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					Placenta previa
The placenta provides the fetus with oxygen and nutrients and
takes away waste such as carbon dioxide via the umbilical cord.
• Definition    Placenta previa is a condition that
 may occur during pregnancy when the placenta
 implants in the lower part of the uterus and
 obstructs the cervical opening to the vagina
 (birth canal).


 孕28周后胎盘附着于子宫下段,其下缘甚至
 达到或覆盖宫颈内口,其位置低于胎儿先露
 部。
                Incidence
• The incidence of placenta previa is
  approximately 1 out of 200 births.
• increases with each pregnancy, and it is
  estimated that the incidence in women
  who have had 6 or more previous
  deliveries may be as high as 1 in 20 births.
• doubled in multiple pregnancy (such as
  twins and triplets).
                  Etiology
• Endometrium factors:
  – a scarred endometrium (lining of the uterus)
  – Curretage for several times
  – an abnormal uterus
• Placental factors
  – Large
  – abnormal formation of the placenta.
• Development retardation of fertilized egg
• Risk factors include multiparity (previous
  deliveries), multiple pregnancy, previous
  myomectomy (removal of uterine fibroids
  through an incision in the uterus), and a
  previous C-section (if the scar is low and
  close to the vaginal cervix region).
          classification
• Complete placenta previa
• Partial placenta previa
• Marginal placenta previa
           Clinical findings
• Symptoms
 – Spotting during the first and second trimesters
 – Sudden, painless, and profuse vaginal
   bleeding in pregnancy during the third
   trimester (usually after 28 weeks)
 --Bleeding may not occur until after labor starts
   in some cases
 --Anemia,shock
• Signs
  – The uterus is usually soft and relaxed.
  – The infant position is oblique ( // ) or
    transverse ( == ) in about 15% of cases.
  – Fetal distress is not usually present unless
    vaginal blood loss has been heavy enough to
    induce maternal shock, placenta abruptio, or
    a cord accident occurs.
  – No digital examination!
     Accessory examinations
• Ultrasonography:
  – Accuracy 95%
  – 34th week
• Postpartum examination of placenta and
  membrane
  – 7cm
• Diagnosis
• Differential diagnosis
            Complications
• Maternal complications
  – major hemorrhage, shock, and death.
  – Implanted placenta
  – Anemia and infection
• Fetal complications
  – Prematurity (infant is less than 36 weeks gestation) is
    responsible for about 60% of infant deaths secondary
    to placenta previa.
  – Fetal blood loss or hemorrhage may occur because of
    the placenta tearing away from the uterine wall during
    labor. It may also occur with entry into the uterus
    during a C-section delivery. Maternal complications
               Treatment
• The course of treatment depends on the
  amount of abnormal uterine bleeding,
  whether the fetus is developed enough to
  survive outside the uterus, the amount of
  placenta over the cervix, the position of
  the fetus, the parity (number of previous
  births) for the mother, and the presence or
  absence of labor.
Early in pregnancy, transfusions may be given
 to replace maternal blood loss. Medications
 may be given to prevent premature labor,
 prolonging pregnancy to at least 36 weeks.
 Beyond 36 weeks, the benefits of additional
 infant maturity have to be weighed against the
 potential for major hemorrhage.
• Cesarean section is the method for
  delivery. It has proven to be the most
  important factor in reducing maternal and
  infant death rates.
   Expectations (prognosis)
• The maternal prognosis (probable
  outcome) is excellent when managed
  appropriately. This is done by hospitalizing
  those at risk who are exhibiting signs and
  symptoms, and by performing C-section
  delivery.
ABRUPTIO PLACENTAE
               Definition
• Abruptio Placentae( placental
  abruption):
  premature separation of the normally
  implanted placenta from the uterine wall.

Incidence:0.51%~2.33% 200~300/1000
          1%          150/1000
               Etiology
• Mechanism: hemorrhage into the decidua
  basalis, leading to premature placental
  separation and further bleeding.
Associated factors:
• Maternal hypertension
• Sudden decompression of the uterus
• Maternal cocaine use
• trauma
Classification

