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1、Placetal Previa,Long Xiaoyu 龍曉宇XuanWu Hospital宣武醫(yī)院,Case,1. 30 G3P2 at 32 weeks’ gestation, painless vaginal bleeding. Four weeks ago , postcoital vaginal spotting2. BP:110/70mmHg ,abdom

2、en is soft uterus nontender , FHR :140-150bpm,Case 1,,What is most likely diagnosis?,What is your next step?,Long-term management of this patient?,,,,What are the most common causes of Antepartum Hemorrhage ?,COMMO

3、N CAUSES,Placenta PreviaPlacental AbruptionPreterm labor,UNCOMMON CAUSES,Uterine rupture Fetal(chorionic ) vessel rupture Cervical or vaginal lacerations Cervical or vaginal lesions, including cancer Congenital ble

4、eding disorder Unknown ( by exclusion of the above),Placental Previa,Understand that placenta previa and placental abruption are major causes of antepartum hemorrhage Know the painless vaginal bleeding is consistent

5、 with placenta previaUnderstand that the ultrasound examination is a good method for assessing placental location,Objectives,Defined as the inferior edge of placenta load at the lower uterine segment, or even reach th

6、e internal cervical os after 28 weeks gestation.Incidence rate: Internal：0.24%~1.57%； International：0.5%~0.9%。,Placental Previa,“ the placenta overlying the internal os of the cervix”,Classification,Class

7、ification,Complete(central ) placenta previaPartial placenta previaMarginal placenta previa Low-lying placenta previa,What are the risk factors for placental Previa?,Question,ETIOLOGY,Increased maternal ageUterine fa

8、ctors:Previous CSInstrumentation of the uterine cavity (D and C for miscarriages or Induced Abortions)Placental factors:MultiparityMultiple gestation Prior placenta previa,ETIOLOGY,Manifestation It charact

9、eristically presents with unprovoked and repeated painless vaginal bleeding.,Clinical Presentation,Manifestation,The classification of previa placenta sometimes determines the occurrence period and the volume of losing

10、 blood.,,Total placenta previaEarly(20-28wks)Large amountSeveral times,Partial placenta previa Between total and marginal,Bleeding time and volume,Central placenta previaEarly(20-28wks)Large amount

11、Several times,,Partial placenta previa Between total and marginal,,Marginal placenta previa Late(37-40WKS or in labor ) Less bleeding,symptom,Severe blood losing leads to several shock s

12、igns ,such as paleness ,weak and quick pulse and hypotension. Malpresentation maybe exists, and floating presentation could be found during late gestational weeks.,Complication of mother

13、 and fetus,Bleeding at or post partum Implantation of placenta Anemia and puerperal infection Premature delivery,How to diagnose the placental Previa?,Question,Patient History – Placenta Previa,Painless bl

14、eeding2nd or 3rd trimester, or at termOften following intercourseMay have preterm contractions“Sentinel bleed”,Physical Exam – Placenta Previa,The uterus is usually soft and relaxed Anomaly of fetal condition Fet

15、us is usually alive and well Per vagina examinationNO digital vaginal exam unless placental location known,Auxiliary examination,B-ultrasound examination Ultrasound is the easiest, most reliable way to

16、diagnose (95-98+% accuracy) False positive- ultrasound with distended bladder Transvaginal or transperineal often superior to transabdominal methods MRI Posterior previa

17、 High cost Limited availability,,Laboratory – Placenta Previa,Hematocrit or complete blood countBlood type and RhCoagulation testsWhile waiting – serum clot tube taped to wall,Differentiation diagnosis,Pl

18、acental abruption vessel PreviaCervical polypusCervical erosionCervical carcinoma,,,Management,Expectant delivery aim at achieving amixmum fetal maturity possible while minimizing the risk to both moth

19、er and fetus.,Management,expectant treatment Indication: Fewer vaginal bleeding Patient’s condition stabilization <36 weeks gestation,

20、fetal weight<2300g Management: Lying in bed to take a rest Inhibition of uterine contraction Treatment aim at symptoms

21、 Promote development of fetus Prevention of infection,Termination of pregnancyCStotal placenta previa (36th week), Partial placenta previa (37th week) and

22、 heavy bleeding with shockPreventing postpartum hemorrhage: pitocin and PGHysterectomy: Placenta accreta or uncontroled bleeding,Management,,Vaginal delivery Marginal placenta previa Vaginal bleeding is

23、 limited,Management,Admit to hospitalNO VAGINAL EXAMINATIONIV accessPlacental localizationCesarean delivery is necessary in practically all women with placental previa,Management,Placenta PreviaManagement,Severe

24、 bleeding,,Caesarean section,Moderate bleeding,,Gestation,,>34,,<34,,,ResuscitateSteroids,,Unstable,,,Stable,Resuscitate,,Mildbleeding,,Gestation,,,<36,,Conservative care,,>36,,,,,Management,Management of p

25、lacenta previa?,Individualized based onGestational ageAmount of bleedingFetal condition and presentation,,Ultrasound examination,Placenta previa,Expectant management as long as the bleeding is not excessive. Cesarean

26、delivery at 36 to 37 weeks’ gestation,Each of the following is a risk factor of placenta previa except:A ) Prior cesarean section;B ) Hypertension;C ) Multiple gestation;D ) Prior uterine curettage,Exercise 1,B,Eac

27、h of the following is a typical feature of placenta previa except:A ) Painless bleeding;B ) Commonly associated with coagulopathy;C ) First episode of bleeding is usually self-limited;D ) Associated with postcoita

28、l spotting,Exercise 2,B,A 33-year-old woman at 37 week’s gestation, confirmed by first trimester sonography, presents with moderatedly severe vaginal bleeding. She is noted on sonography to have a placenta previa. Which

29、of the following is the best management for this patient?A ) Induction of labor;B ) Tocolysis of labor;C ) Cesarean delivery;D ) Expectant managementE ) Intrauterine transfusion,Exercise 3,C,A 22-year-old G1P0 w

30、oman at 34 week’s gestation presents with moderate vaginal bleeding and no uterine contractions. Which of the following sequence of examinations is most appropriate ?A ) Speculum examination, ultrasound examination, dig

31、ital examination;B ) Ultrasound examination, digital examination, speculum examination;C ) Digital examination, ultrasound examination, speculum examination;D ) Ultrasound examination, speculum examination, digital

32、 examination;,Exercise 4,D,An 18-yeas-old woman is noted to have a marginal placenta previa on an ultrasound examination at 22 week’s gestation. Which of the following is the most appropriate management?A ) Schedule ces

33、arean delivery at 39 weeks;B ) Schedule an amniocentesis at 36 weeks and deliver by cesarean if the fetal lungs are mature;C ) Schedule an MRI examination at 35 weeks to assess for possible percreta involving the blad

34、der;D ) Reassess placental position at 32 weeksE ) Recommend termination of pregnancy,Exercise 5,D,Understand that placenta previa and placental abruption are major causes of antepartum hemorrhage Know the painless