Dr. Mostajeran

1. In the name of God Dr. Mostajeran

2. Obstetrical hemorrhage • Antepartum hemorrhage • Placental abroption • placental previa • vasaprevia • Bloody show

3. Post partum hemorrhage • Third stage • Uterine atony • Retained placental • P- accreta increta precreta • Inversion • Laceration • Hematomas • Rapture uterus

4. 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%

5. Antepartum hemorrhage

7. 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

8. Prenatal morbidity and mortality • 1994 12% still birth due to p. abruption • 15% infant does survive first year of life neurological deficits

9. Etiology

10. 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

11. 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

12. Fetal to maternal hemorrhageNon 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

14. Clinical diagnosis • Signs and symptoms vary • Ex – bleeding ± • DIC • Back pain • U.S 25% confirmed clinical diagnosis • Shock • Thromboplactin (DIC Af embolism)

15. D.D • Severe P.ab diagnosis obvious • Milder more common forms difficalt • Nither lab test nor diagnostic methods • No pain previa pretermlabor

16. Consumptive coagulopathy • Most common p.ab • Hypophibrinogenemia (<15-mg/dl) ↑ FDP ↑ D-dimer ↓ other coagulation f in 30% p.ab • A hypofibrinogenemia ± thrombocytopenia

17. Renal failure • In severe p.ab (hypovolemia delayed or incomplete) • 32% pregnancy with R-F had p.ab • 75% ATN reversible • Even p.ab complicated → severe DIC • Vigorous • Prompt treatment • By blood crystalloid solution prevents renal dysfunction • proteinuria in severe p.ab?

18. Couvelaire uterus • 1900 uteroplacental apoplexy • extravasation blood into uterine mosculature • Seldom interfere with uterine contraction

19. 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

20. 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

21. Vaginal delivery • Amniotomy mature DIC • Oxytocin • Hypertonus characterizes myo-function • If no rhytmic uterin contraction → oxytocin

23. Placenta previa

24. Placenta previa • Placenta located over or near in – os • Total p.previa • Partial p.previa • Marginal p.p edge of p at margin of in – os • Low – lying placenta p.edge does not reach in –as but close • Vasa previa p.vessels course through membranes and present at cervical os

25. 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

26. Etiology • Advance M-age • 1.1500 19 years of age • 1.100 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 previa • Repeat c+ previa →c.hysterectomy 25% • Primary cesarean + previa → c.hysterectomy 6% • * Smoking ↑ Two fold

27. 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

28. Placenta accreta, increta, and precreta • Poorly development deciduas in L-segment (7%) • Coagulation defects • Is rare with p.previa • Thromboplastin escapes cervical canal

29. 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

30. Automibile accidents • 1_3% pregnant woman Fetal injury and death direct fetal placental injury M_ shock pelvic fracture Maternal head injury hypoxia

31. Fetal death →trauma • 82% motor vehicle crashes • 50% placenta injury • 4% uterine rupture

32. Placental abruption and uterine rupture and placental tear • traumatic placental abruption • 1-6% minor injuries some degree of abruption • 50% major injury

33. Management • Fetus preterm no indication for delivery • Fetus reasonably mature • Those in labor • Hemorrhage so severe

34. Preterm fetus no active bleeding • Close observation • Her family must fully appreciate problem P.P

35. Delivery • C.S All women with P.P • Most often transverse U-incision • Sometimes vertical incision