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1、Placetal PreviaLong Xiaoyu 龙晓宇XuanWu Hospital宣武医院1.Case 1. 30 G3P2 at 32 weeks gestation, painless vaginal bleeding. Four weeks ago , postcoital vaginal spotting2. BP:110/70mmHg ,abdomen is soft uterus nontender , FHR :140-150bpmCase 12.What is most likely diagnosis?What is your next step?Long-term
2、management of this patient?3.4.5.What are the most common causes of Antepartum Hemorrhage ?6.COMMON CAUSESPlacenta PreviaPlacental AbruptionPreterm laborUNCOMMON CAUSES Uterine rupture Fetal(chorionic ) vessel rupture Cervical or vaginal lacerations Cervical or vaginal lesions, including cancer Cong
3、enital bleeding disorder Unknown ( by exclusion of the above)7. Placental Previa8. Understand that placenta previa and placental abruption are major causes of antepartum hemorrhage Know the painless vaginal bleeding is consistent with placenta previaUnderstand that the ultrasound examination is a go
4、od method for assessing placental locationObjectives9.Defined as 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%。Placental Previa10.“ the placenta overlying th
5、e internal os of the cervix”11.Classification 12.ClassificationComplete(central ) placenta previaPartial placenta previaMarginal placenta previa Low-lying placenta previa13.What are the risk factors for placental Previa?Question 14.ETIOLOGYvIncreased maternal agevUterine factors:Previous CSInstrumen
6、tation of the uterine cavity (D and C for miscarriages or Induced Abortions)vPlacental factors:MultiparityMultiple gestation Prior placenta previaETIOLOGY 15.Manifestation It characteristically presents with unprovoked and repeated painless vaginal bleeding.Clinical Presentation 16.ManifestationMani
7、festation The classification of previa placenta sometimes determines the occurrence period and the volume of losing blood.17.Total placenta previaEarly(20-28wks)Large amountSeveral timesBleeding time and volumeCentral placenta previaEarly(20-28wks)Large amountSeveral timesMarginal placenta previa La
8、te(37-40WKS or in labor ) Less bleeding18. symptomsymptom Severe blood losing leads to several shock signs ,such as paleness ,weak and quick pulse and hypotension. Malpresentation maybe exists, and floating presentation could be found during late gestational weeks.19.Complication of mother Complicat
9、ion of mother and fetus and fetus nBleeding at or post partumn Implantation of placentan Anemia and puerperal infectionn Premature delivery20.How to diagnose the placental Previa?Question 21.Patient History Placenta PreviaPatient History Placenta PreviaPainless bleeding2nd or 3rd trimester, or at te
10、rmOften following intercourseMay have preterm contractions“Sentinel bleed”22.Physical Exam Placenta PreviaPhysical Exam Placenta Previan The uterus is usually soft and relaxedn Anomaly of fetal conditionn Fetus is usually alive and welln Per vagina examinationNO digital vaginal exam unless placental
11、 location known23.Auxiliary examinationAuxiliary examination B-ultrasound examinationl Ultrasound is the easiest, most reliable way to diagnose (95-98+% accuracy)l False positive- ultrasound with distended bladder l Transvaginal or transperineal often superior to transabdominal methods MRI Posterior
12、 previa High cost Limited availability 24.25.Laboratory Placenta PreviaLaboratory Placenta PreviaHematocrit or complete blood countBlood type and RhCoagulation testsWhile waiting serum clot tube taped to wall26.Differentiation diagnosisPlacental abruption vessel PreviaCervical polypusCervical erosio
13、nCervical carcinoma 27.28.Management Expectant delivery aim at achieving amixmum fetal maturity possible while minimizing the risk to both mother and fetus.29.Management n expectant treatment Indication: Fewer vaginal bleeding Patients condition stabilization 36 weeks gestation, fetal weight3434Resu
14、scitateSteroidsUnstableStableResuscitateMildbleedingGestation36 Management 35.Management of placenta previa?Individualized based onGestational ageAmount of bleedingFetal condition and presentation36.Ultrasound examination Placenta previa Expectant management as long as the bleeding is not excessive.
15、 Cesarean delivery at 36 to 37 weeks gestation37.Each of the following is a risk factor of placenta previa except:A ) Prior cesarean section;B ) Hypertension;C ) Multiple gestation;D ) Prior uterine curettageExercise 1 38.Each of the following is a typical feature of placenta previa except:A ) Painl
16、ess bleeding;B ) Commonly associated with coagulopathy;C ) First episode of bleeding is usually self-limited;D ) Associated with postcoital spottingExercise 2 39. A 33-year-old woman at 37 weeks gestation, confirmed by first trimester sonography, presents with moderatedly severe vaginal bleeding. Sh
17、e is noted on sonography to have a placenta previa. Which 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 transfusionExercise 3 40.A 22-year-old G1P0 woman at 34 weeks gestation pres
18、ents with moderate vaginal bleeding and no uterine contractions. Which of the following sequence of examinations is most appropriate ?A ) Speculum examination, ultrasound examination, digital examination;B ) Ultrasound examination, digital examination, speculum examination;C ) Digital examination, u
19、ltrasound examination, speculum examination;D ) Ultrasound examination, speculum examination, digital examination;Exercise 4 41. An 18-yeas-old woman is noted to have a marginal placenta previa on an ultrasound examination at 22 weeks gestation. Which of the following is the most appropriate managem
20、ent?A ) Schedule cesarean 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 bladder;D ) Reassess placental position at 32 weeksE ) Recommend te
21、rmination of pregnancyExercise 5 42. Understand that placenta previa and placental abruption are major causes of antepartum hemorrhage Know the painless vaginal bleeding is consistent with placenta previaUnderstand that the ultrasound examination is a good method for assessing placental locationObjectives43.44.后面内容直接删除就行资料可以编辑修改使用资料可以编辑修改使用资料仅供参考，实际情况实际分析45.The user can demonstrate on a projector or computer, or print the presentation and make it into a film to be used in a wider field46.