Case 56 - abruptio placentae and placenta previa Flashcards
what are the major causes of third-trimester bleeding
- placenta aburption
- painful vaginal bleeding
- placenta previa
- painles vaginal bleeding
- vasa previa
- umbilial cord vessels traveling within the placental membranes and covering cervical os
- uterine rupture
- maternal coagulopathy
- DIC
- pre-eclampsia
what are RF for aburptio placentae?
- premature separation of placenta
- RF
- older age
- african
- pregnancy-induced HTN
- multiparity
- cigarette smoking
- cocaine
how can placenta abuprtion dx be made?
clinical manifestations
- painful, vaginal bleeding
- retroplacental bleeding (no gross bleeding found) + maternal shock
- fetal distress, maternal shock
- DIC
- open venous sinuses beneath the detached placenta allow thromboplastic material to enter maternal circulation and cause DIC
imaging
- ultrasound
patient has a placenta abruption. It is deemed to be small. Mom and fetus are stable. Would you advocate for delivering the fetus now? Suppose mom becomes unstable, would you deliver fetus now? If you choose to deliver the fetus, would you advocate for trial of labor or c/s?
Small Placenta abruption + HD stable + no fetal distress
- conservative management
- monitor closely
Abruption + fetal or maternal compromise
- EMERGENT C/S in term or pre-term
describe the effects of pregancy on coagulation
-
Pregnancy is a hypercoagulable state
- assoc with inc incidence of thombotic dz (DVT)
-
increased levels of clotting factors
- dec PT, INR, PTT
- increased levels of fibrinogen
- No change in Platelet count
What is DIC and how is it managed?
DIC
- consumptive coagulopathy
-
consumption of clotting factors and activation of secondary fibrinolysis
- state of constant clot and lysis of clot -> consume all coagulation factors
s/sx
- oozing, hemorrhage
- poor clot formation, bleeding from puncture sites
Labs
- hypofibrinogenima, thrombocytopenia, fibrin degradation products
- inc PT/INR, inc PTT,
- dec PLT, dec fibrinogen
- presence of fibrin degradation products
TX
- Removal of source (delivery of placenta or fetus)
- FFP, cryo, PLT, PRBC transfusion
What do you look for in a fetal heart monitoring?
Fetal Heart Monitoring
1) fetal HR
- 110-160 bpm
- balance betwen symp and parasymp innervation of fetal heart
2) beat-to-beat variability
-
moderate variability = 6-25 bpm = normal
- most sensitive indicator of fetal well-being
-
minimal variability = 1-5 bpm = abnormal
- sign of fetal hypoxia
- can also be due to maternal opiods, local anes, atropine
3) Accels and Decels
- accels = reassuring
- Decels = may be non-reassuring
what are the types of fetal decels and describe them as well as give etiology?
Fetal heart Rate Decels
- compare decels in reference to peak of uterine contraction
1) Early - nadir HR coincides with peak of uterine contraction
- Fetal Head Compression
- NOT assoc with fetal compromise
2) Variable
- Nadir HR is unrelated to peak of contraction = variable
- umbilical cord compression
- vagal mediated effect
- Rarely associated with fetal compromise
3) LATE DECEL
- Nadir HR occurs AFTER peak of uterine contract
- uteroplacental insuffiency
- Fetal hypoxemia -> stimulates vagal-mediated slowing of FHR
- NOT GOOD -> OMINOUS SIGN OF FETAL COMPROMISE
you are starting to see fetal late decels on fetal heart rate monitoring. What do you do?
1) Correct identifiable causes
- maternal hypotension
-
hyperstim of uterine contraction from pitocin
- excessive uterine contraction decreases arterial blood flow to uterus
2) Treat
- left uterine displacement
- oxygen to mother
- fluids
- pressors
3) If that does not work, emergent c/s
Patient comes to L&D with painful vaginal bleeding. OB says no need for c/s at this moment; however, OB want you to place an epidural. What are your anesthetic concerns and how will you proceed?
Painful vaginal bleeding = placenta abruption
- can be associated with DIC
- maternal shock, hypotension, fetal compromise
- retroplacental bleeding if no gross bleeding found
Prior to epidural,
1) Intravascular volume status
* crystalloid, colloid, or PRBC if indicated
2) H/H
- retroplacental bleeding can occur
- mom can decompensate at any point due to this
3) Coag studies
- associated with DIC
- PT/INR, PTT, fibrinogen, D-dimer
pregnant patient is in L&D suite, all of a sudden becomes hypotensinve and tachycardic, signifiant vaginal bleeding is noted. FHR shows minimal variability, late decels. what is going on?
Placenta Abruption
- placenta abruption -> acute blood loss anemia -> maternal hypotension
- maternal hypotension -> decrease uterine blood flow -> uteroplacental insuffiency
- uteroplacental insuffiency -> fetal hypoxemia -> vagal mediated slowing of FHR -> FETAL COMPROMISE
pregnant patient is in L&D suite, all of a sudden becomes hypotensinve and tachycardic, signifiant vaginal bleeding is noted. FHR shows minimal variability, late decels.
Patient does not have an epidural, how would you anesthetize this patient for emergent c/s delivery?
CALL FOR HELP
1) Establish large bore IV access (and a-line if you have time)
2) Left Uterine Displacement
3) fluid resuscitation
- crystalloids, colloids, blood products
- do not wait for labs to come back if DIC is suspected
- Vasopressors: Phenylephrine, ephedrine
4) Labs
- evaluate for DIC
- h/h, PT/INR, PTT, fibrinogen, d-dimer
- Type and crossmatch
5) EMERGENT C/S
6) General Anesthesia
-
**regional - contraindicated in setting of coagulopathy and/or hypovolemia**
- general = less prepatory time
- sodium bicitrate if time allows
- Emergency equip, suction, emergency meds, extra help, GLIDESCOPE ON STAND BY
-
RSI & I with cricoid pressure
- Etomidate or ketamine (1 mg/kg)
- SUX
what is placenta previa
- low-lying placenta covers internal cervical os
- marginal, partial, or complete
- if complete -> elective c/s
how is placenta previa diagnosed?
Clinical Manifestations
- painless vaginal bleeding
- not associated with DIC
- Bright Red Blood
- placenta abruption = port wine color
imaging
- ultrasound
how do you anesthezise a patient with placenta previea coming for c/s?
1) Is mom and fetus stable
- if not, absence of coag and maternal hypo -> spinal
- if not + coagulopathic or maternal is hypo -> general
2) IV access
3) Left uterine displacement
4) prophylaxis of aspiration (sodium bicit, metoclopramide, H2 blocker)
5) Type and cross
- in case of unexpected hemorrhage
- placenta previa can be assoc with placenta accreta
6) general (RSI&I) or spinal -> dependent on situation
