Placenta previa Treatment
Treatment:
In recent years, the principle of treatment has a major change in expectations of positive therapy, namely, gestational age as long as possible, so gestational age increased, and there is likely to reduce bleeding placenta upward migration opportunities, and maternal and fetal safety is significantly increased.
1. Look forward to Bill therapy in 1927 first proposed the use of placenta praevia look forward to therapy so far, more than 70 years of history, along with the development of perinatal medicine means of fetal monitoring progress, so look forward to therapy added to the positive factors, actively look forward to the treatment of and the use of the relaxation of indications for cesarean section are placenta previa treatment to reduce mother and infant mortality in two points.
(1) looking forward to the treatment of indications: placenta praevia look forward to the principles of therapy to ensure that mother and child are at the premise of safety, to extend the gestational age, the protection of the fetus to survive, to reduce perinatal mortality. The main features of placenta praevia in late pregnancy are no incentives repeated painless vaginal bleeding, its time to happen occasionally early to have 14 weeks of pregnancy, childbirth late to start, but most happen at 30 ~ 35 weeks of pregnancy; probably start bleeding volume relatively minor, can naturally stop can happen repeatedly, or even substantial vaginal bleeding, heavy bleeding may also be the first time. These cases due to the degree of placenta pre-vary. In general look for the treatment of vaginal bleeding little fetus is not yet ripe, not easy to survive after birth in patients with placenta previa. However, more patients with vaginal bleeding according to the specific circumstances, such as gestational age, the degree of pre-placental hemorrhage in pregnant women, such as the degree of rescue measures for the specific analysis, decided to adopt it or not look forward to treatment. Therefore, looks forward to therapy Although mainly used for vaginal bleeding in patients with small, but the higher number of vaginal bleeding and the specific conditions under the condition does not rule out the application looks forward to therapy.
(2) look forward to treatment measures:
① hospitalized for observation: Once the diagnosis of placenta previa should be hospitalized for observation. Determination of blood type, preparation of blood, the absolute supine rest, pregnant women often take the left side of lying, so as to remove the uterus dextral to the inferior vena cava of oppression, there is conducive to improving the blood circulation of the placenta. To avoid excessive or brutal abdominal soft stool examination to maintain patency and reduce the sudden increase in intra-abdominal pressure is also very important.
② regular B-type ultrasonography: B-mode ultrasound examination can clearly placenta previa type, earlier in the month of pregnancy, the placenta may increase as the month of pregnancy and lower segment happened gradually stretching displacement, to be conducted regularly in B-mode ultrasonography Inspection follow-up In addition, through the B-mode ultrasound examination may know the main parts of the placenta in the womb or the next paragraph on paragraph, placental size and thickness, with or without implants look on the estimated duration of bleeding, frequency of blood transfusion, surgical staff are vital. Such as the placenta near the cervix and Vietnam the main Department of mouth, or the placenta is located in the lower anterior uterine bleeding time, while earlier, the volume and frequency of many high, it is estimated that the timely delivery of time earlier, the incidence of postpartum hemorrhage higher hysterectomy increase the likelihood.
③ fetal maturity assessment: The assessment of fetal maturity is also looking forward to the treatment of one of the key issues. In normal pregnancy, with the increasing gestational age, fetal weight in proportion increased fetal lung maturity is also the root
According to the last menstrual period projected birth to determine the clinical gestational age are the most commonly used method is simple. Menstrual cycle, but for those who are not allowed to determine the gestational age of the patients must be careful, according to early pregnancy and fetal movement reaction time, high and Palais abdominal circumference measurement B-mode ultrasound examination of fetal biparietal diameter, thoracic diameter, femur length to determine a more comprehensive analysis correct for gestational age, especially through the amniotic fluid bubble test and the ratio of lecithin and sphingomyelin determination to determine whether the fetus mature, sophisticated, once the fetus should be considered timely termination of pregnancy, can be avoided leading to Wait for blind mother's bleeding and fetal death. Therefore, the expectations of modern obstetric treatment to avoid unnecessary delays, especially in patients with recurrent bleeding
④ actively correct anemia: A look at the treatment of antepartum haemorrhage in both the number of possible increased bleeding will lead to varying degrees of anemia, anemia in pregnant women will not only reduce once again to increase tolerance to hemorrhage shock dangerous, but also cause fetal anemia or fetal death. Therefore, in looking forward to not only pay attention to during the amount of vaginal bleeding, and must actively correct the anemia, substantial loss of blood when the intravenous infusion to maintain the channel should be added as far as possible the number of how much blood loss, recurring bleeding and blood transfusion should be repeated also have required preparation of blood to prepare an urgent need.
