9,11 post partum hemorrhage, 3rd T bleeding Flashcards
Retained placenta, causing PPH
- cause (2)
- risk factor, why?
- how to dx
- caused by a placenta that 1) burrows deeply (placenta accreta), or 2) accessory lobe
- Multiple pregnancies. Analogy: Oil well. If place already drilled, placenta must drill deeper (acceta) or wider (accessory lobe/placenta previa).
- if accessory lobe, we look at placent post-delivery and see vessels that run to the edge.
placenta previa
- sx
- main risk factors (2), why
- how to dx
- Tx
- painless 3rd trimester bleeding
- multiparity (uterus already penetrated in many regions so placenta much reach farther to find blood), multiple gestations (multiple placentas compete for space)
- U/S shows transverse lie of placenta
- Tx
Uterine inversion
- how to dx
- tx
- With PPH, you don’t feel a uterus
- Transvag surgery: Tack fornices in place, then oxytocin to contract uterus back to original position.
You can also use terbutaline to loosen uterus and try to push back in.
Third trimester bleeding differential dx: (7)
Painless:
- Placenta previa
- Vasa previa
Painful:
- Placental abruption
- Uterine rupture
MCC:
- polyps
- cervical lesions
- Bloody show (onset of labor)
Placental abruption
- sx
- mech
- risk factors/causes (3)
- how to dx
- Tx
- painful 3rd T bleed
- placenta tears off the uterus
- HTN, cocaine, MVC
- dx with U/S. Do NST for baby, may show fetal distress
- C/S
PPH caused by DIC
- mechanism
- What is in DIC panel? (7)
- Tx
- placental contents getting into mom’s blood can cause DIC, which creates fibrin clots, consuming platelets and clotting factors.
- Hematocrit; INR; Fibrinogen; Platelet Count; PT; PTT; D-Dimer
- FFP, Platelets, blood
PPH: differential dx (5)
- uterine atony (boggy uterus)
- uterine inversion (absent uterus)
- retained placenta, caused by placenta accreta or accessory lobe (firm uterus)
- vaginal lac (normal uterus)
- DIC (normal uterus)
Retained placenta, causing PPH
- Tx (2)
- how to f/u
- D&C. do this first
- TAH if D&C doesn’t work
f/u: Fear of choriocarcinoma from retained piece. Do beta-quant and OCPs x1 year to catch and prevent CC. Also do U/S
Pregnant patient at 38 weeks presents with contractions and vaginal bleeding. Think what? and do what (4) typically.
This may just be a Bloody show–normal bleeding in beginning of labor (changing cervical shape can free up mucus and blood)
Suspect the 4 deadly problems (placenta previa, vasa previa, uterine rupture, placental abruption). So,
- check vitals (check mom)
- speculum exam (check vagina)
- non-stress test (check baby)
- U/S (check placenta)
Do CBC/coags/DIC panel is bleeding is strong
Vasa previa
- mech
- sx
- dx
- tx
- vessels across the os that tear, rare. Often caused by a accessory lobe
- painless 3rd T bleeding. Classic: ROM followed by painless vag bleeding and fetal bradycardai
- fetal bradycardia/fetal distress
- C/S, urgent. You have time to do U/S and CST
uterine atony, causing PPH
- how to dx
- tx
- you feel boggy uterus
- Get the uterus contracting. Tx with uterine massage, then methergine (methylergometrine), then oxytocin.
PPH
-MCC
uterine atony (boggy uterus)
PPH definition?
Normal bleeding amount limit in delivery:
Vaginal vs C/S
PPH: bleeding more than values 500/1000 mL
Normal bleeding amounts:
Vaginal: <500 ml
C/S: <1000 ml
Pregnant woman can withstand 1000 ml blood loss. Non-pregnant 500 ml.
Vaginal laceration
- tx
- how to dx
- Local anes and suture
- uterus feels normal
PPH diagnosis: What is it if you feel uterus:
- boggy
- absent
- firm
- normal
- uterine atony
- uterine inversion
- retained placenta (placenta accreta/accessory lobe)
- vaginal lac, or DIC
