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SNRAObPedGer > Anterpartum And PPH > Flashcards

Anterpartum And PPH Flashcards

1
Q

Most common cause of maternal mortality worldwide

A

Hemorrhage

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2
Q

What is the true definition of MAJOR Obstetric hemorrhage

A

Defined as a transfusion of 5 or MORE units of PRBCs

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3
Q

Increase rates of PPH with 3 things (PAC)

A

Postpartum uterine atony
Abnormal placentation
Cesarean deliveries

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4
Q

Most hemorrhage is because of poor

A

Recognizing risk factors
Accurately assess blood loss
Initiate treatment in timely fashion
NOT COMMUNICATING

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5
Q

Most HIGHEST INCIDENCE common cause of pregnancy related deaths due to hemorrhage
ALUCPUR

A 
Abruptio Placenta
Laceration /uterine rupture
Uterine atony
Coagulopathies
Placenta previa--> accreta, increta, percreta
Uterine bleeding
Retained placenta
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6
Q

Is anterpartum hemorrhage a medical or surgical

A

Medical emergency (no need to rush to surgery)

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7
Q

True definition of antepartum hemorrhage____usually what trimester?

A

Vaginal blood loss AFTER 20 weeks of gestation

1st

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8
Q

Biggest threat of hemorrhage BEFORE delivery is to the

A

FETUS

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9
Q

Biggest threat of hemorrhage AFTER delivery is to the

A

Mother

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10
Q

4 main causes of Antepartum hemorrhage

PPUV

A

Placenta Previa
Placenta Abruptio
Uterine Rupture
Vasa Previa

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11
Q

What is placenta previa

A

When placenta is implanted to lower segment of the uterus , presenting ahead of the LEADING POLE OF THE FETUS

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12
Q

4 types of Placenta Previa

TPML

A

Total
Partial
Marginal
Low-lying placenta

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13
Q

What is a TOTAL placenta previa?

A

Internal cervical OS covered completed by placenta

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14
Q

What is a PARTIAL placenta previa>?

A

Internal cervical OS partially covered by placenta

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15
Q

What is a MARGINAL placenta previa?

A

Edge of placenta at margin of internal os

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16
Q

What is a low lying placenta?

A

Placenta is implanted in lower uterine segment –> Placental edge does not actualy reach internal os but in close proximity to it

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17
Q

Os stands for

A

opening

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18
Q

In placenta previa what causes the bleeding?

A

small disruption in placental attachment during normal development and thinning of lower uterine segment

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19
Q

In placenta previa: Perinatal morbidity and mortality primarily related to

A

Prematurity

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20
Q

In placenta previa hemorrhage is a

A

Maternal problem

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21
Q

List etiology of Placenta previa (AMMPPS)

A 
Advanced Maternal Age >35
Multiparity
Multifetal gestations
Prior C-section
Smoking
Prior Placenta previa
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22
Q

What is the hallmark of placenta Previa

A

Painless hemorrhage

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23
Q

When does placenta previa most occur

A

end of/or after 2nd trimester

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24
Q

In placenta previa Bleeding rarely enough to be

A

Fatal

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25
Q

Placenta previa may be associated with

A

placenta accreta, increta, or percreta

May cause massive bleeding

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26
Q

Avoid this at all cost with placenta previa

A

No vaginal or cervical examination

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27
Q

SAFEST diagnostic test with placenta previa

A

Transabdominal US

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28
Q

MOST ACCURATE diagnostic test with placenta previa

A

TRANSVAGINAL ultrasonograpy INCREASE RISK OF BLEEDING THOUGH

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29
Q

Placenta Previa with moderate bleeding if >34/52

A

C-section

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30
Q

Placenta Previa with moderate bleeding if <34/52

A

Resuscitate STEROIDS then if stable Conservative care, if unstable –> C-section

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31
Q

As general if symptoms with bleeding

A

C-section

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32
Q

As general if NO Ssymptoms WITH bleeding

A

Conservative care

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33
Q

With placenta previa deliver via

A

C-section (possible hysterectomy)