⑤ inhibited contraction to reduce the bleeding: bleeding placenta previa physiological mechanism of the strong contraction of the uterus caused by upward extension of lower uterine segment, with the attachment of the placenta and the bleeding happened dislocation separation. Therefore, in order to achieve the purpose of bleeding must be inhibited contraction. This is the treatment of placenta praevia expectations and succeeded in extending the gestational age plays a positive role.
A. magnesium sulfate: a role in inhibiting myometrial activity, serum magnesium reached within 2 ~ 4mmol / L can reduce the activity of uterine muscle. The first load of 4g, that is, with 25% magnesium sulfate add 16ml in 5% glucose solution 100 ~ 250ml, in 30 ~ 60min with slow intravenous drip, and then 25% of magnesium sulfate in 20 ~ 40ml add 5% glucose 500ml Medium 1 ~ 2g per hour speed intravenous drip until the contraction stopped. Application of the process, attention should be given magnesium sulfate poisoning monitoring indicators.
B.β-adrenergic receptor agonists: These drugs can be excited in the uterine smooth muscle receptor β2 inhibit uterine smooth muscle contraction and reduce the extension of uterine activity during pregnancy but more adverse reactions, particularly cardiovascular adverse reactions are more prominent , often by the mother's heart rate quickly, should be noted. Currently used drugs are:
Albuterol (salbutamol): oral 2.4 ~ 4.8mg, usually the first time, 4.8mg, every 8 hours of oral 2.4 ~ 4.8mg, when the drug until the contraction to eliminate.
Ritodrine (hydroxyl benzyl ephedrine hydroxybutyrate): 100mg dissolved in 5% glucose in 500ml infusion fluid, maintained at 0.15 ~ 0.35mg/min be inhibited contraction after continuous infusion of at least 12h, and then changed to oral 10mg, 4 times / d. Tachycardia and the mother has diabetes caution.
C. prostaglandin synthetase inhibitor: it inhibits prostaglandin synthetase, reducing prostaglandin synthesis or inhibition of the release of prostaglandins to inhibit contraction. Commonly used drugs indomethacin and aspirin, but the fetus must have adverse reactions, so indomethacin in pregnancy after 32 weeks should not be applied.
D. calcium antagonist: inhibition of calcium into the uterine muscle cell membranes inhibit oxytocin and prostaglandin release. Commonly used sublingual nifedipine 10mg, 3 to 4 times / d, low blood pressure can lead to the application of attention.
⑥ strengthen fetal monitoring: close observation of fetal growth and development, regular B-mode ultrasound examination, such as found in fetal growth restriction, we should give the necessary intrauterine treatment of pregnant women need to make every day count fetal movement on fetal guardianship regularly make systems such as NST, fetal biophysical score umbilical cord blood flow S / D ratio, etc., especially in the vaginal bleeding before and after intensive care treatment abnormal timely.
⑦ to promote fetal lung maturation: fetal lung maturation affected by a variety of hormone regulation, placenta previa have more obvious to people early termination of pregnancy possible, so active at the same time looking forward to therapy should be to promote the treatment of fetal lung maturity, especially pregnancy 28 weeks or so of patients with placenta previa. On many clinical use of betamethasone and dexamethasone to promote fetal lung maturity Usage: every day betamethasone 12mg, intramuscular injection of a total of 2 days; 5 ~ 10mg of dexamethasone for 2 ~ 3 days intramuscular injection or intravenous injection, to promote fetal the effect of the lung will be the first one happened at 24h after administration, decreased the effect of 7 days a week so, if necessary, repeat until 1 times fetal lung maturity
⑧ avoid local stimulation and prevention of infection: avoid local stimulation including the prohibition of sexual intercourse, not anal and vaginal examinations check a result of these checks may lead to vaginal bleeding, so that has nothing to do with the immediate treatment of the inspection should be avoided, but needed to see overcast browser inspection, except cervix causes bleeding, such as vaginal examinations have to make, we must prepare in the blood transfusion and cesarean section under the conditions carefully in the operating room to be checked. Vaginal bleeding due to repeated infection easily, at clinical attention should be paid to pregnant women on the pulse rate and body temperature changes, make the blood leukocyte count and, if necessary, antibiotics to prevent infection.
