Placenta previaPlacenta previa Placental abruption

Women’s Hospital School of Medicine Women’s Hospital School of Medicine Zhejiang UniversityZhejiang University

Wang ZhengpingWang Zhengping

Antepartum Hemorrhage

• Third-trimester bleedingObstetric: Placental separationPlacental Previa Placenta Abruption Uterine Rupturevasa previa : Fetal Vessel RuptureNo obstetric: Acute vaginitis/cervicitis,

Cervical polyp, Cervical cancer, Trauma

Placenta previaPlacenta previa

Definition• Placenta previa: The inferior edge of placenta load at

the lower uterine segment, or even reach the internal cervical os after 28 weeks gestation.

• Incidence rate: Internal ： 0.24%~1.57% ； International ： 0.5%~0.9% 。

Etiology• High-risk group

Age of gravida>35 Multipara Pregnancy women used to tobacco or dope

• Initial etiologic agnet Damage of endometria Development of the trophoblastic layer of fertilized ovum delayed Anomaly of placenta Cicatricial uterus due to cesarean

section ,e.g.

Classification Classified according to the

relationship between the edge of placenta and the internal cervical os :

complete ( central ) placenta previa partial placenta previa marginal placenta previa

Time to determine classification : the last examination before managed

(1) complete placenta previa (2) partial placenta previa (3) marginal placenta previa

Classification

Types of placenta previa.

Clinical Features Painless 、 recurrent vaginal bleeding in

the second or third trimester of pregnancy Anemia,shock or even death

corresponded to the volume of vaginal bleeding

The uterus is usually soft and relaxed Anomaly of fetal condition Per vagina examination

• Total placenta previa

• Early(20-28wks)

• Large amount

• Several times

Partial placenta Partial placenta previaprevia

Between total Between total and marginaland marginal

Marginal placenta previa Late(37-40WKS or in labor ) Less bleeding Bleeding time and volume

Central placenta previaEarly(20-28wks)Large amountSeveral times

Partial placenta Partial placenta previaprevia Between total and Between total and marginalmarginal

Marginal placenta previa Late(37-40WKS or in labor ) Less bleeding

Auxiliary examination B-ultrasound examination Placenta examination post

partum <7cm MRI

marginal placenta previa

partial placenta previa

central placenta previa

Differential diagnosis• Placental abruption• Disruption of vasa previa• Cervical polyp or erosion• Cancer of cervix

Complication of mother and fetus

Bleeding at or post partum Implantation of placenta Anemia and puerperal infection Premature delivery

Implantation of placenta

Management expectant treatment

Indication: Fewer vaginal bleeding Patient’s condition stabilization <36 weeks gestation, fetal weight<2300g

Management: Lying in bed to take a rest Inhibition of uterine contraction Treatment aim at symptoms Promote development of fetus Prevention of infection

Termination of pregnancyIndication: 1.Severe vaginal bleeding 2.Gestation age >36 weeks, or fetal lung function been matured

Mode of labor:According to the type of placenta previa,volume of vaginal bleeding and condition of gravia, et al.Cesarean delivery is necessary in practically all

women with placental previa

Transport in emergency condition

In the neighborhood Initiatory management

Placental abruption

DefinitionPlacental abruption: placenta in normal

site strip from the uterine parietal partially or completely before the fetus expulsion,after 20 weeks gestation or in the delivery procedure.

Incidence rate: 0.46%~2.1% Neonatal mortality: 200‰~428‰

Etiology Angiopathy of vasa basalis Mechanical agent Venous pressure of uterus elevated

abruptly Volume of uterus deflated abruptly Others: Age of gravida>35,multipara, tobacco,dope

Classification Classify according to vaginal bleeding or

nor: Dominant/Recessive/Mixed Classify according to severity degree: Light type ＜ 1/3 Severe type ＞ 1/3; ＞ 1/2, Dead fetus

Uteroplacental apoplexy: widespread extravasation of blood

into the uterine musculature and beneath the uterine serosa

Clinical Features Abruptly,persistent abdominal pain with

vaginal bleeding Maternal compromise/ shock(Volume of

vaginal bleeding not correspond to patient condition)

Anomaly of fetal condition The uterus touched hard with pain The size of uterus is bigger than it

should be in that gestation age

Auxiliary examinationDiagnotic examination: B-ultrasound examination Placenta examination post partumBlood Rt,Blood

coagulation,blood examination of hepatic and renal function

Sonography

Differential diagnosis

• Placental previa• Uterus rupture

Complications

DIC,dysfunction of coagulationPost partum hemorrhagic/shockAmniotic fluid embolismAcute renal failureFetal death

ManagementTreatment depends on: • Condition of the mother and fetus• Gestational age of the fetus• Cervical examinationPrinciple: If diagnosed,fetus will be

deliveried immediately

ManagementMature fetus DeliverCompromised mother Deliver Immature fetus Expectant, if mother stable

Expectant Management

• Bed rest• Ongoing maternal monitoring• Fetal assessment: age, growth, well

being• Deliver if recurrent signs / symptoms• Deliver at fetal maturation

Severe placental abruption:

• Resuscitation• Evaluate and treat coagulation

defect• Deliver the fetus: Cesarean section • Prevention of PPH• Monitor renal status closely