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Endo/Repro II Test 1 > 16. Obstetric Hemorrhage and Puerperal Sepsis > Flashcards

16. Obstetric Hemorrhage and Puerperal Sepsis Flashcards

1
Q

If a patient is hemorrhaging (bleeding profusely) before birth, what should you do?

A
    1. Set up a team (OB, anesthesia, nursing, bleeding protocal) to establish hemodynamic stability
  • 2. Give 2 large bore IV lines
  • 3. Access vitals, amount of bleeding and mental status
  • 4. Medical hx
    1. labs (CBC, coag profile, serial H/H, type and crossmatch)
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2
Q

If a patient is bleeding, how do you replace their blood?

A

Type and crossmatch for 4 units of blood via PRBC (packed RBC) transfusion

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3
Q

How much will 1 unit of PRBC raise Hct and Hgb?

A

Raise Hct by 3% and Hgb by 1g/dL

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4
Q

What should be avoided during the initial examination of antepartum hemorrhage?

A
  • AVOID digital exam (looks at dilation of cervix) until placenta previa is ruled out
  • Instead do sterile speculum exam to look for genital lacerations/cervical lesions.
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5
Q

How many units of blood should you type and crossmatch for during antepartum hemorrhage?

A

4 untis of blood

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6
Q

When assesing the entire situation during the intial evaluation of antepartum hemorrhage, what do you do?

A
  1. US to look at location of placenta and presentation of fetus
  2. Amount of bleeding/maternal status
  3. Gestations age
  4. Conintour FH monitoring
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7
Q

DDx for Vaginal Bleeding BEFORE 20 weeks

A
  1. Abortion
  2. Ectopic PG
  3. Problem with cervix/vagina (cancer, polyp)
  4. Subchorioninc hemorrhage/retroplacental clot
  5. Insufficient cervix
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8
Q

DDx for Vaginal Bleeding AFTER 20 weeks (upper genital tract etiology)

A
  1. Placenta abruption
  2. Placental previa
  3. Uterine rupture
  4. Vasa previa
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9
Q

DDx for Vaginal Bleeding AFTER 20 weeks (lower genital tract etiology)

A
  1. Bloody show labor
  2. cervical polyps
  3. infection/trauma/cancer
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10
Q

What is the most common type of abnormal placentation?

A

Placenta previa => implantation of the placenta over the cervical os, causing 20% of antepartum hemorrhage.

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11
Q

Placenta previa classically presents how?

A

Painless vaginal bleeding

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12
Q

Risk factors for placenta previa, including age?

A
  1. Maternal age >35
  2. Multiparity
  3. Prior previa or C-section
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13
Q

What are the 3 types of placenta previa?

A
    1. Marginal PP => edge of placenta is over margin of cervical os, but does NOT cover it.
    1. Partial PP => partial occlusion of the placenta
    1. Complete PP => placenta completly cover
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14
Q

What is the most serious type of placenta previa and is associated with the most blood loss?

A

Complete PP

least likely to resolve

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15
Q

Placent previa is almost exclusively diagnosed how?

A

US

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16
Q

How likely are placenta previas to resolve on their own?

A

90% will resolve by 32-35 weeks, in a process known as placental migration.

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17
Q

Which one is marginal PP and complete PP?

A

L => marginal

R => complete

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18
Q

What is goal of management of placenal previa in preterm pregnancy; can these patients go home?

A
  • Goal = obtain fetal maturation
  • If bleeding not profuse = bed rest initially
  • If stable and bleeding stops = send home on pelvic rest
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19
Q

When should a patient with placenta previa NL be delivered if the fetuses lungs are matured?

A

36-37 weeks

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20
Q

How is a patient with placenta previa stabilized?

A
  1. Hospitalized
  2. IV access => 2 large bore needles if bleeding profusely
  3. Labs (H/H and Type and cross) anf PT/PTT/ fibrinogen if you suspect coagulopathy
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21
Q

If delivering a patient with placenta previa BEFORE 34 weeks, what should be given?

A
  1. Antenal steroids (betamethasone)
  2. Tocolysis if stable
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22
Q

When encountering a patient with previa, OTHER ABNL placental implantations should be considered. What is the most common?

A

Placenta ACCRETA; firm attachment to the superficial linign of the myometrium

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23
Q

What is placenta increta and percreta?

