Anterpartum And PPH Flashcards
Most common cause of maternal mortality worldwide
Hemorrhage
What is the true definition of MAJOR Obstetric hemorrhage
Defined as a transfusion of 5 or MORE units of PRBCs
Increase rates of PPH with 3 things (PAC)
Postpartum uterine atony
Abnormal placentation
Cesarean deliveries
Most hemorrhage is because of poor
Recognizing risk factors
Accurately assess blood loss
Initiate treatment in timely fashion
NOT COMMUNICATING
Most HIGHEST INCIDENCE common cause of pregnancy related deaths due to hemorrhage
ALUCPUR
Abruptio Placenta Laceration /uterine rupture Uterine atony Coagulopathies Placenta previa--> accreta, increta, percreta Uterine bleeding Retained placenta
Is anterpartum hemorrhage a medical or surgical
Medical emergency (no need to rush to surgery)
True definition of antepartum hemorrhage____usually what trimester?
Vaginal blood loss AFTER 20 weeks of gestation
1st
Biggest threat of hemorrhage BEFORE delivery is to the
FETUS
Biggest threat of hemorrhage AFTER delivery is to the
Mother
4 main causes of Antepartum hemorrhage
PPUV
Placenta Previa
Placenta Abruptio
Uterine Rupture
Vasa Previa
What is placenta previa
When placenta is implanted to lower segment of the uterus , presenting ahead of the LEADING POLE OF THE FETUS
4 types of Placenta Previa
TPML
Total
Partial
Marginal
Low-lying placenta
What is a TOTAL placenta previa?
Internal cervical OS covered completed by placenta
What is a PARTIAL placenta previa>?
Internal cervical OS partially covered by placenta
What is a MARGINAL placenta previa?
Edge of placenta at margin of internal os
What is a low lying placenta?
Placenta is implanted in lower uterine segment –> Placental edge does not actualy reach internal os but in close proximity to it
Os stands for
opening
In placenta previa what causes the bleeding?
small disruption in placental attachment during normal development and thinning of lower uterine segment
In placenta previa: Perinatal morbidity and mortality primarily related to
Prematurity
In placenta previa hemorrhage is a
Maternal problem
List etiology of Placenta previa (AMMPPS)
Advanced Maternal Age >35 Multiparity Multifetal gestations Prior C-section Smoking Prior Placenta previa
What is the hallmark of placenta Previa
Painless hemorrhage
When does placenta previa most occur
end of/or after 2nd trimester
In placenta previa Bleeding rarely enough to be
Fatal
Placenta previa may be associated with
placenta accreta, increta, or percreta
May cause massive bleeding
Avoid this at all cost with placenta previa
No vaginal or cervical examination
SAFEST diagnostic test with placenta previa
Transabdominal US
MOST ACCURATE diagnostic test with placenta previa
TRANSVAGINAL ultrasonograpy INCREASE RISK OF BLEEDING THOUGH
Placenta Previa with moderate bleeding if >34/52
C-section
Placenta Previa with moderate bleeding if <34/52
Resuscitate STEROIDS then if stable Conservative care, if unstable –> C-section
As general if symptoms with bleeding
C-section
As general if NO Ssymptoms WITH bleeding
Conservative care
With placenta previa deliver via
C-section (possible hysterectomy)
Placenta abruptio
Premature separation of NORMALLY IMPLANTED PLACENTA , spiral arteries comes out start bleeding
Placenta abruption factors
External hemorrhage
Concealed (internal hemorrhage)
Total
Partial
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
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
In placenta Abruption bleeding can be either
Fetal or maternal
Fetal bleeding results from
tear or fracture in placenta RATHER THAN From separation itself
Placenta abruption signs and symptoms HALLMARK
Bleeding with PAIN varying from mild cramping to severe
What does not exclude platenta abruption
Negative US
Placenta abruption signs and symptoms uterus
Firm , tender uterus with INCREASE FUNDUS HEIGHT
What are the complications of Placenta Abruption
DFCC
DIC
Renal failure
Fetal death
Couvelaire uterus
Treatment of Placenta Abruption depends on
Gestational age
Status of mother and fetus
Admit, HandP, IV access, placental localization
Uterine rupture is
Part of baby coming out with an intact amniotic sac
Most common maternal morbidity is from
Hemorrhage
Uterine Rupture most common with
VBAC
Women with uterine scar and hx of leiomyomectomy at risk for
Uterine rupture
Classic presentation of Uterine rupture, what do you see?
Feet coming out
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
Risk factors for Uterine Rupture
PPP TEMSF
Excessive uterine stimulation Previous C section Trauma Prior rupture Previous uterine sx Multiparity Shoulder distocia Forceps delivery
Uterine rupture management
EMERGENT LAPAROTOMY
Arterial line
Placenta accreta is
whole or partly invades uterine wall and is INSEPARABLE FROM IT
What are the 3 types of placenta accreta
Accreta vera
Placenta increta
Placenta percreta
Placenta Accreta vera is
Adherence of basal plate of placenta directly to uterine myometrium without penetrating the decidua layer
Placenta Accreta increta is
Chorionic villi invade myometrium
Placenta accreta percreta is
Invasion through MYOMETRIUM into SEROSA and even adjacent ORGANS (bladder)
Placenta accreta blood loss can be as high as
20,000ml
VASA Previa is
rare condition where fetal vessels from placenta cross entrance of birth canal
VASA previa associated with
increased fetal mortality
3 typical causes of Vasa previa
bi-lobed placenta
Velamentous insertion of umbilicord
Succenturiate (accessory lobe)
Risk factors of VASA PREVIA
fu
Management of vasa previa ; if detected prior to labor
HIGH FETAL survival
How is vasa previa detected?
