Anterpartum And PPH Flashcards
1
Q
Most common cause of maternal mortality worldwide
A
Hemorrhage
2
Q
What is the true definition of MAJOR Obstetric hemorrhage
A
Defined as a transfusion of 5 or MORE units of PRBCs
3
Q
Increase rates of PPH with 3 things (PAC)
A
Postpartum uterine atony
Abnormal placentation
Cesarean deliveries
4
Q
Most hemorrhage is because of poor
A
Recognizing risk factors
Accurately assess blood loss
Initiate treatment in timely fashion
NOT COMMUNICATING
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
6
Q
Is anterpartum hemorrhage a medical or surgical
A
Medical emergency (no need to rush to surgery)
7
Q
True definition of antepartum hemorrhage____usually what trimester?
A
Vaginal blood loss AFTER 20 weeks of gestation
1st
8
Q
Biggest threat of hemorrhage BEFORE delivery is to the
A
FETUS
9
Q
Biggest threat of hemorrhage AFTER delivery is to the
A
Mother
10
Q
4 main causes of Antepartum hemorrhage
PPUV
A
Placenta Previa
Placenta Abruptio
Uterine Rupture
Vasa Previa
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
12
Q
4 types of Placenta Previa
TPML
A
Total
Partial
Marginal
Low-lying placenta
13
Q
What is a TOTAL placenta previa?
A
Internal cervical OS covered completed by placenta
14
Q
What is a PARTIAL placenta previa>?
A
Internal cervical OS partially covered by placenta
15
Q
What is a MARGINAL placenta previa?
A
Edge of placenta at margin of internal os
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
17
Q
Os stands for
A
opening
18
Q
In placenta previa what causes the bleeding?
A
small disruption in placental attachment during normal development and thinning of lower uterine segment
19
Q
In placenta previa: Perinatal morbidity and mortality primarily related to
A
Prematurity
20
Q
In placenta previa hemorrhage is a
A
Maternal problem
21
Q
List etiology of Placenta previa (AMMPPS)
A
Advanced Maternal Age >35 Multiparity Multifetal gestations Prior C-section Smoking Prior Placenta previa
22
Q
What is the hallmark of placenta Previa
A
Painless hemorrhage
23
Q
When does placenta previa most occur
A
end of/or after 2nd trimester
24
Q
In placenta previa Bleeding rarely enough to be
A
Fatal
25
Placenta previa may be associated with
placenta accreta, increta, or percreta
| May cause massive bleeding
26
Avoid this at all cost with placenta previa
No vaginal or cervical examination
27
SAFEST diagnostic test with placenta previa
Transabdominal US
28
MOST ACCURATE diagnostic test with placenta previa
TRANSVAGINAL ultrasonograpy INCREASE RISK OF BLEEDING THOUGH
29
Placenta Previa with moderate bleeding if >34/52
C-section
30
Placenta Previa with moderate bleeding if <34/52
Resuscitate STEROIDS then if stable Conservative care, if unstable --> C-section
31
As general if symptoms with bleeding
C-section
32
As general if NO Ssymptoms WITH bleeding
Conservative care
33
With placenta previa deliver via
C-section (possible hysterectomy)
34
Placenta abruptio
Premature separation of NORMALLY IMPLANTED PLACENTA , spiral arteries comes out start bleeding
35
Placenta abruption factors
External hemorrhage
Concealed (internal hemorrhage)
Total
Partial
36
Placental Abruption primary cause unknown but associated with
PPP CCC IPUEM
```
Increage age and parity
Pre-eclampsia
Chronic HTN
PROM
Multiple gestation
Hydramnios
CIgarette smoking
Cocaine use
Prior abruption
Uterine Leiomyoma
External Trauma
```
37
Pathophysiology of Placenta Abruption
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
38
In placenta Abruption bleeding can be either
Fetal or maternal
39
Fetal bleeding results from
tear or fracture in placenta RATHER THAN From separation itself
40
Placenta abruption signs and symptoms HALLMARK
Bleeding with PAIN varying from mild cramping to severe
41
What does not exclude platenta abruption
Negative US
42
Placenta abruption signs and symptoms uterus
Firm , tender uterus with INCREASE FUNDUS HEIGHT
43
What are the complications of Placenta Abruption
| DFCC
DIC
Renal failure
Fetal death
Couvelaire uterus
44
Treatment of Placenta Abruption depends on
Gestational age
Status of mother and fetus
Admit, HandP, IV access, placental localization
45
Uterine rupture is
Part of baby coming out with an intact amniotic sac
46
Most common maternal morbidity is from
Hemorrhage
47
Uterine Rupture most common with
VBAC
48
Women with uterine scar and hx of leiomyomectomy at risk for
Uterine rupture
49
Classic presentation of Uterine rupture, what do you see?
