3rd trimester and post-partum bleeding

Question 1

What is placenta previa?

Answer 1

Implantation of the placenta either partially or completely over the cervical os.

1. Complete
2. Partial
3. Marginal

Question 2

Which placenta previa types need C-section delivery?

Answer 2

Complete and most partials

Question 3

What is placenta abruption?

Answer 3

Premature separation of the placenta from the uterine wall.

Question 4

Illicit drug that can cause placenta abruption.

Answer 4

Cocaine

Question 5

Main risk factor for a uterine rupture.

Answer 5

Previous C-section

Question 6

What is the definition of post-partum hemorrhage?

Answer 6

Excess of 500mL blood loss after vaginal delivery

Excess 1000mL blood loss after C-section

Question 7

Name and describe the 3 types of abnormal placenta attachments.

Answer 7

Accreta: attachment to the myometrium
Increta: invasion of the myometrium
Percreta: penetration thru the serosa or beyond

Question 8

How much does maternal blood volume increase in pregnancy?

Answer 8

40%

Question 9

What happens to maternal blood pressure and HR in pregnancy?

Answer 9

BP decreases

HR increases

Question 10

Top 3 causes of maternal death in the U.S.

Answer 10

1. Embolism
2. Hypertensive Disease
3. Obstetrical Hemorrhage

Question 11

How much blood loss can occur in obstetrical hemorrhage before symptoms arise?

Answer 11

1000mL

Question 12

2 most common causes of antepartum bleeding.

Answer 12

1. Placenta Abruptio

2. Placenta Previa

Question 13

What is important to remember before examining a patient with antepartum hemorrhage?

Answer 13

DO NOT check the cervix until placenta previa has been ruled out.

Question 14

Most accurate means of determining cause of antepartum bleeding.

Answer 14

Ultrasound, very good at detecting placenta previa but not abruption

Question 15

What should a physician considered if a patient had painful vagina bleeding antepartum that was temporarily relieved?

Answer 15

Uterine Rupture

Question 16

What should a physician consider if a patient has painless bright red antepartum vaginal bleeding?

Answer 16

Placenta Previa

Question 17

What should a physician consider if a patient has painful red antepartum vaginal bleeding?

Answer 17

Placenta Abruptio

Question 18

How is a placenta previa case handled with a preterm infant and a stable mother?

Answer 18

Amniocentesis to test for lung maturity

Deliver by C-section (unless lungs immature, then bed rest for mother with possible transfusion)

Rhogam if mother is Rh(-)

Question 19

What is the Kleihauer-Betke test?

Answer 19

Test to see what dose of Rhogam is needed to cover the amount of blood mixing that occurs between the mother and fetus in an Rh(-) mother

Question 20

How is a placenta previa case handled in an unstable mother or baby?

Answer 20

Immediate C-section

Question 21

2 biggest risk factors for placenta abruptio.

Answer 21

1. Maternal HTN

2. Cocaine abuse

Question 22

What is Couvelaire Uterus?

Answer 22

Bluish purple discoloration of the uterus caused by blood dissecting the myometrium after placenta abruptio.

Question 23

How is placenta abruptio managed?

Answer 23

Primary goal is to stabilize the mother. Keep blood products on hand in case of DIC. Vaginal delivery preferred.

Question 24

What is the treatment of choice for a Uterine Rupture?

Answer 24

Total Abdominal Hysterectomy

uterus and cervix removed

Question 25

Main cause of post-partum hemorrhage.

Answer 25

Uterine Atony | -failure of uterine contraction preventing myometrium blood vessels that were supplying the placenta from closing off.

Question 26

How is postpartum hemorrhage diagnosed?

Answer 26

Insepction/palpation for all causes except coagulation defects.

Question 27

Best 3 medications to treat postpartum bleeding caused by uterine atony.

Answer 27

Pitocin (IV) Methergine (ergonovine) PG F2-alpha

Question 28

Second most common cause of postpartum bleeding.

Answer 28

Genital Tract Trauma | uterus will be hypertonic on palpation, as opposed to atony where it will be soft

Question 29

What is the management strategy for postpartum bleeding due to a "retained placenta"?

Answer 29

Manual removal or D&C. -often caused by accreta, increta, or percreta in which case evaluation may be necessary to determine if a hysterectomy is needed.

Question 30

Main cause of a uterine inversion.

Answer 30

Delivering placenta too early, leads to vasovagal shock.

Question 31

Treatment for a uterine inversion.

Answer 31

OMT

Question 32

Medications used in management of uterine inversion.

Answer 32

Halothan or terbutaline for anesthesia | Pitocin after uterus is put back in place

Question 33

Most lethal form of a coagulation disorder leading to postpartum bleeding.

Answer 33

Amniotic Fluid Embolism | -leads to DIC (80% mortality)