Placenta previa Placental abruption

1. Placenta previaPlacental abruption Women’s Hospital School of Medicine Zhejiang University Wang Zhengping

2. Antepartum Hemorrhage • Third-trimester bleeding • Obstetric: Placental separation • Placental Previa • Placenta Abruption • Uterine Rupture • vasa previa : Fetal Vessel Rupture • No obstetric: Acute vaginitis/cervicitis, Cervical polyp, Cervical cancer, Trauma

3. Placenta previa

4. 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%。

5. 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.

6. 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

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

8. Classification Types of placenta previa.

9. 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

10. Central placenta previa Early(20-28wks) Large amount Several times • Total placenta previa • Early(20-28wks) • Large amount • Several times Partial placenta previa Between total and marginal Partial placenta previa Between total and marginal Marginal placenta previa Late(37-40WKS or in labor ) Less bleeding • Marginal placenta previa • Late(37-40WKS or in labor ) • Less bleeding Bleeding time and volume

11. Auxiliary examination • B-ultrasound examination • Placenta examination post partum <7cm • MRI

12. marginal placenta previa

13. partial placenta previa

14. central placenta previa

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

16. Complication of mother and fetus • Bleeding at or post partum • Implantation of placenta • Anemia and puerperal infection • Premature delivery

17. Implantation of placenta

18. 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

19. Termination of pregnancy • Indication: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

21. Transport in emergency condition In the neighborhood Initiatory management

22. Placental abruption

23. Definition Placental 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‰

24. 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

25. 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

26. Uteroplacental apoplexy: widespread extravasation of blood into the uterine musculature and beneath the uterine serosa

27. 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

28. Auxiliary examination Diagnotic examination: B-ultrasound examination Placenta examination post partum Blood Rt,Blood coagulation,blood examination of hepatic and renal function

29. Sonography

30. Differential diagnosis • Placental previa • Uterus rupture

31. Complications DIC,dysfunction of coagulation Post partum hemorrhagic/shock Amniotic fluid embolism Acute renal failure Fetal death

32. Management Treatment depends on: • Condition of the mother and fetus • Gestational age of the fetus • Cervical examination • Principle: If diagnosed,fetus will be deliveried immediately

33. Management Mature fetus Deliver Compromised mother Deliver Immature fetus Expectant, if mother stable

34. Expectant Management • Bed rest • Ongoing maternal monitoring • Fetal assessment: age, growth, well being • Deliver if recurrent signs / symptoms • Deliver at fetal maturation

35. Severe placental abruption: • Resuscitation • Evaluate and treat coagulation defect • Deliver the fetus: Cesarean section • Prevention of PPH • Monitor renal status closely

36. THANKS