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