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34
Q

Placenta abruptio

A

Premature separation of NORMALLY IMPLANTED PLACENTA , spiral arteries comes out start bleeding

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35
Q

Placenta abruption factors

A

External hemorrhage
Concealed (internal hemorrhage)
Total
Partial

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36
Q

Placental Abruption primary cause unknown but associated with
PPP CCC IPUEM

A 
Increage age and parity
Pre-eclampsia
Chronic HTN
PROM
Multiple gestation
Hydramnios
CIgarette smoking
Cocaine use
Prior abruption
Uterine Leiomyoma
External Trauma
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37
Q

Pathophysiology of Placenta Abruption

A

There is hemorrhage to DECIDUA BASALIS –> DESIDUAL SPLIT leaving thin layer that stucks to myometrium –> develop dedidua hemorrhage leads to separation, compression and ultimate destruction of adjacent placental tissue

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38
Q

In placenta Abruption bleeding can be either

A

Fetal or maternal

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39
Q

Fetal bleeding results from

A

tear or fracture in placenta RATHER THAN From separation itself

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40
Q

Placenta abruption signs and symptoms HALLMARK

A

Bleeding with PAIN varying from mild cramping to severe

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41
Q

What does not exclude platenta abruption

A

Negative US

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42
Q

Placenta abruption signs and symptoms uterus

A

Firm , tender uterus with INCREASE FUNDUS HEIGHT

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43
Q

What are the complications of Placenta Abruption

DFCC

A

DIC
Renal failure
Fetal death
Couvelaire uterus

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44
Q

Treatment of Placenta Abruption depends on

A

Gestational age
Status of mother and fetus

Admit, HandP, IV access, placental localization

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45
Q

Uterine rupture is

A

Part of baby coming out with an intact amniotic sac

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46
Q

Most common maternal morbidity is from

A

Hemorrhage

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47
Q

Uterine Rupture most common with

A

VBAC

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48
Q

Women with uterine scar and hx of leiomyomectomy at risk for

A

Uterine rupture

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49
Q

Classic presentation of Uterine rupture, what do you see?

A

Feet coming out

50
Q

Uterine rupture classic presentation

VPACLEP

A

Vaginal bleeding
Pain
Cessation of contraction
Absence/deterioration of FHR
Loss of station of the fetal head from birth canal
Easily palpate fetal parts
Profound Maternal TACHYCARDIA and HYPOTENSION

51
Q

Risk factors for Uterine Rupture

PPP TEMSF

A 
Excessive uterine stimulation 
Previous C section
Trauma
Prior rupture
Previous uterine sx 
Multiparity
Shoulder distocia
Forceps delivery
52
Q

Uterine rupture management

A

EMERGENT LAPAROTOMY

Arterial line

53
Q

Placenta accreta is

A

whole or partly invades uterine wall and is INSEPARABLE FROM IT

54
Q

What are the 3 types of placenta accreta

A

Accreta vera
Placenta increta
Placenta percreta

55
Q

Placenta Accreta vera is

A

Adherence of basal plate of placenta directly to uterine myometrium without penetrating the decidua layer

56
Q

Placenta Accreta increta is

A

Chorionic villi invade myometrium

57
Q

Placenta accreta percreta is

A

Invasion through MYOMETRIUM into SEROSA and even adjacent ORGANS (bladder)

58
Q

Placenta accreta blood loss can be as high as

A

20,000ml

59
Q

VASA Previa is

A

rare condition where fetal vessels from placenta cross entrance of birth canal

60
Q

VASA previa associated with

A

increased fetal mortality

61
Q

3 typical causes of Vasa previa

A

bi-lobed placenta
Velamentous insertion of umbilicord
Succenturiate (accessory lobe)

62
Q

Risk factors of VASA PREVIA

A

fu

63
Q

Management of vasa previa ; if detected prior to labor

A

HIGH FETAL survival

64
Q

How is vasa previa detected?

