9 产科出血
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OBSTETRICAL HEMORRHAGE
Women's Hospital, School of Medicine, Zhejiang University HANXIUJUN
1
Rationale (why we care…)
• 4-5% of pregnancies complicated by 3rd trimester bleeding
• Immediate evaluation needed • Significant threat to mother & fetus
(consider physiologic increase in uterine blood flow) • Consider causes of maternal & fetal death • Priorities in management (triage!)
2
OBSTETRICAL HEMORRHAGE
OBSTETRICS - “bloody business”
Delivery should be considered in any woman at term with unexplained vaginal bleeding
- hemorrhage is leading cause of maternal mortality and ICU care in obstetrics hospital
3
Vaginal Bleeding:
Differential diagnosis
• Common:
• Abruption, previa, preterm labor, labor
• Less common:
• Uterine rupture, lacerations/lesions, vasa previa, fetal vessel rupture
• cervicitis, polyps, cervical cancer, foreign body, bleeding disorders
• Unknown • NOT vaginal bleeding!!!
(happens more than you think!)
4
normal hemorrhage
Bloody show: - antepartum in active labor the consequence of effacement & dilatation of cervix tearing of small veins
5
Definition conditions
The definition of obstetrical hemorrhage cannot
be determined precisely
Bleeding>500ml Need transfusion Hct drop of 10 vol%
6
Predisposing conditions
Predisposing conditions cannot be determined precisely 3.9% in vaginal delivery 6~8% in cesarean delivery the high risk factors
7
8
Causes of hemorrhage
causes of hemorrhage
number(%)
Placental abruption Laceration/uterine rupture Uterine atony Coagulopathies Placental previa Uterine bleeding Placenta accreta/increta/percreta Retained placenta
141(19) 125(16) 115(15) 108(14) 50(7) 47(6) 44(6) 32(4)
9
OBSTETRICAL HEMORRHAGE
Antepartum
placental previa placetal abruption vasa previa
Postpatrum
uterine atony normal placentation genital tract laceration coagulation defects
10
PLACENTA PREVIA
Definition - the placenta is located over or very near the internal os of cervix total partial marginal low-lying
11
Etiology
- multiparity - multifetal gestations - prior cesarean delivery : 1.9 % (2 times c/sec)
4.1% (>3 times c/sec) →prior uterine incision with a previa increases the
incidence of cesarean hysterectomy - smoking
: CO hypoxemia → compensatory placetal hypertrophy
12
Diagnosis
The time of uterine bleeding
during the later half of pregnancy
digital examination : torrential hemorrhage!!! sonography
- placental location can almost be obtained - transabdominal - transvaginal - transperineal - MRI
13
14
Management
may be considered as follows: 1. fetus is preterm 2. indication for delivery or in labor
Women's Hospital, School of Medicine, Zhejiang University HANXIUJUN
1
Rationale (why we care…)
• 4-5% of pregnancies complicated by 3rd trimester bleeding
• Immediate evaluation needed • Significant threat to mother & fetus
(consider physiologic increase in uterine blood flow) • Consider causes of maternal & fetal death • Priorities in management (triage!)
2
OBSTETRICAL HEMORRHAGE
OBSTETRICS - “bloody business”
Delivery should be considered in any woman at term with unexplained vaginal bleeding
- hemorrhage is leading cause of maternal mortality and ICU care in obstetrics hospital
3
Vaginal Bleeding:
Differential diagnosis
• Common:
• Abruption, previa, preterm labor, labor
• Less common:
• Uterine rupture, lacerations/lesions, vasa previa, fetal vessel rupture
• cervicitis, polyps, cervical cancer, foreign body, bleeding disorders
• Unknown • NOT vaginal bleeding!!!
(happens more than you think!)
4
normal hemorrhage
Bloody show: - antepartum in active labor the consequence of effacement & dilatation of cervix tearing of small veins
5
Definition conditions
The definition of obstetrical hemorrhage cannot
be determined precisely
Bleeding>500ml Need transfusion Hct drop of 10 vol%
6
Predisposing conditions
Predisposing conditions cannot be determined precisely 3.9% in vaginal delivery 6~8% in cesarean delivery the high risk factors
7
8
Causes of hemorrhage
causes of hemorrhage
number(%)
Placental abruption Laceration/uterine rupture Uterine atony Coagulopathies Placental previa Uterine bleeding Placenta accreta/increta/percreta Retained placenta
141(19) 125(16) 115(15) 108(14) 50(7) 47(6) 44(6) 32(4)
9
OBSTETRICAL HEMORRHAGE
Antepartum
placental previa placetal abruption vasa previa
Postpatrum
uterine atony normal placentation genital tract laceration coagulation defects
10
PLACENTA PREVIA
Definition - the placenta is located over or very near the internal os of cervix total partial marginal low-lying
11
Etiology
- multiparity - multifetal gestations - prior cesarean delivery : 1.9 % (2 times c/sec)
4.1% (>3 times c/sec) →prior uterine incision with a previa increases the
incidence of cesarean hysterectomy - smoking
: CO hypoxemia → compensatory placetal hypertrophy
12
Diagnosis
The time of uterine bleeding
during the later half of pregnancy
digital examination : torrential hemorrhage!!! sonography
- placental location can almost be obtained - transabdominal - transvaginal - transperineal - MRI
13
14
Management
may be considered as follows: 1. fetus is preterm 2. indication for delivery or in labor