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EndoRepro 2 Exam 1 > Clin: Obstetric Hemorrhage and Puerperal Sepsis - Moulton > Flashcards

Clin: Obstetric Hemorrhage and Puerperal Sepsis - Moulton Flashcards

1
Q

what labs should be drawn on initial evaluation of antepartum hemorrhage?

A
  • CBC and coagulation profile
  • serial Hgb/Hct
  • blood type and crossmatch for 4 units of blood (packed RBC)
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2
Q

1 unit (250-300cc) will raise the Hct/Hgb by how much?

A

Hct: 3%

Hgb by 1g/dL

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3
Q

always avoid a digital exam until what has been ruled out by US?

A

placenta previa

- do a sterile speculum exam instead

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4
Q

what are the most common reasons for vaginal bleeding BEFORE 20 weeks?

A
  • abortion
  • ectopics
  • cervical/vaginal etiology (cancer, trauma, polyps)
  • cervical insufficiency
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5
Q

what are the most common reasons for vaginal bleeding AFTER 20 weeks (upper genital tract)?

A
  • placental abruption
  • placenta previa
  • uterine rupture
  • vasa previa (placental blood vessels near cervical opening)
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6
Q

what are the most common reasons for vaginal bleeding AFTER 20 weeks (LOWER genital tract)?

A
  • “bloody show” labor
  • cervical polyps
  • infections
  • trauma
  • cancer
  • vulvar varicosities
  • blood dyscrasia
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7
Q

implantation of the placenta over the cervical os

  • most common type of abnormal placentation
  • 1 in 200 pregnancies
  • accounts for 20% of all cases of antepartum hemorrhage
  • presents classically as PAINLESS vaginal bleeding (75% of the time, 20% will have associated contractions)
A

placenta previa

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8
Q

what are the risk factors for placenta previa?

A
  • maternal age >35
  • multiparity
  • multiple gestations
  • cocaine and smoking
  • prior previa (up to 8% risk of previa in subsequent pregnancy)
  • previous c-section
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9
Q

characterized by the edge of the placenta extending to the margin of the cervical os
- does NOT cover the os

A

marginal placenta previa

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10
Q

partial occlusion of the cervical os by the placenta

A

partial placenta previa

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11
Q

cervical os is completely covered by the placenta

- most serious type, is associated with greater blood loss

A

complete placenta previa

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12
Q

how is placenta previa diagnosed?

A

almost completely by US

  • 4-5% of patients will have some degree of previa at 24 weeks gestation
  • repeat US at 30 weeks -> 90% will resolve by 32-35 weeks (known as placental migration)
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13
Q

which type of previa is the least likely to resolve?

A

complete

- only 10% of cases resolve by third trimester

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14
Q

what is the management of placenta previa?

A
  • if bleeding not profuse, pt is managed in hospital on bed rest, may send home if stable and bleeding stops 970% of patients will have recurrent bleeding)
  • deliver via c-section at 36-37 weeks with documented fetal lung maturity
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15
Q

how do you prepare for serial blood draws?

A
  • serial blood draws
  • NPO status
  • type and cross 4 units of blood
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16
Q

what is the Kleihauer-Betke test?

A

blood test to determine the amount of fetal Hgb transferred from the fetus to the mom’s bloodstream
- give Rhogam if indicated (Rh negative)

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17
Q

what should you also give if prior to 34 weeks to prepare for preterm delivery?

A

betamethasome (antenatal steroids)

- tocolysis can be used in stable patients

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18
Q

abnormal firm attachment to the superficial lining of the myometrium
- most common

A

placenta ACCRETA

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19
Q

when the placenta invades the myometrium

A

placenta INCRETA

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20
Q

when the placenta invades through the myometrium into the uterine serosa
- least common

A

placenta PERCRETA

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21
Q

what are the risk factors for placenta accreta?

