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TN Obstetrics > 5. Obstetrical Hemorrhage > Flashcards

5. Obstetrical Hemorrhage Flashcards

1
Q

Define: Obstetrical Hemorrhage (1)

A

vaginal bleeding from 20 wk to term

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2
Q

Name DDX for obstetrical hemorrhage (7)

A
  • bloody show (represents cervical changes/early stages of dilation) – most common etiology in T3
  • placenta previa
  • abruptio placentae – most common pathological etiology in T3
  • vasa previa
  • cervical lesion (cervicitis, polyp, ectropion, cervical cancer)
  • uterine rupture
  • other: bleeding from bowel or bladder, abnormal coagulation
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3
Q

Define: Placenta Previa (1)

A

Abnormal location of the placenta near, partially, or completely over the internal cervical os

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4
Q

Name etiology and epidemiology: Placenta Previa (2)

A
  • Idiopathic
  • 0.5-0.8% of all pregnancies
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5
Q

Name etiology and epidemiology: Abruptio Placentae (2)

A
  • Idiopathic
  • 1-2% of all pregnancies
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6
Q

Define: Abruptio Placentae (1)

A

Premature separation of a normally implanted placenta after 20 wk GA

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7
Q

Name risk factors: Placenta Previa (6)

A
  • History of placenta previa (4-8% recurrence risk)
  • Multiparity
  • Increased maternal age
  • Multiple gestation
  • Uterine tumour (e.g. fibroids) or other uterine anomalies
  • Uterine scar due to previous abortion, C/S, D&C, myomectomy
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8
Q

Name risk factors: Abruptio Placentae (8)

A
  • Previous abruption (recurrence rate 5-16%)
  • Maternal HTN (chronic or gestational HTN in 50% of abruptions) or vascular disease
  • Cigarette smoking (>1 pack/d), excessive alcohol consumption, cocaine
  • Multiparity and/or maternal age >35 yr
  • preterm premature rupture of membranes (PPROM)
  • Rapid decompression of a distended uterus (polyhydramnios, multiple gestation)
  • Uterine anomaly, fibroids
  • Trauma (e.g. motor vehicle collision, maternal battery)
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9
Q

Differentiate bleeding of Placenta Previa and Abruptio Placentae (2)

A
  • Placenta Previa: Painless
  • Abruptio Placentae: Usually painful
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10
Q

Define: Placenta Previa (2)

A
  • placenta implanted in the lower segment of the uterus, presenting ahead of the leading pole of the fetus
  • placental position is described in relation to the internal os as “mm away” or “mm of overlap”
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11
Q

Name clinical features: Placenta Previa (7)

A
  • PAINLESS bright red vaginal bleeding (recurrent), may be minimized and cease spontaneously but can become catastrophic
  • mean onset of bleeding is 30 wk GA, but onset depends on degree of previa
  • physical exam
    • do not perform digital vaginal exam until ruling out placenta previa
    • uterus soft and non-tender
    • presenting fetal part high or displaced
    • FHR usually normal
    • shock/anemia correspond to degree of apparent blood loss
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12
Q

Name FETAL complications: Placenta Previa (6)

A
  • perinatal mortality low but still higher than with a normal pregnancy
  • prematurity (bleeding often dictates early C/S)
  • intrauterine hypoxia (acute or intrauterine growth restriction IUGR)
  • fetal malpresentation
  • preterm premature rupture of membranes (PPROM)
  • risk of fetal blood loss from placenta, especially if incised during C/S
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13
Q

Name FETAL complications: Placenta Previa (6)

A
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14
Q

Name MATERNAL complications: Placenta Previa (4)

A
  • <1% maternal mortality
  • hemorrhage and hypovolemic shock, anemia, acute renal failure, and pituitary necrosis (Sheehan syndrome)
  • placenta accreta – especially if previous uterine surgery or anterior placenta previa
  • hysterectomy
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15
Q

Name investigations: Placenta Previa (3)

A
  • transvaginal U/S is more accurate than transabdominal U/S at diagnosing placenta previa at any gestational age
  • spontaneously resolution is likely with increasing uterine distention if the placenta obscures the internal os by less than 20 mm at 20 wk GA
  • transvaginal U/S should be repeated in the T3 as continued change in the placental location is likely
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16
Q

Name goal of management of: Placenta Previa (1)

A
  • keep pregnancy intrauterine until the risk of continuing pregnancy outweighs the risk of preterm delivery
17
Q

Describe the management of Placenta Previa (8)

A
  • stabilize and monitor
    • maternal stabilization: large bore IV with hydration, O2 for hypotensive patients
    • maternal monitoring: vitals, urine output, blood loss, blood work (hematocrit, CBC, INR/PTT, platelets, fibrinogen, FDP, type and cross match)
    • electronic fetal monitoring
    • U/S assessment: when fetal and maternal conditions permit, determine fetal viability, GA, and placental position
  • Rhogam® if mother is Rh negative
  • Kleihauer-Betke test to determine extent of fetomaternal transfusion and administer Rhogam® at adequate dose
  • GA <37 wk and minimal bleeding: expectant management
    • admit to hospital
    • limited physical activity, no douches, enemas, or sexual intercourse
    • consider corticosteroids for fetal lung maturity
    • delivery when fetus is mature or hemorrhage indicating maternal or fetal compromise
  • GA ≥37 wk – deliver by C/S
18
Q

