Pa And Pp

PA AND

PP

The third subsidiary hospital of Zhengzhou University Guan Yichun

PA and PP  

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PA(Placenta Abruption) PP(Placenta Previa)

They are all the main causes of the third trimester bleeding

Placenta Abruption 

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PA(Placenta Abruption) : after 20 weeks’ gestation age or at term, the normally implanted placenta prematurely separated from the uterine wall,partially or completely . It may cause maternal hemorrhagic shock ,and result in maternal and fetal mortality.Once the diagnosis obtianed,the patient should be managed as soon as possible .

Epidemiology 

incidence varies from 1 in 86 to 1 in 206 births.

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5-17% after an episode in one previous pregnancy

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25% after episodes in two previous pregancies.

Etiology  

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many causes are not apparent maternal hypertension, preeclampsiaeclampsia,chronic renal disease,cociane use and tobacco use . Placenta abruption history. Abdominal trauma Rapidly contraction of overdistened uterus such as rupture of menbrane with polyhydramnios or delivery of one infant in a multiple gestation.

Pathophysiology 

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several mechanism are thought to be important . one is local vascular injury , another is an abrupt rise in uterine venous pressure → result in vacular rupture into the decidua basalis

Pathology 

Decidua basalis hemorrhage→hematoma behind the placenta→placenta partial or complete separation from uterine wall

1.In early stage, retroplacental hematoma is small(no clinical symptoms) →disease may be discovered, when placenta is examined after labor 2.when hematoma expands →disrupt more vessels →more separation,reaches the margin of placenta →the blood may dissect the membranes from the uterine wall →appear externally →revealed abruption →completely retained in the uterus →concealed abruption (more dangerous)

Classification 1. Revealed abruption (external hemorrhage) bleeding between the membrane and uterus→escape through the cervix →appears externally

2. Concealed abruption (internal hemorrhage)

the blood doesn't escape externally →retain between the detached placenta and the uterus →concealed abruption

2.Uteroplacental apoplexy Definition: In some severe cases ,the wide spread blood infiltrates the uterine wall,and disrupt the uterine muscle bundles and arrive the uterine serosa . we call it uteroplacental apoplexy,also call it Couvelaire uterus. It can be demonstrated at C.S . There are purple eccbymosis on the surface of uterus, especially near the site of the placenta attachment.

2.Uteroplacental apoplexy 

It is a indurated organ that all but loses its power of contraction.Rarely,Couvelaire uterus may lead to uterine atony and massive hemorrhage,which necessitates aggressive measures such as selective arterial embolization or cesarean hysterectomy to control the bleeding .

3.Consumptive coagulopathy Placenta abruption →consumptive coagulopathy →DIC →formation of microembolus in vessels of important organs (such as kidney 、 lungs) →organal dysfunction

Clinical features

Mild type

(1)revealed abruption or discovered during delivery (2)area of abruption ＜ 1/3 (3)with or without abdominal pain 、 no back pain (4)not prominent anemia ,without shock (5)uterus is soft 、 mild tenderness.the size is proportional to the pregnant weeks. (6)fetal position and fetal heart sound is clear

Severe type (1)massive hemorrhage( revealed or concealed )→ hemorrhagic shock or DIC (2)area of abruption >1/3 (3)sudden persist abdominal pain 、 back pain. (4)with anemia. the degree isn’t proportional to the amount of external bleeding. (5)the uterus is plate-like hard .fundus is elevated highly than that of pregnant weeks. (6)the fetal position and heartsound isn’t clear. (7)if the area >1/2 →fetal distress →fetal heart sound may disappear.

Accessory examination 1.Lab tests:

blood routine 、 Urine routine test for consumptive coagulopathy (TT 、 APTT 、 3p

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2.ultrasonography The significant findings include: Retroplacental hematoma The placenta is thicker than normal size The chorial plate is convex to the amniotic cavity

Diagnosis   

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Clinical feature Abdominal pain Ultrasonography reveals hypoechioc area between placenta and uterine wall Labor test manifest hemorrhage or coagulation failure.At the same time determine the blood type and crossmatch.

Management 1.Correct shock 2.Terminated pregnancy in time 3.Management of postpartum hemorrhage 4.Treatment of consumptive coagulation 5.Prevention of Renal Failure 6.Careful observation during the management 7.Other supporting therapies

Anemia Infection

1.Vaginal delivery Indications: Delivered woman with good general

conditions or first delivery woman with mild type abruption

Benefits (1)Vaginal delivery can avoid the

incisions of abdomen and uterus (2)with vaginal delivery →vessles may be contracted sufficiently →serious hemorrhage can be avoided

Method (1)Artificial rupture of the membrane (2)use of oxytocin (3)carefully observe FHR 、 NST 、 maternal hypertention

2.C.S Indications (1)severe type patient .especially first

delivery woman (2)mild type with intrauterine fetal distress (3)no progress after amniotomy (4)the condition of patient is worse

Method:control postpartum hemorrhage (1)use oxytocin and soft massotheraphy (2)fresh blood transfusion (3)ligation of internal iliac (4)hysterectomy