antepartum and postpartum hemorrhage Flashcards
antepartum hemorrhage definition
20+ weeks bleeding
differential diagnosis for antepartum hemorrhage
abruption
placenta previa
vasa previa labour lower genital tract lesion uterine rupture unclassified / marginal separation
management/workup of antepartum hemorrhage
vitals / stability
fetal heart rate monitor + toco
if unstable, stabilize +/- deliver
hx - FM, amount, ctxns, ROM, pain, other
US for placental location
spec exam - lesions, ROM, bleeding amount + location VE - ONLY after US to r/o previa: cervix
CBC, group + screen, coags, Betker-Kleinhaur test
Rh if indicated
admit for monitoring for 48hrs if had significant bleed
placenta previa definitions
complete: covers os
central: int os equidistant from ant + post edge
partial: covers part
marginal: adjacent but doesn’t cover
low lying: within 2 cm
can do TOL if >10mm
diagnosis of placenta previa
TVUS
RFs for placenta accreta
prior placenta previa prior CS or surgery multiples multiparity AMA
asymptomatic placenta previa management
- if <2cm at anatomy scan, repeat at 32-32wks
- avoid intercourse, exercise, seek attention if ctxn or bleed
- C/S at 37-38wks
- cross match and type blood at delivery
- can use tranexamic acid if need at delivery
- can use cell saver to return blood
management of bleed in previa
- painless vag bleed
- admit + start maternal + fetal monitoring
- ABCs
- give IV crystalloids
- take blood: CBC, coags, group and screen, cross match and type 4 units RBCs
- O2 and pulse oximetry
if mom or fetus unstable
- stablize
- transfuse, watch for DIC
- call code OB
- immediate CS
both stable:
- mature fetus: CS
- immature: steroids, transfusion, transfer, monitor, can discharge if no bleed for 48 hrs + outpatient monitor
Rhogam if indicated
abruptio placenta causes
- chronic vasculopathy, thromboses, failed transformation
- trauma
- PPROM
RF for abruption
prev hx trauma ROM fibroid uterine or placental anomaly smoking HTN parity AMA cocaine thrombophilias multiples polyhydramnios
symptoms + signs + labs of abruption
- vag bleed
- abdo pain
- contractions
- FHR abnormality/demise
- back pain
- US may be normal
- coagulopathy: hypofibrinoginemia and thrombocytopenia
note: concealed hemorrhage or couvelaire uterus is possible
management of abruption
- determine stability of mom + baby
- 2 large bore IV, crystalloids
- blood: CBC, coags, G + S, cross + type
- cont monitoring
- O2 + pulse oximetry
if unstable:
- call for help
- rescus/stabilize
- deliver
- watch for DIC
if stable:
- mature: vag delivery or CS
- immature: steroids, transfuse, transfer, admit for monitoring, induce when term
- if dead fetus: induce labour + watch for DIC
Give Rh if indicated + Betke Kleihauer test
vasa previa description + management
- fetal vessels transverse membranes ahead of presenting part
- usually /w velementous cord insertion (naked vessels in membranes)
- rupture –> sinusoidal heart rate, fetal hypotension + anemia
- mild vag bleeding
- high fetal mortality
- emergency CS
- rare can dx on VE or US
- fetal surveillance + cervical length, schedule CS at maturity
defintion of PPH, immed, delayed
> 500cc in VD
1000cc in CS
immed = within 24 hrs delayed = 24hrs - 6 wks
causes of PPH
Tone - atony, multiples, macrosomia, precipitous or long, polyhydraminos, oxytocin, GA, grand multip, infection (fever, prolonged ROM), fibroids, previa
Trauma - uterine, cervical or vac laceration, uterine rupture or inversion
Tissue - RPOC, abnormal placentation, retained clot
Thrombin- coagulopathy (hemophilia, VWD), acquired (ITP, thrombocytopenia /w pre-eclampsia, DIC), anticoagulants