When to perferm vaginal exam for placenta previa? (1)

A

Do NOT perform a vaginal exam until placenta previa has been ruled out by U/S

19
Q

Define: Abruptio Placentae (2)

A
  • partial or total placental detachment that is premature and caused by bleeding at the decidual-placental interface
  • occurring >20 wk gestation
20
Q

Describe classification: Abruptio Placentae (4)

A
  • total (fetal death inevitable) vs. partial
  • external/revealed/apparent: blood dissects downward toward cervix
  • internal/concealed/occult (20%): blood dissects upward toward fetus, may or may not present with vaginal bleeding
  • most are mixed
21
Q

Describe presentation: Abruptio Placentae (4)

A
  • usually PAINFUL (80%) vaginal bleeding (bleeding not always present if abruption is concealed), uterine tenderness, uterine contractions/hypertonus
  • pain: sudden onset, constant, localized to lower back and uterus
  • shock/anemia out of proportion to apparent blood loss
  • ± fetal distress, fetal demise (15% present with demise), bloody amniotic fluid (fetal presentation typically normal)
  • ± coagulopathy
22
Q

Name complications: Abruptio Placentae (10)

A
  • fetal complications:
    • perinatal mortality 25-60%
    • prematurity
    • intrauterine hypoxia
  • maternal complications:
    • <1% maternal mortality
    • disseminated intravascular coagulation DIC (in 20% of abruptions)
    • acute renal failure
    • anemia
    • hemorrhagic shock
    • pituitary necrosis (Sheehan syndrome)
    • amniotic fluid embolus
23
Q

Name investigations: Abruptio Placentae (1)

A

clinical diagnosis, U/S not sensitive for diagnosing abruption (sensitivity = 15%)

24
Q

Describe management: Abruptio Placentae (7)

A
  • maternal stabilization: large bore IV with hydration, O2 for hypotensive patients
  • maternal monitoring: vitals, urine output, blood loss, blood work (hematocrit, CBC, PTT/PT, platelets, fibrinogen, FDP, type and cross match)
  • electronic fetal monitoring
  • blood products on hand (red cells, platelets, cryoprecipitate) because of DIC risk
  • Rhogam® if Rh negative
    • Kleihauer-Betke test may confirm abruption
  • abruption without fetal/maternal compromise (mild abruption)
    • GA <37 wk: use serial Hct to assess concealed bleeding, deliver when fetus is mature or when hemorrhage dictates
    • GA ≥37 wk: stabilize and deliver
  • abruption with fetal/maternal compromise (moderate to severe abruption)
    • hydrate and restore blood loss and correct coagulation defect if present
    • vaginal delivery if no contraindication and no evidence of fetal or maternal distress
    • C/S if live fetus and fetal or maternal distress develops with fluid/blood replacement, labour fails to progress, or if vaginal delivery otherwise contraindicated
25
Q

Name the most common cause of disseminated intravascular coagulation (DIC) in pregnancy (1)

A

Abruptio placentae

26
Q

Describe: Kleihauer-Betke Test (1)

A

Quantifies fetal cells in the maternal circulation

27
Q

Define: Vasa Previa (2)

A
  • unprotected fetal vessels pass over the cervical os
  • associated with velamentous insertion of cord into membranes of placenta or succenturiate (accessory) lobe
28
Q

Describe epidemiology: Vasa Previa (1)

A
  • 1 in 5000 deliveries – higher in twin pregnancies
29
Q

Describe clinical features: Vasa Previa (3)

A
  • PAINLESS vaginal bleeding and fetal distress (tachy-to-bradyarrhythmia in a sinusoidal pattern)
  • if undiagnosed, 50% perinatal mortality, increasing to 75% if membranes rupture (most infants die of exsanguination)
  • if diagnosed antenatally on U/S without labour or symptoms, then 97% survival
30
Q

Describe investigations: Vasa Previa (2)

A
  • Apt test (NaOH mixed with the blood) can be done immediately to determine if the source of bleeding is fetal (supernatant turns pink) or maternal (supernatant turns yellow)
  • Wright’s stain on blood smear and look for nucleated red blood cells (in cord, not maternal blood)
31
Q

Describe management: Vasa Previa (2)

A
  • planned C/S (35-36 weeks)
  • or if bleeding, emergency C/S (since bleeding is from fetus, a small amount of blood loss can have catastrophic consequences)
32
Q

Name Obstetrical Complications (7)

A
  • Preterm Labour
  • Premature Rupture of Membranes
  • Postterm Pregnancy
  • Intrauterine Fetal Demise
  • Intrauterine Growth Restriction
  • Macrosomia
  • Polyhydramnios/Oligohydramnios

TN Obstetrics (16 decks)

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