antepartum and postpartum hemorrhage

Question 1

antepartum hemorrhage definition

Answer 1

20+ weeks bleeding

Question 2

differential diagnosis for antepartum hemorrhage

Answer 2

abruption
placenta previa

vasa previa
labour
lower genital tract lesion
uterine rupture
unclassified /  marginal separation

Question 3

management/workup of antepartum hemorrhage

Answer 3

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

Question 4

placenta previa definitions

Answer 4

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

Question 5

diagnosis of placenta previa

Answer 5

TVUS

Question 6

RFs for placenta accreta

Answer 6

prior placenta previa
prior CS or surgery
multiples
multiparity
AMA

Question 7

asymptomatic placenta previa management

Answer 7

• 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

Question 8

management of bleed in previa

Answer 8

• 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

Question 9

abruptio placenta causes

Answer 9

• chronic vasculopathy, thromboses, failed transformation
• trauma
• PPROM

Question 10

RF for abruption

Answer 10

prev hx
trauma
ROM
fibroid
uterine or placental anomaly
smoking
HTN
parity
AMA
cocaine
thrombophilias
multiples
polyhydramnios

Question 11

symptoms + signs + labs of abruption

Answer 11

• 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

Question 12

management of abruption

Answer 12

• 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

Question 13

vasa previa description + management

Answer 13

• 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

Question 14

defintion of PPH, immed, delayed

Answer 14

> 500cc in VD
1000cc in CS

immed = within 24 hrs
delayed = 24hrs - 6 wks

Question 15

causes of PPH

Answer 15

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

Question 16

prevention of PPH

Answer 16

• oxytocin after delivery
• clamp + cut cord
• palpate fundus, firm
• gental cord traction + counter traction - avoid inversion
• oxytocin infusion if placenta not delivered in 15 min
• palpate fundus after placenta
• inspect placenta
• examine genitalia for lac, hematoma

Question 17

management of PPH

Answer 17

• ABC: vitals, large bore IV, crystalloids wide open
• CBC, cross match and PT/PTT, fibrinogen levels
• call help, notify blood bank possible MTP
• assess fundus, if boggy bimanual massage
• explore cavity for retained products, inversion, or rupture if analgesia permits
• look for genital lesions, placenta complete
• empty bladder + monitor urine output
• may need to examine under anaesthesia

drugs

• oxytocin: 5 units IV bolus, 20-40 units/250ml crystalloid, 10 units IM if no IV
• carbetocin: 100ug IV/IM
• hemabate: 250ug IM or intramyometrial, repeat q15min PRN up to 2mg - CI if asthma
• methylergonovine maleate: 0.25mg IM/0.125mg IV, q5min up to 5x - CI in HTN
• misoprostol: 600-800ug SL or PR, SE = pyrexia
• tranexamic acid: 1g IV

procedures

• bakri balloon
• uterine vessel ligation
• internal iliac artery ligation
• uterine suturing techniques
• hysterctomy

If coagulopathy

• FFP
• cyroprecipitate
• platelets
• RBCs

Question 18

RF/causes of inversion

Answer 18

iatrogenic often

grand multip /w fundal placenta

Question 19

diagnosis + effects + tx of inversion

Answer 19

placenta at introitus /w mass attached

shock: bradycardia from vagal tone

replace uterus promptly /w placenta

NO (tocolytic) may help replace

if fails laparotomy