A

Transvaginal sonography

65
Q

Method of delivery for vasa previa (preferred)

A

Elective C section

66
Q

What is the Kleihauer-Betke test

A

Measures amount of fetal Hgb transferred from fetus to mother’s bloodstream

67
Q

Kleihauer-Betke determine

A

dose of Rh Immunoglobulin (RHOGAM)

68
Q

Use for detecting fetal-maternal hemorrhage

A

Kleihauer-Betke

69
Q

APT test helps

A

determine origin of blood (Fetal vs maternal )

70
Q

PostPartum Hemorrhage (PPH) timing of bleeding

A

if occurs in first 24 hours after delivery , termed early PPH late if>24 hours.

71
Q

Early PPH Involves

A

Heavier bleeding and increased mortality

72
Q

PPH you can see

A

White lips in mucous membrane

73
Q

Key in interventions of PPH

A

Prevention
Early recognition
Prompt interventions

74
Q

Normal blood loss for Vaginal

A

500ml

75
Q

Normal blood loss for C-section

A

1000ml

76
Q

PPH definition are

A

> 500 vaginal

>1000 C-section

77
Q

What is the alternative definition for PPH

A

10% in hematocrit

78
Q

Conditions that DECREASE maternal Blood volume (SES)

A

Small stature
Severe preeclampsia/eclampsia
Early gestational age

79
Q

Clinical findings in PPH: Compensation
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________

A

500-1000ml (10-15%)
none4
Palpitations, dizziness, tachycardia (DPT)

80
Q

Clinical findings in PPH: MILD
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________

A

1000-1500 (15-25%)
slight fall (80-100mmhg)
Weakness, sweating, tachycardia (WTS)

81
Q

Clinical findings in PPH: MODERATE
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________

A

1500-2000ml (25-35%)
marked fall (70-80mmhg)
restlessness, pallor, oliguria (POR)

82
Q

Clinical findings in PPH: SEVERE
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________

A

2000-3000ml (35-45%)
Profound fall (50-70mmhg)
Collapse, air hunger, anuria (ACA)

83
Q

Postparthum hemorrhage : Etiology (4) Ts

A

Tone
Tissue
Trauma
Thrombin

84
Q

Tissue cause of PPH

A

Retained products of conception

85
Q

Trauma cause of PPH

A

Genitral tract trauma

86
Q

Thrombin cause of PPH

A

Coagulation abnormalities.

87
Q

Take home message for PPH

A

Do not go over 1 MAC of anesthesia with FURTHER DECREASE UTERINE TONE

88
Q

Possible med combo for PPH

A

1/2 MAC, N2O + Ketamine

89
Q

2 thrombin cause of PPH

A

Vonwillebrand

Hemophillia A

90
Q

Uterotonic drug

A

Pitocin (oxytocin)

91
Q

When do you administer PITOCIN

A

After delivery of anterior shoulder

92
Q

How do you administer pitocin

A

20 units in 1L fluids , 10 units in 500ml

93
Q

Prophylactic use of pitocin

A

decrease therapeutic use

94
Q

Routine administration of pitocin in 3rd stage which is ________stage ______pph risk

A

delivery of placenta

Decrease

95
Q

Do not use this for pitocin

A

Pressure bag

96
Q

PPH drug therapy Methergine dose

A

0.2mg IM REPEAT every 5 minutes as needed maximum of 5 doses

97
Q

PPH drug therapy CARBOPROST (Hemabate)

A

0.25 IM q15 min as needed

98
Q

PPH summary of treatment of 4 Ts: Tone

PROM-MH

A 
Rule out uterine atony
Palpate fundus
Massage uterus
oxytocin
Methergine
Hemabate
99
Q

PPH summary of treatment of 4 Ts: Tissue

RIET

A

Rule out retained placenta
Inspect placenta for missing parts
Explore uterus
Treat abdominal implantation

100
Q

PPH summary of treatment of 4 Ts: Trauma

ROWIT

A 
Rule out cervical vaginal laceration
Obtain good exposure
Inspect cervix/ vagina
Worry about slow bleeders\
Treat hematomas
101
Q

Anesthesia management of peripartum hysterectomy

Blood management

A

Potential for massive blood loss

Have at least 4 units of PRBCs and other procoagulants immediately available.