 • Concealed
   separation: no
   vaginal bleeding
 • Apparent
   separation :vaginal
   bleeding will be
 • Mixed separation :
   vaginal bleeding will
   be apparent
                Diagnosis
Classic clinical presentation:
•   vaginal bleeding
•   Tender uterus
•   Uterine contractions
•   Fetal distress
Coagulation abnormalities
• Hypofibrinogenemia
• Increaseing levels of fibrin degradation
  products
• decreasing platelet count
• Increasing prothrombin time and partial
  thromboplastin time
• Decreasing other serum clotting factors
• Ultrasonography:
  relatively large retroplacental clots may be
  detected
• Placental examination
  The extent of placental abruption of the
  maternal surface of the placenta on which
  a clot is detect at the time of delivery.
Complication
DIC
Shock
Amniotic fluid embolism
Acute renal dysfunction
           Management
Maintain hemodynamic stabilization
  ( Transfusion therapy)
• Crystalloid transfusion
• Whole blood therapy
• Component therapy
• Correct coagulation status
Delivery
• When the fetus is mature,vaginal delivery
  is preferable unless there is evidence of
  fetal distress or hemodynamic instability.
• When the fetus is not mature and
  placental abruption is limited,observation
  with close monitoring of both fetal and
  maternal status.
Normal and Abnormal Puerperium
         Definition
The time from the delivery of the
 placenta through the first few weeks
 after the delivery.
6 weeks in duration.
By 6 weeks after delivery, most of the
 changes of pregnancy, labor, and
 delivery have resolved and the body
 has reverted to the nonpregnant state.
The relevant anatomy and physiology in the
   puerperium
1. Reproductive organs
1)Uterus
 1000g → 50-100g
 The endometrial lining rapidly regenerates
   (16 days)
 The placental site undergoes a series of
   changes in the postpartum period
2) Cervix
 it never returns to the nulliparous state.
 the external os is closed to the extent that a
   finger could not be easily introduced.
3) Vagina
 shrinks to a nonpregnant state
 resolution of the increased vascularity and
   edema occurs by 3 weeks
 the vaginal epithelium appears atrophic on
   smear. This is restored by weeks 6-10.
4) Perineum
 swelling and engorgement are completely
   gone within 1-2 weeks
 the muscle tone may or may not return to
   normal, depending on the extent of injury.
5) Ovaries
 ovulate as early as 27 days after delivery
   (not breastfeed ); 12 weeks (most); 7-9
   weeks (mean).
 the suppression of ovulation due to the
   elevation in prolactin
6) Breasts
 Lactation can occur by 16 weeks' gestation.
 Lactogenesis is initially triggered by the
   delivery of the placenta (E↓P↓and prolactin).
 the prolactin levels decrease and return to
   normal within 2-3 weeks (not breastfeeding)
 The colostrum初乳(the first 7 days)
 The milk continues to change throughout
   the period of breastfeeding to meet the
   changing demands of the baby.
            Manifestation
1. Fever (24 hours)
2. Pain (uterine contraction)
3. Sweat
4. Lochia 恶露
 a large amount of red blood initially flows
   from the uterus as the contraction phase
   rapidly occurs. (5 weeks)
 lochia rubra; lochia serosa (brownish red,
   with a more watery consistency); lochia alba
   (yellow)
               Management
1.   2 hours after delivery
     Bleeding
     Uterine contraction
     HR and Bp and R and T
2.    1 weeks after delivery
     Bleeding
3.    Emiction and defecate
4.    Lochia
5.    Episiotomy and Laceration
6.    Breast
         Puerperal Infection
• Puerperal Infection
  any bacterial infection of the genital tract
  after delivery. Incidence: 6%. The most
  important cause of maternal death.
• Puerperal Morbidity
  temperature 38.0℃ or highter, the
  temperature to occur on any 2 of the first
  10days postpartum, exclusive of the first 24
  hours, and to be taken by mouth by a
  standard technique at least four times daily.
• Risk factors
1.PROM
2.Anemia
3.Hemorrhage
4.EP and CS
5.Placenta retain
• Common pathogens
1.Aerobes
Group A, B, and D streptococci溶血性链
  球菌
Gram-negative bacteria: Escherichia
  coli大肠杆菌, Klebsiella克雷伯氏菌
Staphylococcus aureus葡萄球菌
2.   Anaerobes
    Petococcus species消化球菌
    Petostreptococcus species消化链球菌
    Bacteroides fragilis group脆弱类杆菌
    Clostridium species梭状芽孢杆菌
3.   Other
    Chlamydia trachomatis沙眼衣原体
    Mycoplasma species支原体
• Manifestation
Acute vulvitis vaginitis and cervicitis
Uterine infection
Adnexal infections
Septic pelvic thrombophlebitis 血栓性静
  脉炎
败血症
• Diagnosis
History
Physical examination and PV
Lab finding
Differential diagnosis
• Treatment
1.Nutrition: anemia prevention
2.Antimicrobial treatment
    broad-spectrum, high dose, long time
3.Drainage
4.Treatment of thrombophlebitis
Late Postpartum Hemorrhage
• Definition
  Uterine bleeding by 24 hours after delivery.
• Etiology
 Placenta or membrane or decidua retain
 Abnormal redintegration
 Infection
 Problems of incision
 tumor
• Diagnosis
• Treatment
1.antibotics oxytocin PG   益母草冲剂 产
 复康
2.uterine curettage
3.hysterectomy
THANKS FOR YOUR ATTENTION

				
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