A
  • 1 previous c-sections and previa (incidence of accreta is 25%)
  • multiple c-sections and previa (incidence of accreta is 65%)
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22
Q

premature separation of the normally implanted placenta

  • 1 in 150 live births
  • the most common cause of third trimester bleeding
  • accounts for 30% of all cases of antepartum hemorrhage
  • presents as PAINFUL bleeding, uterine tenderness, uterine hyperactivity, fetal distress and/or death
A

placental abruption (abrupto placenta)

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23
Q

what is the most common risk factor for placental abruption?

A
  • maternal HTN
  • cocaine use
  • blunt trauma
  • polyhydramnios and multiparity
  • previous abruption
24
Q

pt presents with painful vaginal bleeding, uterine tenderness, often associated with uterine hyperactivity and fetal distress or death

  • bleeding in 80% of cases
  • fetal distress in 60%
  • uterine hyperactivity in 34%
A

placental abruption

25
Q

if both mom and baby are stable with placental abruption, what do you do?

A

proceed with vaginal delivery

- often a rapid delivery ensues

26
Q

if remote from vaginal delivery w/signs of fetal distress or uncontrolled bleeding with placental abruption, what do you do?

A

proceed with c-section

27
Q

what is the most common cause of disseminated intravascular coagulation (DIC) in pregnancy?

A

abruption

  • results from release of thromboplastin from disrupted placenta and subplacental decidua causing a consumptive coagulopathy
  • clinically significant DIC occurs in 20% of cases and it most commonly seen with massive abruption
28
Q

life-threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity

A

couvelaire uterus

- causes red and purple discoloration of the serosa

29
Q

complete separation of the uterine musculature through all of it’s layers

  • is rare
  • may be spontaneous, traumatic, or associated with previous uterine scar
  • fetal mortality or permanent neurologic squealae can occur up to 30%
A

uterine rupture

  • sudden onset of intense abd pain +/- bleeding
  • abnormal fetal heart pattern
  • regression of presenting part
  • fetal parts may be easily palpable on abd exam
30
Q

what are the risk factors for uterine rupture?

A

pior uterine incision

  • incidious use of oxytocin
  • trauma
  • external cephalic version
  • multiparity
31
Q

what is the management of uterine rupture?

A
  • immediate laparotomy and delivery
  • repair ruptured site if possible
  • if large rupture, may have to do cesarean hysterectomy
32
Q

what is the workup for future pregnancies if a woman has a uterine rupture?

A

deliver via c-section

  • upper segment uterine rupture recurrence = 32%
  • lower segment recurrence = 6%
33
Q

what are the causes of third trimester bleeding?

A

rare, but usually associated with rupture of fetal vessels

  • often secondary to velamentous insertion of the umbilical cord
  • presents as vaginal bleeding with a change in fetal heart rate (initial tachycardia followed by bradycardia)
34
Q

the umbilical cord inserts into the fetal membranes (choriamniotic membranes), then travels within the membranes to the placenta (between the amnion and the chorion). The exposed vessels are not protected by Wharton’s jelly and hence are vulnerable to rupture.

A

velamentous insertion

35
Q

what is vasa previa?

A

unprotected vessels pass over the cervical os

- 1 in 5000 pregnancies

36
Q

> 500cc after vaginal birth

>1000cc after c-section

A

postpartum hemorrhage (PPH)

37
Q

when does primary PPH occur?

A

within the first 24 hours

  • is secondary to uterine atony 80% of the time
  • more than half of all maternal deaths happen w/in first 24 hours
38
Q

when does secondary PPH occur?

A

24 hours to 12 weeks

- can occur with subinvolution of the uterus, sloughing of the eschar or retained products

39
Q

what is the leading cause of maternal death worldwide?

A
  • *POSTPARTUM HEMORRHAGE**

- 1 death every 4 minutes (140,000 women every year)

40
Q

usually occurs immediately preceding or after placental delivery

  • excessive blood loss most commonly results when the uterus fails to contract after delivery of placenta
  • palpation reveals a “boggy uterus”
A

uterine atony

41
Q

what is the management of uterine atony?