⑨ cerclage question: Arias (1988) made at 24 ~ 30 weeks of pregnancy there is vaginal bleeding of placenta previa to do a cervical cerclage will contribute to delivery delays, but on this point, scholars have no consensus. Such as Tessarolo et al (1996) report of its 10 years, has 12,965 births have 103 cases of placenta previa, one of six cases of pregnancy from 24 to 30 weeks for Law McDonald cerclage to prevent serious bleeding, longer, on average 8.2 weeks gestational age, fetal 1820 ~ 3360g, newborns without RDS happen, pregnant women do not need blood transfusion, so the authors consider cerclage method can be used to happen earlier bleeding placenta previa. However, Cobo, etc. (1998) of 19 cases of pregnancy 24 to 30 weeks of placenta previa Does cervical cerclage, and 20 cases of conservative treatment of patients to do for the control group, the treatment effect is basically the same. So the effect of cervical cerclage on the evaluation, to be more practical to illustrate.
Placenta praevia the question of termination of pregnancy, should be based on the type of placenta previa, and actively look forward to the effect of gestational age therapy, fetal size and bleeding such as the case may be actively looking forward to a successful pregnancy therapy has reached 35 ~ 36 weeks, the fetus is estimated at 2500g, the No bleeding or less bleeding, if for complete placenta previa can consider terminating the pregnancy. Otherwise, a serious bleeding is about to impact the prognosis of mother and fetus. If partial placenta previa, the placenta is visible inside the mouth of the cervix to cover the case may be; if look at treatment or therapy, the repeated occurrence of massive bleeding, first of all, safety considerations for pregnant women, should take immediate surgery, if the birth weight has been Tatsu 1000 ~ 1500g, at the close surveillance of feeding in the NICU, there is much chance of survival
To sum up, about 36 weeks of pregnancy, fetal sophisticated timely after childbirth, should not due to a temporary non-bleeding or blood volume is very small relative to long-term to continue to wait for the event of acute hemorrhage and (or) natural labor before termination of pregnancy, lost look on the significance of
2. Termination of Pregnancy
(1) indications for termination of pregnancy: Pregnant women repeated bleeding and even shock-induced anemia, and this time the size of the fetus regardless of gestational age ripe or not, for safe motherhood should immediately terminate pregnancy; such as small amount of bleeding after 36 weeks gestational age Tatsu; fetal sophisticated Tests for fetal lung maturity tips, and were also indications for termination of pregnancy
(2) termination of pregnancy by:
① cesarean section: This is placenta previa has become the main mode of termination of pregnancy, placenta previa is bleeding to save the fundamental measure for a short period of time at the end of the rapid delivery and suppression of bleeding, the safety of both mother and fetus. Complete and partial treatment of placenta previa, 70% ~ 90% the use of cesarean section. More than half of cesarean hemorrhage more than 500ml, a result of bleeding hysterectomy line Tatsu 4% ~ 5% of cesarean section, therefore, when placenta previa must want to do a good job to prevent bleeding and rescue all ready, prepared to react to emphasize.
Decide on cesarean section in patients with placenta previa should be through the B-type ultrasonography know the location of the placenta plant location, such as the level and fetal position in order to advance the design of the incision site and removed the fetus Ways to do have to prepare another blood transfusion and rescue maternal and child preparation.
Placenta previa during cesarean section uterine incision should be carefully considered selection of the incision should be avoided as far as possible the placenta is located in the placenta of the posterior wall of lower uterine segment, will be from the lower uterine segment into the anterior wall; but attached to the anterior wall shall, in accordance with B-mode ultrasonography see selection incision, such as the anterior wall of plant at left, then from the right of access to better access to the contrary from the left; the following paragraph for the placenta to occupy the entire anterior wall, the lower segment incision slightly higher optional vertical incision or body incision; placenta large and thin, covering the entire anterior wall of the uterus can be cut directly from the lower segment quickly torn placenta, the fetus removed.
