Clinical 2 Gline- 3rd trimester and Postpartum bleeding Flashcards
DEFINITION OF PLACENTA PREVIA
The implantation of the placenta over the cervical os. There are three types;
Complete or Total Previa
the placenta completely covers the os. (20-40%)
Partial Previa
the placenta partially covers the internal os. (30%)
Marginal Previa
the edge of the placenta extends to the margin of the internal os. (30-50%)
Postpartum hemorrhage
blood loss in excess of 500 ml for a vaginal delivery or 1000 ml for a c-section
Placenta Accreta
Myometrial wall (there is an absence of Decidua basalis)
Placenta increta
placenta invades the myometrium
Placenta percreta
the placenta penetrates the myomterium to the serosa or beyond
Vasa Previa
when the unprotected vessels from a velamentous insertion, pass over the os. They are predisposed to rupturing
Antepartum and postpartum bleeding
4%
OB hemorrhage fact
• *3rd *Most frequent cause of maternal death in the U.S. This ranks behind #1 Embolism and #2 Hypertensive Disease.
Common causes of Antepartum bleeding
Placenta Previa (20%) Placenta Abruptio( 30%)
Antepartum hemorrhage
Do not check cervic until placenta previa has been ruled out.
Take Hx and vitals first.
Antepatrum bleeding diagnostics
CBC coag US monitoring
US is good at previas (100% of the time harder with abruptions)
Three times of Placenta Previa
Complete, Partial and Marginal
Predisposing factors of Placenta Previa
previous c-section, Multipartiy, multiple gestation, advancing maternal age, previous placenta previa.
Diagnosis for Placenta Previa
Classical presentation in painless, bright, red bleeding
Uterine Abruption
hard, contraction, dark blood loss
Hallmark is “painful vaginal bleeding in association with uterine tenderness, hyperactivity and increased tone.”
uterine rupture
intense pain and then temporarily relief.
Management of Placenta Previa
Mom: IVs, CBC, type and cross
Fetus: monitor, us, determine gestational age/maturity
Management Preterm infant and mother stable
Amniocentesis for Lung maturity
If mature, deliver by c-section
If immature, hospital bed rest, possible transfusions, cautious use of tocolytics (magnesium sulfate is drug of choice). Beta mimetics could mask tachycardia etc.
Don’t forget Rhogam if mother is Rh negative.
Placenta Abruptio Risk Factors
Maternal Hypertension
Cocaine abuse, especially “crack”
Trauma
Smoking
Polyhydramnios and Multiple gestation (rapid decompression of an over- distended uterus).
Previous Abruption 5% recurrence, if two or more 25% recurrence rate.
Complicating factors for Placenta Abruptio
Perinatal mortality rate due to abruption, is 35%.
Accounts for 15% of third trimester stillbirths.
15% of livebirths have neurologic damage.
Most common cause of DIC in pregnancy.
Hypovolemic shock, renal failure.
Sheehan’s syndrome
MOA for Placenta Abruptio
- Hemorrhage into the decidua basalis with formation of a hematoma.
- The seperation of the decidua from the basal plate perpetuates itself causing further separation as well as compression and destruction of tissue.
Diagnosis for Placenta Abruptio
Diagnosis is clinical. U.S. not very effective. 80% will have associated vaginal bleeding. The blood is usually dark red. Pain 66% Fetal Distress 60% Uterine Hyperactivity 34% Fetal Demise 15%
Management of Placenta Abruptio
- Stabilize Mother
- IV’s
- Serial Coagulation Prophiles
- Keep blood products on hand (DIC)
- Fetal Monitoring
- Vaginal Delivery preferred route. C-section for obstetrical reasons only.
Uterine Rupture
- “Complete separation of the uterine musculature through all of it’s layers.”
- Usually the fetus is extruded in the abdomen.
- Incidence 0.5%
- May occur during or before labor or at the time of delivery.
Uterine Rupture Risk Factors
• Previous Uterine Scar assoc. 40%
o C/s most common- with prior LTCS -0.5% risk, with a previous vertical incision 5% risk.
o myomectomy
o metroplasty
• 60 % occur in a previously unscarred uterus. (Grand multip.) etc.
Diagnosis of Uterine Rupture
Must have high index of suspicion.
Sudden onset of intense abdominal pain and vaginal bleeding
Hyperventilation, agitation and tachycardia
After rupture, momentary relief of pain but it returns.
Fetal Distress
Palpable fetal parts in abdomen.
Management of Uterine Rupture
• Immediate Laparotomy
• Usually a TAH (total abdominal hysterorectomy) is performed. (Tx. of Choice).
o Total is uterus and cervix
• Possibly a debridement of rupture site and primary closure if fertility is still desired by patient.
Postpatrum hemorrhage
The uterus fails to contract around the myometrial spiral arterioles and decidual veins at the attachment site after placental separation.
Postpatrum hemorrhage causes
Uterine Atony Genital Tract Trauma Retained placental fragments Uterine Inversion Low Placental Implantation Coagulation disorders (abruption, retained dead fetus, inherited coagulopathy, amniotic fluid embolism)
Uterine Atony Predisposition
Overdistension of the uterus (multiple gestation, polyhydramnios, fetal macrosomia)
Prolonged Labor
Grand Multip (>5)
Pitocin stimulation/ Magnesium Sulfate Tx.
Chorioamnionitis
Diagosis of Postpatrum hemorrhage
Inspection/palpation is the diagnosis for all causes of postpatrum hemorrhage except coagulation defects
Management of Postpartum hemorrhage
IV Pictocin, Massage, methergrine, • Prostaglandin F2-Alpha, Cytotec, Embolization of Uterine Arteries, Ligation of Uterine or Hypogastric arts., B-Lynch Stitch, Supracervical hysterectomy
Genital Tract Trauma
2nd most common cause of postpartum hemorrhage. lacerations of vagina/cervix, common following operative deliveries. Diagnosis- exploration