A

bimanual massage
simultaneous meds:
- oxytocin
- methylergonovine (contraindicated in HTN pt)
- 15-methyl prostaglandin
- dinoprostone
- misoprostol
uterine backing or large volume balloon catheter
- surgery is LAST RESORT (if unstable, proceed with total abd hysterectomy)

42
Q

what are the two surgical treatment options for atonic uterine hemorrhage

A
  • O Leary stitch

- B-Lynch suture

43
Q

what is the second most common cause of PPH?

A

trauma during delivery

  • inspect for vaginal, perineal, periurethral and cervical lacerations (common after operative deliveries)
  • repair surgically
44
Q

bleeding secondary to inability of uterus to maintain a contraction and involute normally around the placental tissue mass
- risk factors: previous c-section, leiomyomas, prior D&C

A

retained placenta

- tx: manual removal if bleeding is profuse, uterine curettage

45
Q

top of the fundus descends into the vagina and sometimes through the cervix

A

uterine inversion

- if it occurs before placenta is delivered, DO NOT REMOVE placenta until inversion is corrected

46
Q

what is the tx of uterine inversion?

A

manually replace the uterus

- once replaced, start oxytocin to cause uterus to contract

47
Q

rare, has 80% mortality rate

  • thought to be caused by infusion of amniotic fluid into maternal circulation
  • respiratory distress, intense bronchospasm
  • cyanosis
  • CV collapse
  • hemorrhage
  • coma
A

coagulation disorder causing PPH

- tx: respiratory support, correct the hypovolemic shock, replace coagulation factors

48
Q

inherited coagulopathy with prolonged bleeding times

- factor VIII deficiency

A

von Willibrand disease

- tx: factor VIII concentrate or cryoprecipitate

49
Q

platelets function abnormally and have short life span

  • causes thrombocytopenia and tendency to bleed
  • circulating antiplatelet Ab and IgG type can occasionally cross placenta resulting in fetal and neonatal thrombocytopenia
A

idiopathic thrombocytopenia

- tx: require platelet concentration infusion

50
Q

what is febrile morbidity?

A

temp > 100.4 that occurs for more than 2 consecutive days (excluding first 24 hours), at some point during first 10 postpartum days
- most fevers due to endometritis

51
Q

what are the potential pathogenic organisms cultured from the vagina in 80% of pregnant women?

A

enterococci, hemolytic and nonhemolytic streptococci, anaerobic strep, enteric bacilli, pseudodiptheria, neisseria

52
Q

after delivery, pH of vagina becomes more alkaline

  • change in pH favors increase in growth of aerobic organisms
  • 48hrs after delivery, endometrial and placental remnants produce favorable environment for bacteria
A

puerperal sepsis

  • anaerobic orgs: peptosteptococcus, peptococcus, strep
  • aerobic: E.coli most common, then enterococci
53
Q

what are the key clinical findings of puerperal sepsis?

A

postpartum fever and increasing uterine tenderness on postpartum day 2-3

  • purulent lochia, chills, malaise, anorexia
  • tx: abx 48hrs (ampicillin + gentamycin)
54
Q

what is the major pathogen that is resistant to ampicillin + gentamycin tx?

A

bacteroides fragilis

- usually sensitive to clindamycin

55
Q
  • endothelial damage (result of intrapartum trauma, or uterine infection)
  • venous stasis (pregnancy induced ovarian venous dilation)
  • hypercoagulable state of pregnancy
A

septic pelvic thrombophlebitis

  • fulfills Virchow’s triad for the pathogenesis of thrombosis
  • tx: anticoagulation, unfractionated heparin
56
Q
  • fever and abd pain within 1 weeks after delivery

- appear clinically ill

A

ovarian vein thrombophlebitis

57
Q

usually have unlocalized fever in first few days that is nonresponsive to abx

  • do NOT appear clinically ill
  • no radiographic evidence of thrombosis
A

deep septic pelvic vein thrombophlebitis

EndoRepro 2 Exam 1 (25 decks)

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