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dr. Udin Sabarudin, SpOG, MMdr. Udin Sabarudin, SpOG, MM
Depart. of Obstetrics - Gynecology Padjadjaran University / Hasan Sadikin
HospitalBANDUNG
OBSTETRICAL HEMORRHAGE
Bleeding before 20 weeks of pregnancy
Antepartum hemorrhage
Post partum hemorrhage
Cause of vaginal bleeding at the third trimester
Rupture of vaginal varicose
Laceration of vagina or cervix
Placenta previa
Abruptio placentae
ANTEPARTUM HEMORRHAGEANTEPARTUM HEMORRHAGE
Placenta Previa
Abruptio placentae
Normal implantation of the placenta
Normal implantation of the placenta
Fundal Corpus
Front Behind
Implantation at the lower segment
Implantation at the lower segment
PLACENTA PREVIA :
DEFINITION :
Placenta is located over or very near the internal os
Prae : FrontVias : Route
FOUR DEGREES OF THIS ABNORMALITY
1. Total placenta 1. Total placenta previaprevia
The internal cervical The internal cervical os is covered os is covered completelycompletely
2. Partial placenta 2. Partial placenta previaprevia
The internal cervical The internal cervical os is partially os is partially coveredcovered
A BA B
FOUR DEGREES OF THIS ABNORMALITY
3. Marginal placenta previa3. Marginal placenta previa
The edge of placenta is at The edge of placenta is at the margin of the the margin of the internal osinternal os
2. Low lying placenta2. Low lying placenta
The placenta is implanted The placenta is implanted in the lower uterine in the lower uterine segment such that the segment such that the placental edge actually placental edge actually does not reach the does not reach the internal os but is in internal os but is in close proxymity to itclose proxymity to it
A BA B
VASA PREVIA :
The fetal vessels course through membranes and present at the cervical os
Uncommon cause of antepartum hemorrhage, associated with a high rate or fetal death
THE DEGREE OF PLACENTA PREVIATHE DEGREE OF PLACENTA PREVIA
Depend on large measure on the cervical dilatation at the time of examination
Eg. Low lying placenta at 2 cm dilatation may become a partial placenta previa at 8 cm dilatation because the dilating cervix has uncovered placenta
BLEEDING >>> !!!
Total placenta previa
Marginal placenta previa
Placenta
cervix
CHANGING THE DEGREE OF P.PCHANGING THE DEGREE OF P.P
Marginal
Amnion (+)Amnion (+)
Lateral
Dilatation >
Amnion
Bleeding
Retracted
DilatationDilatation
Lower segmen
Cervix
Bleeding
Lower Lower segmensegmen
Partial placenta previa
BLEEDING >>>
BLEEDING >
> 1/2 O
< 1/2 O
PREDISPOSING FACTOR :PREDISPOSING FACTOR :
Multipara, with interval <
Fibroids
Habitual abortion
CLINICAL FINDINGS :CLINICAL FINDINGS :
Hemorrhage : Frequent
Usually does not appear until near the end of the second trimester or after
Painless Spontaneously Initial bleeding is rarely
profuse as to prove fatal
Lacunae
Maternal vessels
HAFT ZOTE
Fetal vessels
CLINICAL FINDINGS :CLINICAL FINDINGS :
Oblique or lie position
Presenting part - high
DIAGNOSIS :DIAGNOSIS :
Speculum
Fornix palpation
Double set up examination at the operating room
USG
WARNING :WARNING :
Digital palpation to try to ascertain changing relations between the edge of the placenta and the internal os as the cervix dilates can incite severe hemorrhage
Examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean section
MANAGEMENT :MANAGEMENT :
Active : Termination
Vaginally CS
Expectative : Depend on maturity
(< 37 weeks ; < 2500 gr) Bleeding Maternal condition
VAGINAL DELIVERY :VAGINAL DELIVERY :
Amniotomy tamponade
Braxton Hicks version
Cunam Willet
TAMPONADE BY PRESENTING PART
Placenta
Cervix
In tact
Amnion
Amnion (+)
Head press the placenta
Head Head Breech Breech
CUNAM-WILLETT
PLACENTAL PLACENTAL ABRUPTION :ABRUPTION :
DEFINITION :DEFINITION :
The separation of the placenta
from its site of normal implantation
before the delivery of the fetus
after 22 weeks of pregnancy
SINONYM :SINONYM :
Accidental hemorrhage
Abruptio placentae
Solutio placentae
Ablatio placentae
Premature separation of the
normally implanted placenta
PATHOLOGYPATHOLOGY
Hemorrhage into the decidua basalis
Decidua then splits, leaving a thin layer adherent to the myometrium
Decidual hematoma
Separation, compression and the ultimate destruction of the placenta adjacent to it
TYPE :TYPE :
Concealed hemorrhage separated completelly freq 20% fatal
External hemorrhage incomplete freq 80%
CONCEALED HEMORRHAGE
EXTERNAL HEMORRHAGE
COMBINED
ETIOLOGY :ETIOLOGY :
Hipertension Trauma Multiparity Folic acid deficiency Hidramnion ; gemelly Umbilical cord - short
CLINICAL DIAGNOSIS :CLINICAL DIAGNOSIS :
Hemorrhage with pain
Fetal - Not palpable
Heart beat - not
detected
Uterine hypertonus
Anemi shock
Amnion bulging
COMPLICATION :COMPLICATION :
Early : - Hemorrhage- Shock
Late : - Consumtive coagulopathy
- Hypofibronogenemia- Utero placental
apoplexy (couvelaire uterus)
- Renal failure
MANAGEMENT :MANAGEMENT :
Depend on status of the mother & Depend on status of the mother &
fetus:fetus:
Transfusion
Electrolyte solution
Corticosteroids
Fibrinogen
OBSTETRIC MANAGEMENT :OBSTETRIC MANAGEMENT :
Amniotomi Oxytocin infusion Cesarean section :
Fetus alive Cervix not dilated 2 hours after oxytocin
infusion uterine contraction (-)