A
  • Placenta increta => invades myometrium
  • Placenta percreta => through the myometrium INTO the uterine serosa
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24
Q

RF and Treatment of Placenta Acreta

A
  • RF = Previous c-section (esp high with multiple)
  • Tx = cesearean hysterectomy
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25
Q

MCC of 3rd trimester bleeding?

A

Placental abruption => premature separateion of NL implanted placenta

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26
Q

Classic case of placenta abruption

A
  • Patient presents in 3rd trimester with PAINFUL bleeding, a tender uterus that is hyperactive and fetal distress/death.
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27
Q

What is the most common risk factor for placental abruption?

A

Maternal HTN

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28
Q

How should pts with placental abruption be delivered?

A
  • Mom and bb stable => vaginal
  • Fetal distress or uncontrolled bleeded => c-section
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29
Q

If pregnant mother presents after MVA or physical abuse how long should they be monitored for placental abruption?

A

4-6 hours

30
Q

What is the most common cause of DIC in pregnancy?

A

Placental abruption

31
Q

Management of placenta abruption?

A

same as placenta previa; stabilize the patient, prepare for catestophic hemoorhage (serial blood draws, NPO, type and cross 4 units) and prepare for preterm delivery (give bexamethasone if before 34 weeks).

32
Q

What is couvelaire uterus?

A

When placental abrupts, blood extravates into the uterus causing red/purple serosa

33
Q

What is uterine rupture and symptoms?

A

Uterine rupture = complete seperates of uterine muscles through all layers

  1. Sudden onset of INTENSE abdominal pain +/- vaginal bleeding
  2. Abnormal FHR/ cessation of fetal heart tones
  3. Regression of the presenting part
34
Q

What is the most common risk factor for uterine rupture?

A
  1. Prior uterine incision (c-section/mymectomy)
35
Q

How is uterine rupture managed?

A
  1. Immediate laparotomy and delivery of fetus
  2. Repair if possible
  3. If large rupture => cesarean hysterectomy
  4. ALL future pregnancies have to be delivered via c-section
36
Q

Fetal bleeding that occurs during the 3rd trimester is most often due to what?

A

Velamentous insertion of umbilical cord => cord inserts at a distance away from the placenta and the vessels have to traverse between chorion/amnoin without the protective Whartons jelly. If unprotected vessel passes over cervical os => vasa previa.

37
Q

What is the leading cause of maternal death worldwide?

A

Post-partum hemorrhage (most occur within 24 hours).

38
Q

Postpartum hemorrhage is defined as how much blood loss following a vaginal birth vs. C-section?

A
  • >500cc following vaginal birth
  • >1000cc following C-section
39
Q

Differentiate primary vs. secondary postpartum hemorrhage?

A
  • Primary is that which occurs within first 24 hours; often uterine atony
  • Secondary occurs from >24 hours - 12 weeks
40
Q

MCC of secondary post-partum hemorrhage

A
    1. Subinvolution of placenta sote
    1. Retained products of conception
    1. Infection
    1. Inherited coagulation defects
41
Q

Post-partum hemorrhage due to uterine atony occurs when?

A

Uterus does not contract after placenta is delivered, creating a “boggy” uterus upon palpation.

42
Q

Uterine atony MC occurs when?

A

RIGHT before or after delivery of placenta

43
Q

RF for uterine atonys

A
  1. LARGE uterus (multiples, polyhydramnois)
  2. ABNL labor
  3. Conditions that infere with contraction of uterus
44
Q

Effective hemostasis after separation of the placenta is dependent on what?

A

Myometrium to compress the severed vessels

45
Q
  • What are some strategies to managin uterine atony?
  • What is the last resort and how can we preserve pregnancy
A
  1. - BIMANUAL MASSAGE of the uterus + start meds at the same time:
    1. Oxytocin, Methylgenovine, 15- methy prostandin F2a, Dinoproston/Misoprostol.
  2. Uterine packing: 4in gauze or large volume balloon
  3. Interventional radiology
  4. Surgery = last resort
    1. if pt wants to preserve fertility = cut uterine arteries
    2. If unstable => total abdominal hysterectomy
46
Q

What confirms the diagnosis of uterine atony?

A

Bimanual massage => uterus will feel bogy => decrease bleeding, expel clots, allow time for other measures to be done

47
Q

Methylergonovine can be given for tx of postpartum hemorrhage, but should be avoided in whom?

A

HTN patients

48
Q

15-methyl PGF2a (Hemabate) can be given for tx of postpartum hemorrhage but should be avoided in which pt’s?

