1. Dr. Mostajeran

2. Obstetrical hemorrhage Antepartum hemorrhage -Placental abroption - placental previa - vasaprevia Bloody show

3. Post partum hemorrhage Third stage Uterine atony Retained placental P- accreta increta precreta Inversion Laceration Hematomas Rapture uterus

4. Pregnancy – related deaths due to hemorrhage p – abroption 19% laceration – rupture 16% U- atony 15% Coagulopathies 14% P.previa 7% U-bleeding 6% Accreta – increta –p 6% Retained p – 4%

5. Antepartum hemorrhage

7. Placental abroption, abraptio placenta, p-abruption definition separation p. sit implantation before delivery premature separation → differentiates p.p External hemorrhage Concealed hemo. (DIC. Extent H not appreciated late diagnosis Partial - total

8. Prenatal morbidity and mortality 1994 12% still birth due to p. abruption 15% infant does survive first year of life neurological deficits

9. Etiology

10. Frequency different criteria 1.200 1.185 1.830 Recurrent abruption Severe abruption 1.8 pregnancy's 1 to 3 weeks earlier than firs abruption

11. Pathology Initiated hemorrhage into decidua basalis Decidua splits thin layer adherent to myometrium hematoma destruction of p adjacent. In early stage no clinical symptoms depression few centimeters maternal surface covered dark clothed blood (several minutes) in some case decidual spiral artery ruptures

12. Fetal to maternal hemorrhage Non truvmatic 20% F.M- Hemor < 10 ml Concealed hemorrhage Margin still remain adhevent Memberan retain their attachment Blood gain access to A.F Fetal head closely applied lower uterine

14. Clinical diagnosis Signs and symptoms vary Ex – bleeding ± DIC Back pain U.S 25% confirmed clinical diagnosis Shock Thromboplactin (DIC Af embolism)

15. D.D Severe P.ab diagnosis obvious Milder more common forms difficalt Nither lab test nor diagnostic methods No pain previa pretermlabor

16. Consumptive coagulopathy Most common p.ab Hypophibrinogenemia (<15-mg/dl) ↑ FDP ↑ D-dimer ↓ other coagulation f in 30% p.ab A hypofibrinogenemia ± thrombocytopenia

17. Renal failure In severe p.ab (hypovolemia delayed or incomplete) 32% pregnancy with R-F had p.ab 75% ATN reversible Even p.ab complicated → severe DIC Vigorous Prompt treatment By blood crystalloid solution prevents renal dysfunction proteinuria in severe p.ab?

18. Couvelaire uterus 1900 uteroplacental apoplexy extravasation blood into uterine mosculature Seldom interfere with uterine contraction

19. Management Depending on gestational age Status mother –fetus Most clinicians live, mature fetus V.D not imminent C.S If diagnosis uncertain fetus alive Without evidence f-compromise close observation

20. Expectant management in PT Delaying delivery may prove beneficial (tacolytic) Very early abrubtion frequently oligohydraminios. With or without PROM Lack of ominous deceleration not guarantee safety intrauterine enviroment any period of time farther separation compromise or kill F C.S F. distress F. death bleeding or other obstetrical Complication to prevent V.D

21. Vaginal delivery Amniotomy mature DIC Oxytocin Hypertonus characterizes myo-function If no rhytmic uterin contraction → oxytocin

23. Placenta previa

24. Placenta located over or near in – os 1.Total p.previa 2.Partial p.previa 3.Marginal p.p edge of p at margin of in – os 4.Low – lying placenta p.edge does not reach in –as but close Vasa previa p.vessels course through membranes and present at cervical os

25. Incidence 1.300 Prenatal morbidity and mortality Preterm delivery Neonatal mortality rate three fold high 500000 singleton births relationship previa FGR PTL found L - Birth weight is due to PT and lesser to found G - impairment

26. Etiology Advance M-age 1.1500 19 years of age 1.100 older than 35 Multiparity para 5 or greather Prior cesarean delivery With two prior c.delivery 1.9% With three or more c. delivery 4.1 Para>4 >4 cesareans > 8 fold previa Repeat c+ previa →c.hysterectomy 25% Primary cesarean + previa → c.hysterectomy 6% * Smoking ↑ Two fold

27. Clinical finding Painless hemorrhage near end second trimester or later Without warning Initialy bleeding rarely so profuse Cause hemorrhage formation L.U.Segment, dilatation in-os

28. Placenta accreta, increta, and precreta Poorly development deciduas in L-segment (7%) Coagulation defects Is rare with p.previa Thromboplastin escapes cervical canal

29. Diagnosis U. Bleeding later half of pregnancy P. Previa seldom establish clinical exam V.E finger pass cervix → p.palpated → torrential Hemorr Planned delivery Doubel set up

30. Automibile accidents 1_3% pregnant woman Fetal injury and death direct fetal placental injury M_ shock pelvic fracture Maternal head injury hypoxia

31. Fetal death →trauma 82% motor vehicle crashes 50% placenta injury 4% uterine rupture

32. Placental abruption and uterine rupture and placental tear traumatic placental abruption 1-6% minor injuries some degree of abruption 50% major injury

33. Management 1.Fetus preterm no indication for delivery 2.Fetus reasonably mature 3.Those in labor 4.Hemorrhage so severe

34. Preterm fetus no active bleeding Close observation Her family must fully appreciate problem P.P

35. Delivery C.S All women with P.P Most often transverse U-incision Sometimes vertical incision