Transvaginal sonography
Method of delivery for vasa previa (preferred)
Elective C section
What is the Kleihauer-Betke test
Measures amount of fetal Hgb transferred from fetus to mother’s bloodstream
Kleihauer-Betke determine
dose of Rh Immunoglobulin (RHOGAM)
Use for detecting fetal-maternal hemorrhage
Kleihauer-Betke
APT test helps
determine origin of blood (Fetal vs maternal )
PostPartum Hemorrhage (PPH) timing of bleeding
if occurs in first 24 hours after delivery , termed early PPH late if>24 hours.
Early PPH Involves
Heavier bleeding and increased mortality
PPH you can see
White lips in mucous membrane
Key in interventions of PPH
Prevention
Early recognition
Prompt interventions
Normal blood loss for Vaginal
500ml
Normal blood loss for C-section
1000ml
PPH definition are
> 500 vaginal
>1000 C-section
What is the alternative definition for PPH
10% in hematocrit
Conditions that DECREASE maternal Blood volume (SES)
Small stature
Severe preeclampsia/eclampsia
Early gestational age
Clinical findings in PPH: Compensation
BLood loss is ______
BP change (SBP) _______
Symptoms and signs __________
500-1000ml (10-15%)
none4
Palpitations, dizziness, tachycardia (DPT)
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)
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)
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)
Postparthum hemorrhage : Etiology (4) Ts
Tone
Tissue
Trauma
Thrombin
Tissue cause of PPH
Retained products of conception
Trauma cause of PPH
Genitral tract trauma
Thrombin cause of PPH
Coagulation abnormalities.
Take home message for PPH
Do not go over 1 MAC of anesthesia with FURTHER DECREASE UTERINE TONE
Possible med combo for PPH
1/2 MAC, N2O + Ketamine
2 thrombin cause of PPH
Vonwillebrand
Hemophillia A
Uterotonic drug
Pitocin (oxytocin)
When do you administer PITOCIN
After delivery of anterior shoulder
How do you administer pitocin
20 units in 1L fluids , 10 units in 500ml
Prophylactic use of pitocin
decrease therapeutic use
Routine administration of pitocin in 3rd stage which is ________stage ______pph risk
delivery of placenta
Decrease
Do not use this for pitocin
Pressure bag
PPH drug therapy Methergine dose
0.2mg IM REPEAT every 5 minutes as needed maximum of 5 doses
PPH drug therapy CARBOPROST (Hemabate)
0.25 IM q15 min as needed
PPH summary of treatment of 4 Ts: Tone
PROM-MH
Rule out uterine atony Palpate fundus Massage uterus oxytocin Methergine Hemabate
PPH summary of treatment of 4 Ts: Tissue
RIET
Rule out retained placenta
Inspect placenta for missing parts
Explore uterus
Treat abdominal implantation
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
Anesthesia management of peripartum hysterectomy
Blood management
Potential for massive blood loss
Have at least 4 units of PRBCs and other procoagulants immediately available.
Anesthesia REGIONAL should be at wich level
T4 Nipple line
Preferred anesthesia for PP hysterctomy
EPIDURAL (spinal won’t last)
ANESTHESIA: If massive hemorrhage or known placenta percreta
GETA
4 arguments for GETA for PP hysterctomy
- Severe hypotension may require airway protection
- Large fluid shifts and massive transfusion can affect oxygenation necessating control of ventilation
- Fluid shifts cause airway edema
- Central line easier to place under GETA
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
Liberal transfusion
may cause harm , studies does not show that it improves morbidity or mortality
Abnormalities with massive transfusion
Hypocalcemia
Hypoerkalemia
Massive transfusion protocol labs
DIC panel (PT, PTT, fibrinogen, Thrombin Time, D-dimer, CBC, ABC, TYPe and cross)
Massive transfusion initial package
6 units of PRBCs
4 units of FFPs
1 Unit of Platelets
If INR> 1.5
give 4 units FFP until bleeding controlled
if platelet < 25000
Give 1 unit of PLT to increase by 30, 000-60000)
If fibrinogen < 100
Give 10 pack of cryoprecipitate
Salvage therapy
rFVII a
Ratio for infusion that increases survial is
1:1
PRBC Dose is ______
Volume per dose______
Expected response______
1 unit
200-325m;
1g increase in hgb
FFP Dose is ______
Volume per dose______
Expected response______
Factor replacement 10-15ml/kg
200ml
Correction of PT, aPTT, INR by replacing coag factors
Platelets Dose is ______
Volume per dose______
Expected response______
4-6 units
200-250ml
Increase platelet count of 30,000 - 60,000
Cryoprecipitate Dose is ______
Volume per dose______
Expected response______
10 pooled units
100ml
Increase levels of fibrinogen , von willebrand factor, factor VIII and XIII
Goals during massive tranfusion protocol : Optimise
Oxygenation
Cardiac output
Tissue Perfusion
Metabolic state
Goals during massive tranfusion protocol : MONITOR q
FICA -____
30-60 minutes Full blood count Coagulation screen Ionised calcium ABG
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
