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Dr. Mostajeran
Obstetrical hemorrhage
•Antepartum hemorrhage
-Placental abroption
- placental previa
- vasaprevia
•Bloody show
Post partum hemorrhage
Third stage
Uterine atony
Retained placental
P- accreta increta precreta
Inversion
Laceration
Hematomas
Rapture uterus
Pregnancy – related deaths due to hemorrhage
• p – abroption 19%
• laceration – rupture 16%
•U- atony 15%
•Coagulopathies 14%
•P.previa 7%
•U-bleeding 6%
•Accreta – increta –p 6%
•Retained p – 4%
Antepartum hemorrhage
Placental abroption, abraptio placenta,
p-abruption definition separation p. sit
implantation before delivery premature
separation → differentiates p.p
External hemorrhage
Concealed hemo . (DIC . Extent H not
appreciated late diagnosis
Partial - total
Prenatal morbidity and mortality
1994 12% still birth due to p. abruption
15% infant does survive first year of life
neurological deficits
Etiology
Frequency different criteria
1.200 1.185 1.830
Recurrent abruption
Severe abruption 1.8 pregnancy's
1 to 3 weeks earlier than firs abruption
Pathology
Initiated hemorrhage into decidua basalis Decidua
splits thin layer adherent to myometrium
hematoma destruction of p adjacent.
In early stage no clinical symptoms depression few
centimeters maternal surface covered dark
clothed blood (several minutes) in some case
decidual spiral artery ruptures
Fetal to maternal hemorrhage
Non truvmatic 20% F.M- Hemor < 10 ml
Concealed hemorrhage
• Margin still remain adhevent
• Memberan retain their attachment
• Blood gain access to A.F
• Fetal head closely applied lower uterine
Clinical diagnosis
Signs and symptoms vary
Ex – bleeding ±
DIC
Back pain
U.S 25% confirmed clinical diagnosis
Shock
Thromboplactin (DIC Af embolism)
D.D
Severe P.ab diagnosis obvious
Milder more common forms difficalt
Nither lab test nor diagnostic methods
No pain previa pretermlabor
Consumptive coagulopathy
Most common p.ab
Hypophibrinogenemia (<15-mg/dl) ↑ FDP ↑
D-dimer ↓ other coagulation f in 30% p.ab
A hypofibrinogenemia ± thrombocytopenia
Renal failureIn severe p.ab (hypovolemia delayed or
incomplete)32% pregnancy with R-F had p.ab
75% ATN reversibleEven p.ab complicated → severe DIC
VigorousPrompt treatment
By blood crystalloid solution prevents renal dysfunction
proteinuria in severe p.ab?
Couvelaire uterus
1900 uteroplacental apoplexy
extravasation blood into uterine mosculature
Seldom interfere with uterine contraction
Management
Depending on gestational age
Status mother –fetus
Most clinicians live, mature fetus V.D
not imminent C.S
If diagnosis uncertain fetus alive
Without evidence f-compromise close observation
Expectant management in PT
Delaying delivery may prove beneficial (tacolytic)
Very early abrubtion frequently oligohydraminios.
With or without PROM
Lack of ominous deceleration not guarantee safety
intrauterine enviroment any period of time farther
separation compromise or kill F
C.S F. distress
F. death bleeding or other obstetrical
Complication to prevent V.D
Vaginal delivery
Amniotomy mature DIC
Oxytocin
Hypertonus characterizes myo-function
If no rhytmic uterin contraction → oxytocin
Placenta previa
Placenta previa
Placenta located over or near in – os
1. Total p.previa
2. Partial p.previa
3. Marginal p.p edge of p at margin of in – os
4. Low – lying placenta p.edge does not reach in –as but close
Vasa previa p.vessels course through membranes and present at cervical os
Incidence 1.300
Prenatal morbidity and mortality
•Preterm delivery
Neonatal mortality rate three fold high
500000 singleton births relationship previa
FGR PTL found L - Birth weight is due to
PT and lesser to found G - impairment
Etiology •Advance M-age
1.1500 19 years of age1.100 older than 35
•Multiparity para 5 or greather•Prior cesarean delivery
With two prior c.delivery 1.9%With three or more c. delivery 4.1
Para>4 >4 cesareans > 8 fold previaRepeat c+ previa →c.hysterectomy 25%
Primary cesarean + previa → c.hysterectomy 6%* Smoking ↑ Two fold
Clinical finding
Painless hemorrhage near end second
trimester or later
Without warning
Initialy bleeding rarely so profuse
Cause hemorrhage formation L.U.Segment,
dilatation in-os
Placenta accreta, increta, and precreta
Poorly development deciduas in L-segment
(7%)
Coagulation defects
Is rare with p.previa
Thromboplastin escapes cervical canal
Diagnosis
U. Bleeding later half of pregnancy
P. Previa seldom establish clinical exam
V.E finger pass cervix → p.palpated →
torrential Hemorr
Planned delivery
Doubel set up
Automibile accidents
1_3% pregnant woman
Fetal injury and death
direct fetal placental injury
M_ shock
pelvic fracture
Maternal head injury
hypoxia
Fetal death →trauma
82% motor vehicle crashes
50% placenta injury
4% uterine rupture
Placental abruption and uterine rupture and placental tear
traumatic placental abruption
1-6% minor injuries some degree of abruption
50% major injury
Management
1. Fetus preterm no indication for delivery
2. Fetus reasonably mature
3. Those in labor
4. Hemorrhage so severe
Preterm fetus no active bleeding
Close observation
Her family must fully appreciate problem
P.P
Delivery
C.S All women with P.P
Most often transverse U-incision
Sometimes vertical incision