPrematurebirthKeyPointsIdentifythecauseTimelyintervention第三頁，共二十九頁。編輯課件InitialAssessmentHistoryAmountofbleeding,recentintercourseordigitalexam,severityofpain,traumaPhysicalexamVitalsigns,speculum,digitalonlyifnoplacentaprevia,maynotecervicitis/polyp/cancerUltrasoundEvaluationforplacentapreviaPeriodofobservation第四頁，共二十九頁。編輯課件InitialManagementofSignificantBleedingHemodynamicinstabilityHypotensionTachycardiaIVfluidsConsiderbloodproducts/transfusionLabtestsHematocrit,platelets,fibrinogen,coagulation,bloodtype,andantibodyscreenContinuousfetalmonitoringConsideremergentcesareansection第五頁，共二十九頁。編輯課件PlacentaPreviaCompleteCoverstheinternalcervicalosMarginalEdgelieswithin2cmofinternalcervicalosLowlyingEdgelies2–3.5cmfromtheinternalos第六頁，共二十九頁。編輯課件第七頁，共二十九頁。編輯課件PlacentaPrevia(continued)Notedinmid-pregnancyin40/1000pregnanciesAtterm,only4/1000BestvisualizedwithtransvaginalultrasoundRiskfactorsIncreasedageIncreasedparityTobaccouseIncreasingnumberofcesareandeliveries第八頁，共二十九頁。編輯課件PlacentaPrevia(continued)Presentation“painlessbleeding”O(jiān)ften“sentinelbleed”inthelate2ndorearly3rdtrimesterOftenaftersexualintercourse第九頁，共二十九頁。編輯課件PlacentaPrevia(continued)ManagementGoalistopromotefetallungmaturityAdmittohospitalinitiallyAdministersteroidsif24-34weeksgestationConsidertocolyticsOutpatientmanagementinselectedsituationsSerialultrasoundsIfdoesnotresolve,cesareandeliveryatterm第十頁，共二十九頁。編輯課件PlacentaPrevia(continued)ModeofdeliveryIfunstable,immediatecesareandeliveryIfstable,ultrasoundat36weeksIfplacentaledge>2cmfromos,vaginaldeliveryIfplacentaledge1-2cmfromos,mayattemptvaginaldeliveryifoperatingroomnearbyIffetallungsaremature,cesareanforcompletepreviaIfhistoryofcesarean,evaluateforinvasiveplacentaColorflowDopplerMRIIfconfirmed,prepareforpossiblecesarean/hysterectomy第十一頁，共二十九頁。編輯課件第十二頁，共二十九頁。編輯課件PlacentalAbruptionSeparationofplacentafromuterinewallMostcommoncauseofseriousbleeding1%ofpregnanciesNeonatalmortalityis10-30%50%ofabruptionsoccurpriorto36weeksgestation第十三頁，共二十九頁。編輯課件第十四頁，共二十九頁。編輯課件第十五頁，共二十九頁。編輯課件PlacentalAbruption(continued)RiskfactorsSmokingtobaccoCocaineuseChronichypertensionPreeclampsiaThrombophiliasAbdominaltraumaHistoryofabruptioninpreviouspregnancy第十六頁，共二十九頁。編輯課件PlacentalAbruption(continued)ClinicalPresentationBleedingUterinetendernessorbackpainFetaldistressPretermlaborIntrauterinefetaldeathDisseminatedintravascularcoagulationRecurrentbleeding,pain,contractions第十七頁，共二十九頁。編輯課件PlacentalAbruption(continued)ManagementStabilizethemotherAssessfetalwell-beingUltrasoundisnotreliableSeriallabs(Hctandcoagulationstudies)Rarely,administercorticosteroidsRAPIDDELIVERY!第十八頁，共二十九頁。編輯課件PlacentalAbruption(continued)PreventionNotobaccouseNoillegaldrugusePropermanagementofHTNinpregnancy第十九頁，共二十九頁。編輯課件第二十頁，共二十九頁。編輯課件VasaPreviaInsertionoftheumbilicalcordintotheamnioticmembranesintheloweruterinesegmentResultsinfetalvesselsbetweenthecervixandthepresentingpart1in2500births33to100percentperinatalmortality第二十一頁，共二十九頁。編輯課件第二十二頁，共二十九頁。編輯課件第二十三頁，共二十九頁。編輯課件VasaPrevia(continued)RiskfactorsInvitrofertilizationPlacentapreviaMulti-lobedplacentas第二十四頁，共二十九頁。編輯課件VasaPrevia(continued)PresentationHemorrhageatthetimeofamniotomyorspontaneousruptureofmembranesExsanguinationoffetalbloodcanoccurrapidly第二十五頁，共二十九頁。編輯課件VasaPrevia(continued)ManagementIffetalwell-beingisnotreassuring,orifhemorrhageissevere,RAPIDDELIVERY!Iffetalhearttonesarereassuring,APTtestcanbeperformed第二十六頁，共二十九頁。編輯課件第二十七頁，共二十九頁。編輯課件ReferencesSakornbut,E,Leeman,L,Fontaine,P“LatePregnancyBleeding”AmericanFamilyPhysician,Vol7