Immediately after fetal delivery intramural uterine muscle contraction agent injection such as ergometrine, oxytocin and incision to the edge of the oval clamp hemostatic forceps, the placenta rapidly stripped bare hot saline gauze pad oppression major bleeding. Uterine bleeding more agents does not work, the most simple and quickest way is to put on absorbable gelatin sponge or thrombin Batroxobin, Express Purchase bleeding gauze pad sites plus oppression, repression, at least at the time more than 10min, because the uterus lower segment myometrium low, and its retraction, or smooth muscle contraction effectively rearrange to the time required for oppression sinusoid length, so long oppressed by external forces, contribute to the formation of blood clots, but the oppression gauze to stop bleeding in some cases only effective . Of large open sinusoids, blood such as those that simply does not work with the oppressed, available absorption lines can be partially "8" then suturing combined with hot saline gauze pad oppression, be patient, usually can obtain satisfactory results. For the above method is still bleeding after treatment, with gauze packing can intrauterine Act, 24h later removed. The specific method is to use its wide ribbon (5 ~ 6cm wide four-fold) along the palace at the bottom of the first from left to right then gradually returning to tightly fill the upper portion of uterine cavity, it is estimated that filling the lower uterine segment after the length of gauze cut spare parts, and then check the other side of wide ribbon stretching from the neck vagina then fill lower uterine segment, and then lower uterine segment myometrial suture, paying attention not to be slit into the gauze. Postoperative use of broad-spectrum antibiotic to prevent infection after 24h since the gauze out slowly Vagina generally been able to meet the hemostatic effect. The above does not work feasible bilateral internal iliac artery ligation, but generally at about 1h of its collateral circulation probably also set up to re-bleeding, therefore this law is sometimes used first-aid can not fully solve the lower uterine segment placenta previa bleeding. As uterine artery ligation, commonly used in the uterine body contraction adverse bleeding, and lower uterine segment placenta previa bleeding lower position, and its blood supply is not an ordinary artery ligation site supplied Therefore, the ligation and the effect can not achieve hemostasis. After a number of ways in patients with uterine bleeding is still more than a state of shock, should act decisively line or low hysterectomy hysterectomy (to be attached to the placenta bleeding Department resection).
Cesarean section after fetal delivery, placental spin-off problems, should not be forced to divest a high degree of suspicion of possible placenta accreta. If part of placenta accreta feasible resection of part of uterine incision fusiform muscle tissue using absorbable catgut suture to stop bleeding; if most of implantation bleeding can not be corrected should be held in hysterectomy. At the same time, the rescue of hemorrhagic shock, and the attention of central venous pressure monitoring blood volume to correct cardiac dysfunction, acidosis, renal failure and to give antibiotics to prevent infection.
② vaginal delivery: only applies to marginal placenta previa occipital presentation, vaginal bleeding much, it is estimated that at the end of a short period of time to delivery persons. Decide vaginal delivery, the first artificial rupture of membrane, rupture of fetal head after the decline in placental hemostasis oppression, and to strengthen the promotion of birth if uterine rupture decreased after the fetal head is not satisfactory, there is still bleeding, or childbirth does not progress smoothly, and should be immediately diverted to cesarean section.
③ transshipment problem: there is such as in patients with vaginal bleeding, and those who deal with local conditions, emergency rehydration, preferably at the same time for a blood transfusion at the vulva after disinfection with large gauze packing to stop bleeding after the transfer of oppression
Inhibit contraction principle is to stop the bleeding, to correct anemia, prevention of infection and prolong the gestational age, to promote fetal maturity, that is, take a positive look forward to therapy, to reduce perinatal mortality. Look at the process, according to the volume of vaginal bleeding, with or without shock, pregnancy weeks, production times, fetal position, fetal survival is choosing the best delivery period. Cesarean section delivery may be a speedy end to remove the placenta and the purpose of hemostasis, the treatment of placenta praevia are haemorrhage key measures, but when the surgical incision surgery selection, haemostasis is also worth noting that the selection problem.
It must be emphasized inaccessible mountain or rural encountered bleeding placenta previa and unconditional termination of pregnancy in situ should not make vaginal or anal inspection check Infusion can blood transfusion, at disinfection, the use of sterile gauze vaginal packing with a view to put the placenta was caught in the fetal presentation, and the temporary reduction of gauze between the bleeding, abdominal compression bandage, and then quickly transfer the treatment of patients with escort.