102
Q

Anesthesia REGIONAL should be at wich level

A

T4 Nipple line

103
Q

Preferred anesthesia for PP hysterctomy

A

EPIDURAL (spinal won’t last)

104
Q

ANESTHESIA: If massive hemorrhage or known placenta percreta

A

GETA

105
Q

4 arguments for GETA for PP hysterctomy

A
  1. Severe hypotension may require airway protection
  2. Large fluid shifts and massive transfusion can affect oxygenation necessating control of ventilation
  3. Fluid shifts cause airway edema
  4. Central line easier to place under GETA
106
Q

TRALI Criteria (AHB ONNN)

A

Acute lung injury with acute onset
Hypoxemia (reserach PaO2/FiO2 <300, spo2<90
non research PaO2/FiO2 <300, spo2<90 OR OTHER
clinical evidence of hypoxemia
Bilateral infiltrates on frontal chest radiograph
No EVIDENCE OF left atrial HTN
No previous lung injury before transfusion
Occurs during or within 6 hour of transfusion
No relationship to an alternative cause of acute LI

107
Q

Liberal transfusion

A

may cause harm , studies does not show that it improves morbidity or mortality

108
Q

Abnormalities with massive transfusion

A

Hypocalcemia

Hypoerkalemia

109
Q

Massive transfusion protocol labs

A

DIC panel (PT, PTT, fibrinogen, Thrombin Time, D-dimer, CBC, ABC, TYPe and cross)

110
Q

Massive transfusion initial package

A

6 units of PRBCs
4 units of FFPs
1 Unit of Platelets

111
Q

If INR> 1.5

A

give 4 units FFP until bleeding controlled

112
Q

if platelet < 25000

A

Give 1 unit of PLT to increase by 30, 000-60000)

113
Q

If fibrinogen < 100

A

Give 10 pack of cryoprecipitate

114
Q

Salvage therapy

A

rFVII a

115
Q

Ratio for infusion that increases survial is

A

1:1

116
Q

PRBC Dose is ______
Volume per dose______
Expected response______

A

1 unit
200-325m;
1g increase in hgb

117
Q

FFP Dose is ______
Volume per dose______
Expected response______

A

Factor replacement 10-15ml/kg
200ml
Correction of PT, aPTT, INR by replacing coag factors

118
Q

Platelets Dose is ______
Volume per dose______
Expected response______

A

4-6 units
200-250ml
Increase platelet count of 30,000 - 60,000

119
Q

Cryoprecipitate Dose is ______
Volume per dose______
Expected response______

A

10 pooled units
100ml
Increase levels of fibrinogen , von willebrand factor, factor VIII and XIII

120
Q

Goals during massive tranfusion protocol : Optimise

A

Oxygenation
Cardiac output
Tissue Perfusion
Metabolic state

121
Q

Goals during massive tranfusion protocol : MONITOR q

FICA -____

A 
30-60 minutes
Full blood count
Coagulation screen
Ionised calcium
ABG
122
Q 
Goals during massive tranfusion protocol : AIM FOR
Temperature \_\_\_\_\_\_
ph\_\_\_\_\_
Bases excess\_\_\_\_
Lactate\_\_\_\_\_\_
Ca2+ \_\_\_\_\_\_\_
Platelets \_\_\_\_\_
PT/APTT \_\_\_\_
INR \_\_\_\_
Fibrinogen \_\_\_\_\_
A 
Temperature >35C
ph>7.2
Bases excess < -6
Lactate < 4
Ca2+> 1.1
Platelets > 50
PT/APTT < 1.5
INR < 1.5 
Fibrinogen > 1.0

SNRAObPedGer (25 decks)

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