16. Obestetric Hemorrhage and Puerperal Sepsis Flashcards
Vaginal bleeding before 20 weeks MC due to abortions, ectopics, cervical/vaginal etiology (cancer/trauma), subchorionic hemorrhage/retorplacental clot, cervical insufficiency, after 20 weeks (antepartum) due to placental abruptions/previa, uterine rupture, vasa previa, bloody show labor, cervical polyps, infections, trauma, vulvar varicosities and?
cancer
What is defined as implantation of placenta over the cervical so, MC type of abnormal placentation, accounts fo 20% of antepartum hemorrhage, presents as PAINLESS bleeding: 75% present with that, 20% will have contractions, 10% dx incidentally via US, risks include maternal age >35, multparity, multiple gestations, coacine, smoking, prior hx, previous C section?
Placenta Previa
Placenta previa classifications include marginal- edge of placenta extends into cervical os, partial- some occlusion of cervical os, complete- cervical os is completely covered by placenta- most SERIOUS and associated w most amount of blood loss… Classic presentation is painless bleeding, usually 30 weeks, dx via US- seen 24 weeks but by repeat US at 30 weeks- what will most likely happen?
90% resolve by 32-35weeks!
*deliver via C section at 36-37 weeks w fetal lung maturity
Any preterm delivery prior to 34 weeks you must give antenatal seroids such as what? (fetal lung maturation?)
Bethamethasone
when encoutnering patient with previa or other abnormal placental implantations- consider placenta accreta (MC) attachment to superficial lining of myometrium, placenta increta invades the endometrium and what goes through the myometrium into the uterine serosa - worst but least common?
Placenta Percreta
for both previa and placenta accreta/in/per - prior C section increases risk, multiple C section largely increases risk
What is defined as premature separation of normally implanted placenta, MCC of 3rd trimester bleeding , 30% of antepartum hemorrhage, presents as PAINFUL bleeding, uterine tenderness, uterine hyperactivity, fetal distress and or death, risk factors is MC HTN, cocaine, external maternal blunt trauma, polyhydramnios, multiparity, and previous abortion?
Placental Abruption
Diagnosis of Placental Abruption is when pt presents with PAINFUL vaginal bleeding,(80%), abd pain/uterine tenderness seen in 66%, fetal distress in 60%, US can detect some abruption but are better at diagnosing previas, if both mom and fetus are stable then proceed to vaginal delivery. Abruption is the MCC of WHAT in pregnancy?
DIC- results from release of thromboplastin from the placenta and subplacental decidua causes a consumptive coagulopathy- 20% MC seen when abruption is massive
Placental Abruption can cause couvelaire utereus which is extravastion of blood into the uterus, causing red and purple discoloration of the serosa. What implies complete separation of the uterine musculature through all of its layers, RARE, spontaneous, traumatic or due to uterine scar, fetal mortality/neurologic sequale in 30%?
Uterine Rupture
Uterine Rupture risk factors include prior uterine incision, huge use of oxytocin, trauma, external cephalic version, multiparity, dx via sudden onset abd pain +/- vaginal bleeding, abnormal FHR pattern or cessation of fetal heart tones, regression of presenting part, causes for immediated laparotomy and?
delivery of BB (repair or hysterectomy)
*future bbs via Csection
What is a cause of third trimester bleeding that is rare but IMPORTANT causes associated with rupture of fetal vessel, usually secondary to velamentous insertion of umbilical cord, when vessel ruptures often acute vaginal bleeding with change in FHR (tachy to brady) need to dx rapidly and proceed to delivery?
Fetal Bleeding
Velamentous insertions of umblical cord= cord inserts a distance away from placenta and its vessels must traverse between the chorion and amnion wihtout the protective wharton’s jelly….. fetal bleeding also caused by what, which is unprotected vessels passing over the cervical os - high mortality rate?
Vasa previa
Postpartum hemorrhage define as 500cc vaginal or 1000cc csection bleeding,primary occurs in first 24 hours, secondary occurs from 24 hours to 12 weeks- due to subinvolution of uterus, sloguhing of eschar or retained product, what is primary MC due to?
Uterine atony ** (80%)
*1/2 maternal deaths occur within 24 hours delivery
Postpartum hemorrhage risk factors include prolonged labor, augmented labor, precipitous labor (<3hrs), hx of, placental abruption/previa, operative vaginal delivery, chorioamnionitis.. What usually occurs immediated preceeding or after delivery of PLACENTA, cause by the uterus failing to contract after delivery of placenta - palpation=boggy uterus?
Uterine Atony
Uterine Atony risk factors include enlargement of utuers, abnormal labor, conditions interfering with contraction such as leiomyomas/magnesium sulfate, managment includes massaging uterus while starting meds: oxytocing/pitocin, methylergonivine (contra in HTN pts), dinoprostone, misoprostol, uterine packing or large volume baloon cath, interventional radiology or?
surgical measure / hysterectomy
uterine atony is helped with uterine packing: 4inch gauze layer back and forth from one cornu to other, large volume balloon, Interventional radiology patient has stable vitals and persistent bleeding - arterial embolization, surgery is last resort if patient desires future fertility may ligate uterine arteries, if unstable proceed with total abdominal?
Hysterectomy (supracervical)
