武功密笈

小黃藏書

　

Concealed Hemorrhage

External Hemorrhage

Concealed Hemorrhage

External Hemorrhage

« Placental abruption with concealed hemorrhage carries with it much greater

maternal hazards, not only because of the possibility of consumptive

coagulopathy, but also because the extent of the hemorrhage is not

appreciated.

? Incidence: 1/75 ~ 1/150 (cases/deliveries)

‚ Perinatal mortality: 20% ~ 35%

ƒ Recurrence rate: high, about 4%

v Primary cause: unknown

v Risk factors:

? Older age

‚ Great parity

ƒ African-American women

„ Pregnancy-induced or chronic hypertension

… Preterm prematurely rupture of membrane

† External trauma

‡ Cigarette smoking

ˆ Cocaine abuse

‰ Uterine leiomyoma (especially if located behind the placental implantation site)

　

- S/S may be considerably variable.

　

Symptom of Sign	Frequency (%)
Vaginal bleeding	78
Uterine tenderness or back pain	66
Fetal distress	60
High frequency contraction	17
Hypertonus	17
Idiopathic preterm labor	22
Dead fetus	15

v In severe cases of placental abruption, the diagnosis is generally obvious.

Milder and more common forms of abruption are difficult to recognize with

certainty, and the diagnosis is often made by exclusion.

v It has long been taught, perhaps with some justification, that painful uterine

bleeding means abruptio placentae, while painless uterine bleeding is

indicative of placenta previa. Unfortunately, the differential diagnosis is not

that simple. Labor accompanying placenta previa may cause pain suggestive

of abruptio placentae. On the other hand, abruptio placentae may mimic

normal labor.

　

? Shock

‚ Consumptive coagulopathy:

§ Diagnosis:

Plasma fibrinogen < 150 mg/mL

Fibrinogen-fibrin degradation products (FDP) £

D-dimer £

ƒ Renal failure

„ Uteroplacental apoplexy (Couvelaire uterus):

§ Widespread extravasation of blood into the uterine musculature and

beneath the uterine serosa

§ Usually found in the more sever form

§ Management: ~ depending on gestational age and the status of mother and futus

? Keep vital signs stable, renal perfusion, etc.

¶ Whole blood, lactated ringer solution, etc.

‚ If the fetus is alive:

¶ Cesarean section

ƒ If the fetus is dead:

¶ Vaginal delivery (unless hemorrhage is hard to control or there are other

obstetrical complications that prevent vaginal delivery)

　

1. Williams Obstetrics, 20^th Edition