Dr Hisham Al-rahahla · Def. : Bleeding from the genital tract between 28th weeks of preg. onset of...
Transcript of Dr Hisham Al-rahahla · Def. : Bleeding from the genital tract between 28th weeks of preg. onset of...
Def. :
Bleeding from the genital tract
between 28th
weeks of preg. &
onset of labour .
(28 weeks was the limit of fetal
viability)
C.E.M.D.
M.M. :
- Inadequate resuscitation.
- Inexperienced doctors & delay
in senior staff responding to
calls for help.
Mx. Of massive
obstetric Hge
1. Summond help.
2. Take bl. For xmatch, coag. Studies.
3. Transfusion of bl.
4. At least 2 periph. Lines.
5. Facilities that should be available
(CVP, intraant. press., ECG, ABG) .
6. Discuss with haemotologist.
7. Rapid infusion: compression calf,
blood warming. No need for
filtration.
General Principles of
Mx.
- Maternal & fetal condition must be
assessed.
- Maternal resuscitation must be
started promptly .
- Consideration must be given to early
delivery if there is evidence of fetal
distress & if baby is of sufficient
maturity to survive .
- V/E by speculum or digitaly must be
postponed till PP is R/O by U/S .
- Anti D .
Placenta Praevia
Def. :
Placenta situated wholly or
partially within the L. Segment
at or after 28 weeks.
Incidence :
0.55% range (0.29 – 1.24%)
follows def.
PNM 81/1000 . 22% due to
RDS. MM is rare but morbidity
hosp. & C/S.
Classification :
Helps in Mx. 6 types of class. But
follow U/S classification.
Types :
I Low lying, within 5 cm. of the OS
II Marginal
III Partial, partially covering the OS
IV Total , completely covering the OS
Etiology & Ass. Factor
• Cause unknown but certain factors
predispose to it :
1. Parity ranges from 0.2% to 5% .
2. Mat. Age increase with age 3
X > 35 yrs.
3. Ethnic origin: slightly higher
in blacks.
4. Placental size more in twin .
5. Endometrial damage .
6. Preterm del. 2.9% 28-37 weeks.
7. Previous C/S increased in linear way
mainly in the preg. Following.
8. Smoking & compersatory pl. enlargement.
9. Ut. Scars & path. Myomectomy, submuc.
Fibroid, ut. Adhesions.
10. Pl. pathology: marginal or vilamentous
cord insertion, succinaturate lobe
11. Previous p.p. recurrence 4 – 8% .
Associated Preg.
Complications
• Spont. Abs.
• PIH protective
(prematurity).
• Abn. Placentation (acreta).
Increased esp. with previous C/S
• Malpresentation (breech/TV lie)
• SGA conflicting !? No difference.
Diagnosis :
1/3 are asymptomatic.
Routine Dx. :
U/S abdo. 93-97% accuracy .
false -ve 7%
Vag. U/S Better resolution
less false -ve
rarely is essential (obesity-post
placenta)
Management
Basics :
- No V/E.
- Prolongation of preg till
maturity.
- Transfusion support .
- Delivery by C/S .
The av. time of complication is 35 wks.
* If starts earlier PNM
The Asymptomatic Pt.
1/3 of pts. with PP
1. ? Admission in the last trimester.
2. Serial rescanning till 38 wks.
Particularly I & II
3. Maintain Hb at higher N. limits.
4. Del. By C/S for all II, III, IV not
before 37 weeks.
Type I rescan at 36-37 wks. If BPD
is below loweredge of placenta
allow labour .
The Symptomatic Pt.
Depend on 2 factors :
* Fetal maturity .
* Degree of hge.
Deliver immediately :
Any bleeding at :
* Fetal maturity.
* Fetal distress at viable gest.
* Persistent hge.
Initial Mx.
• Assess maternal CVS followed
by fetal assessment .
• IV 16 gauge cannula .
• Hb., x match, clotting studies.
• Crystalloid, calloid if heavy loss.
• Fetal monitoring (at viable gestation
means possible C/S at fetal
compromise)
Tocolytics ?? Be careful time to give
steroids.
nefidipine MgSO4 NSAI
Cx. cerclage
• Vasa Praevia rare .
Vag. Blood can be tested for
fetal Hb.
Women stabilized following a
bleeding episode at any time should
be hospitalized for the rest of their
preg.
? Social stress
PPH Suspect, ut. Atony
synto, carboprost., ut. artery
lig. Hystrectomy.
transfusion
Anaesthesia : G.A.
LSCS : If placenta is ant. Avoid
cutting through it. No place for
double set up examination.
Abruptio Placenta
Def. :
Premature separation of a
normally sited placenta. It is a
self extending process.
Causes :
Unknown
Causes :
• Hypertension.
• The “sick placenta” .
mid trimester FP with fetal abn.
IUGR, prem labour & pl. abruption.
( uteropl. Doppler waveform )
not screening
3. Trauma , usually RTA
ECV & cordocentesis.
4. Fibroid
5. Cocaine still uncertain.
6. Rupture of memb. Esp. in
polyhydramnios .
7. F.A. def. : evidence not
convincing.
8. Multiple preg. Cause unclear.
9. Chorioamnioritis esp. with
PROM .
Clinical Presentation :
• Bleeding Concealed
revealed
• Pain Continuous
intermittent labour
Dx. :
Clinical
Confirmed after del.
U/S minimal role .