12. ANC
ภรรยำ สำมี
Blood group A Rh +
Hb 12.7 12.7
Hct 37.8 40.3
MCV 82.7 79.1
OFT + +
DCIP
Hb typing EA E 30.2% A2A A2 1.6%
Dx E trait A thal trait or normal
13.
14.
15.
16.
17. Physical Examination
• Vital signs:
BP 110/60 mmHg P 80/min RR 20 /min
Temp 36.8 oC B.W. 50 kg Height 151 cm
• General appearance
A pregnant woman with normal consciousness, good
cooperation
• HEENT
No pale conjunctiva, no icteric slcera
18. Physical Examination
• Chest & Lungs
Clear and equal breath sound both lungs
• Heart
Regular rhythm, no murmur
• Abdomen
FH ~3/4 > o
Lie: Longitudinal Presentation: Cephalic
Soft, no tenderness
30. Management
• Admit LR
• Observe bleeding per vagina
• CBC
• Nifedipine SR (20) 1 tab O q 12 hr
• Observe Uterine Contraction
• Monitor FHR
31. Management
• หลังจำก admit มี bleeding per vagina เป็น
เลือดปนลิ่ม ออกมำหลังจำกปัสสำวะเสร็จ
ปริมำณ 5 ml เจ็บครรภ์ห่ำง ลูกดินดี
• NPO
• LRS 1000 ml IV rate 120 ml/hr
• Set OR for C/S with TR
34. Progress Note
• Post op day 1
• S: ปวดแผลมำก ไม่มีเลือดออกทำงช่องคลอด ไม่มี
หน้ำมืดหรือใจสั่น นำคำวปลำสีแดง
• O: v/s: BP 105/60 P 80 RR 20 Temp 37.4
FH ~umbilicus Hct 32%
• A: Post op C/S day 1
• P: Step diet + routine post op care
35. Progress Note
• Post op day 2
• S: ปวดแผลเล็กน้อย ไม่มีไข้ ไม่มีหน้ำมืดหรือใจสั่น
กินได้ดี นำคำวปลำสีแดง ยังไม่ถ่ำย ผำยลมแล้ว
• O: v/s: BP 110/70 P 84 RR 20 Temp 37.3
FH ~umbilicus
• A: Post op C/S day 2
• P: Step diet + routine post op care
36. Progress Note
• Post op day 3
• S: ปวดแผลเล็กน้อย ไม่มีไข้ นำคำวปลำสีแดงจำง กินได้ดี
• O: v/s: stable
Abdomen: soft, not tender
มีปัญหำเรื่องลูกตัวเหลือง on phototherapy
• A: Post op C/S day 3
• P: routine post op care
37. Progress Note
• Post op day 4
• S: ปวดแผลลดลง นำคำวปลำสีแดงจำง กินได้ดี นำนม
ไหลดี
• O: v/s: stable
Abdomen: soft, not tender
รอลูกเนื่องจำกลูกมีนำหนักตัวน้อย
• A: Post op C/S day 4
• P: Discharge ได้ถ้ำลูกพร้อม
39. Antepartum Hemorrhage : Definition
• Bleeding in Pregnancy after 24 weeks
gestation
or
• Vaginal bleeding which occurs after fetal
viability
40. How important in Antepartum Hemorrhage
• Obstetric emergency condition
• Incidence 3 – 5 %
• Perinatal mortality rate about 4 times
• May be the cause of Postpartum
Hemorrhage
43. Antepartum Hemorrhage : Initial Management
Detect life threatening condition and resuscitation
Detect cause of antepartum hemorrhage
Assess fetal variability
44. Antepartum Hemorrhage : Initial Management
• Detect life threatening condition and
resuscitation
• Estimate blood lost and record V/S, I/O
• Large IV access ; Crystalloid (Ringer lactate
Solution or 0.9% Normal saline solution
• Oxygenation
• Investigation ; CBC with platelets, Coagulogram,
Cross match
45. Antepartum Hemorrhage : Initial Management
• Detect cause of antepartum hemorrhage
• Do not PV and PR until exclude placenta previa
• Ultrasound for evaluate placenta previa
(may be detect abruptio placenta)
• PV examination for finding other conditions
49. Placenta Previa
• Definition:
• The presence of placental tissue that is
implanted over or very near the internal
cervical os
• Incidence:
• Complicates approximately 1 in 300
pregnancies.
50. Placenta Previa : Risk factor
• Increasing parity
• Maternal age
• Number of prior cesarean deliveries
• Number of curettages for spontaneous or
induced abortions.
56. Placenta Previa : Management
The fetus is preterm and there are no other
indications for delivery
The fetus is reasonably mature
Labor has ensued
Hemorrhage is so severe as to mandate
delivery despite gestational age.
57. Conservative Management of Stable Preterm Patients
• Admit patient
• Bedrest with bathroom privileges.
• Stool softeners and a high-fiber diet
• Periodic assessment of the maternal
hematocrit.
• Ferrous gluconate supplements
58. Conservative Management of Stable Preterm Patients
• Cross match of packed red blood cells.
• Prophylactic transfusions
• A single course of corticosteroid
(between GA 24 and 34 wks)
• Rh(D)-negative women
-> Rh(D)-immune globulin if they bled.
59. Acute Care of Symptomatic Placenta
Previa
• Maternal Care
• Large bore IV access & administration of crystalloid
• Type and cross-match for PRBC
• Transfuse to maintain a Hct of 30%
(if the patient is actively bleeding)
• Maternal pulse and blood pressure
• Monitor vaginal blood loss
60. Acute Care of Symptomatic Placenta Previa
• Fetal Care
• Monitor FHR
• Ultrasound assess fetal status : Fetal Heart
61. Investigation
• Hb & Hct.
• Serum electrolytes and indices of renal
function.
• Coagulation profile
62. Delivery
• Tocolysis is not administered
to actively bleeding patients.
• Delivery is indicated if
• (1) there is a nonreassuring fetal heart rate.
• (2) life threatening refractory maternal
hemorrhage.
63. Mode of Delivery
• Cesarean delivery is the delivery route of choice.
• Vaginal delivery may be considered in the presence of:
• a fetal demise
• previable fetus
• some cases of marginal previa,
as long as the mother remains hemodynamically stable.