Feet coming out
50
Uterine rupture classic presentation
| VPACLEP
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
Risk factors for Uterine Rupture
| PPP TEMSF
```
Excessive uterine stimulation
Previous C section
Trauma
Prior rupture
Previous uterine sx
Multiparity
Shoulder distocia
Forceps delivery
```
52
Uterine rupture management
EMERGENT LAPAROTOMY
| Arterial line
53
Placenta accreta is
whole or partly invades uterine wall and is INSEPARABLE FROM IT
54
What are the 3 types of placenta accreta
Accreta vera
Placenta increta
Placenta percreta
55
Placenta Accreta vera is
Adherence of basal plate of placenta directly to uterine myometrium without penetrating the decidua layer
56
Placenta Accreta increta is
Chorionic villi invade myometrium
57
Placenta accreta percreta is
Invasion through MYOMETRIUM into SEROSA and even adjacent ORGANS (bladder)
58
Placenta accreta blood loss can be as high as
20,000ml
59
VASA Previa is
rare condition where fetal vessels from placenta cross entrance of birth canal
60
VASA previa associated with
increased fetal mortality
61
3 typical causes of Vasa previa
bi-lobed placenta
Velamentous insertion of umbilicord
Succenturiate (accessory lobe)
62
Risk factors of VASA PREVIA
fu
63
Management of vasa previa ; if detected prior to labor
HIGH FETAL survival
64
How is vasa previa detected?
Transvaginal sonography
65
Method of delivery for vasa previa (preferred)
Elective C section
66
What is the Kleihauer-Betke test
Measures amount of fetal Hgb transferred from fetus to mother's bloodstream
67
Kleihauer-Betke determine
dose of Rh Immunoglobulin (RHOGAM)
68
Use for detecting fetal-maternal hemorrhage
Kleihauer-Betke
69
APT test helps
determine origin of blood (Fetal vs maternal )
70
PostPartum Hemorrhage (PPH) timing of bleeding
if occurs in first 24 hours after delivery , termed early PPH late if>24 hours.
71
Early PPH Involves
Heavier bleeding and increased mortality
72
PPH you can see
White lips in mucous membrane
73
Key in interventions of PPH
Prevention
Early recognition
Prompt interventions
74
Normal blood loss for Vaginal
500ml
75
Normal blood loss for C-section
1000ml
76
PPH definition are
>500 vaginal
| >1000 C-section
77
What is the alternative definition for PPH
10% in hematocrit
78
Conditions that DECREASE maternal Blood volume (SES)
Small stature
Severe preeclampsia/eclampsia
Early gestational age
79
Clinical findings in PPH: Compensation
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________
500-1000ml (10-15%)
none4
Palpitations, dizziness, tachycardia (DPT)
80
Clinical findings in PPH: MILD
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________
1000-1500 (15-25%)
slight fall (80-100mmhg)
Weakness, sweating, tachycardia (WTS)
81
Clinical findings in PPH: MODERATE
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________
1500-2000ml (25-35%)
marked fall (70-80mmhg)
restlessness, pallor, oliguria (POR)
82
Clinical findings in PPH: SEVERE
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________
2000-3000ml (35-45%)
Profound fall (50-70mmhg)
Collapse, air hunger, anuria (ACA)
83
Postparthum hemorrhage : Etiology (4) Ts
Tone
Tissue
Trauma
Thrombin
84
Tissue cause of PPH
Retained products of conception
85
Trauma cause of PPH
Genitral tract trauma
86
Thrombin cause of PPH
Coagulation abnormalities.