A

Asthmatic pts

49
Q

Dinoprostone (PGE2) can be given for postpartum hemorrhage, but should be avoided in which pt’s?

A

HypOtensive

50
Q

What kind of stitches and sutures can we do for atonic uterus?

A
  • O’Leary stritches => ligate uterine arteries
  • B-lynch suture
51
Q

What is the 2nd most common cause of postpartum hemorrhage following vaginal delivery?

A

Trauma during delivery

52
Q

50% of patients with post-partum hemorrhage will have what?

A

Retained placental fragments, which can cause bleeding because the uterus cannot contract around the tissue.

53
Q

What is the treatment for retained placenta?

A
  • Manual removal if bleeding is profuse
  • +/- uterine curettage with or without U/S guidance, being careful not to perforate
54
Q

Uterine inversion, another cause of post-partum hemorrhage, occurs when?

A

Top of the fundus of uterus descends into the vagina and sometimes through the cervix.

55
Q

If uterus inversion occurs BEFORE the placenta is delivered, what should be done?

A

Correct inversion BEFORE you deliver the placenta.

56
Q

Uterine inversion can cause what complications?

A
  1. Copious bleeding
  2. Hypovolemic shock
57
Q

Treatment of Uterine Inversion

A
  • 1. Manually replace => then start oxytocin to cause uterus to contract
    1. If larpartomy, get an anesthesiologist.
58
Q

What coagulation disorders can cause post-partum hemorrhage?

treatments?

A
    1. Amniotic fluid embolism => amnioti fluid is infused into mom
      * Tx: respiratory support, correct hypovolemic shock and replace coag factors
  • 2. VW disease => factor 8 def => prolong bleeding time
    • Tx: Factor 8 concentrate or cryoprecipitate.
  • 3. Idiopathic thrombocytopenia => abnl platelets w short life
    • Tx: platelet infusion
59
Q

What are the contents of fresh frozen plasma and how much does 1 unit increase the fibrinogen?

A
  • Fibrinogen, antithrombin 3, factor 5 and 8
  • 10 mg/dL
60
Q

What are the contents of Crypercipitate and how much does 1 unit increase the fibrinogen?

A
  • Fibrinogen, vWF, factors 8 and 13
  • 10 mg/dL
61
Q

What are the contents of platelets and how much does 1 unit increase the platet count by?

A
  • Platelets, RBC, WBC, plasma
  • 5-10K mm3
62
Q

What is puerperal sepsis?

A

Overgrowth of pathogenic organisms that occur after delivery because the pH of the vagina becomes more alkaline.

63
Q

Puerperal sepsis can cause what symptom?

A

Fetal morbidity => temperature >100.4 for more than 2 consecutive days during the first 10 days after delivery (exclusing first 24 hours), most often due to endometritis

64
Q

Organism with what oxygen dependence cause majority of puerperal infections; which organisms most commonly?

A

ANAEROBIC —> Peptostreptococcus, Peptococcus, and Streptococcus

65
Q

What are the key clinical findings for puerpral sepsis?

A

Postpartum fever and ↑ uterine tenderness on postpartum day 2-3

66
Q

What the treatment for puerperal sepsis; what if caused by Bacteroides fragilis?

A
  • Ampicillin + Gentamicin
  • Bacterioides fragilis is resistant to this combo, but sensitive to Clindamycin
67
Q

Septic pelvic thrombophlebitis fufills the criteria for which pathogenesis of thrombosis?

A

Virchow’s triad

  1. Endothelial damage
  2. Venous stasis
  3. Hypercoagulable state of pregnancy
68
Q

How does the presentation of ovarian vein thrombophlebitis differ from deep septic pelvic vein thrombophlebitis?

A
  • Ovarian vein will have fever + abdominal pain within 1 week of delivery —> appear critically ill
  • Pelvic vein will usually have unlocalized fever in first few days that is NON-responsive to Abx and pt’s do NOT appear critically ill
69
Q

Can thrombosis be seen on radiograph for ovarian vein thrombophelbitis or deep septiv pelvic vein thrombophlebitis?

A
  • OVTP: 20%
  • DSPVTP: no
70
Q
  • How do we prevent more thrombosis in septic pelvic thrombophlebitis?
  • If no thombosis, continue for how long?
  • If ovarian vein thrombosis is seen on XR, anticoagulants should be continued for how long?
A
  • Anticoaguation (unfractionated heparin/ LMW heparin)
  • Fever goes away x 48 hours.
  • 6 weeks

Endo/Repro II Test 1 (23 decks)

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