87
Take home message for PPH
Do not go over 1 MAC of anesthesia with FURTHER DECREASE UTERINE TONE
88
Possible med combo for PPH
1/2 MAC, N2O + Ketamine
89
2 thrombin cause of PPH
Vonwillebrand
| Hemophillia A
90
Uterotonic drug
Pitocin (oxytocin)
91
When do you administer PITOCIN
After delivery of anterior shoulder
92
How do you administer pitocin
20 units in 1L fluids , 10 units in 500ml
93
Prophylactic use of pitocin
decrease therapeutic use
94
Routine administration of pitocin in 3rd stage which is ________stage ______pph risk
delivery of placenta
| Decrease
95
Do not use this for pitocin
Pressure bag
96
PPH drug therapy Methergine dose
0.2mg IM REPEAT every 5 minutes as needed maximum of 5 doses
97
PPH drug therapy CARBOPROST (Hemabate)
0.25 IM q15 min as needed
98
PPH summary of treatment of 4 Ts: Tone
| PROM-MH
```
Rule out uterine atony
Palpate fundus
Massage uterus
oxytocin
Methergine
Hemabate
```
99
PPH summary of treatment of 4 Ts: Tissue
| RIET
Rule out retained placenta
Inspect placenta for missing parts
Explore uterus
Treat abdominal implantation
100
PPH summary of treatment of 4 Ts: Trauma
| ROWIT
```
Rule out cervical vaginal laceration
Obtain good exposure
Inspect cervix/ vagina
Worry about slow bleeders\
Treat hematomas
```
101
Anesthesia management of peripartum hysterectomy
| Blood management
Potential for massive blood loss
| Have at least 4 units of PRBCs and other procoagulants immediately available.
102
Anesthesia REGIONAL should be at wich level
T4 Nipple line
103
Preferred anesthesia for PP hysterctomy
EPIDURAL (spinal won't last)
104
ANESTHESIA: If massive hemorrhage or known placenta percreta
GETA
105
4 arguments for GETA for PP hysterctomy
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
TRALI Criteria (AHB ONNN)
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
Liberal transfusion
may cause harm , studies does not show that it improves morbidity or mortality
108
Abnormalities with massive transfusion
Hypocalcemia
| Hypoerkalemia
109
Massive transfusion protocol labs
DIC panel (PT, PTT, fibrinogen, Thrombin Time, D-dimer, CBC, ABC, TYPe and cross)
110
Massive transfusion initial package
6 units of PRBCs
4 units of FFPs
1 Unit of Platelets
111
If INR> 1.5
give 4 units FFP until bleeding controlled
112
if platelet < 25000
Give 1 unit of PLT to increase by 30, 000-60000)
113
If fibrinogen < 100
Give 10 pack of cryoprecipitate
114
Salvage therapy
rFVII a
115
Ratio for infusion that increases survial is
1:1
116
PRBC Dose is ______
Volume per dose______
Expected response______
1 unit
200-325m;
1g increase in hgb
117
FFP Dose is ______
Volume per dose______
Expected response______
Factor replacement 10-15ml/kg
200ml
Correction of PT, aPTT, INR by replacing coag factors
118
Platelets Dose is ______
Volume per dose______
Expected response______
4-6 units
200-250ml
Increase platelet count of 30,000 - 60,000
119
Cryoprecipitate Dose is ______
Volume per dose______
Expected response______
10 pooled units
100ml
Increase levels of fibrinogen , von willebrand factor, factor VIII and XIII
120
Goals during massive tranfusion protocol : Optimise
Oxygenation
Cardiac output
Tissue Perfusion
Metabolic state
121
Goals during massive tranfusion protocol : MONITOR q
| FICA -____
```
30-60 minutes
Full blood count
Coagulation screen
Ionised calcium
ABG
```
122
```
Goals during massive tranfusion protocol : AIM FOR
Temperature ______
ph_____
Bases excess____
Lactate______
Ca2+ _______
Platelets _____
PT/APTT ____
INR ____
Fibrinogen _____
```
```
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
```
