Clinical 2 Gline- 3rd trimester and Postpartum bleeding

Question 1

DEFINITION OF PLACENTA PREVIA

Answer 1

The implantation of the placenta over the cervical os. There are three types;

Question 2

Complete or Total Previa

Answer 2

the placenta completely covers the os. (20-40%)

Question 3

Partial Previa

Answer 3

the placenta partially covers the internal os. (30%)

Question 4

Marginal Previa

Answer 4

the edge of the placenta extends to the margin of the internal os. (30-50%)

Question 5

Postpartum hemorrhage

Answer 5

blood loss in excess of 500 ml for a vaginal delivery or 1000 ml for a c-section

Question 6

Placenta Accreta

Answer 6

Myometrial wall (there is an absence of Decidua basalis)

Question 7

Placenta increta

Answer 7

placenta invades the myometrium

Question 8

Placenta percreta

Answer 8

the placenta penetrates the myomterium to the serosa or beyond

Question 9

Vasa Previa

Answer 9

when the unprotected vessels from a velamentous insertion, pass over the os. They are predisposed to rupturing

Question 10

Antepartum and postpartum bleeding

Answer 10

4%

Question 11

OB hemorrhage fact

Answer 11

• *3rd *Most frequent cause of maternal death in the U.S. This ranks behind #1 Embolism and #2 Hypertensive Disease.

Question 12

Common causes of Antepartum bleeding

Answer 12

Placenta Previa (20%)
Placenta Abruptio( 30%)

Question 13

Antepartum hemorrhage

Answer 13

Do not check cervic until placenta previa has been ruled out.
Take Hx and vitals first.

Question 14

Antepatrum bleeding diagnostics

Answer 14

CBC coag US monitoring

US is good at previas (100% of the time harder with abruptions)

Question 15

Three times of Placenta Previa

Answer 15

Complete, Partial and Marginal

Question 16

Predisposing factors of Placenta Previa

Answer 16

previous c-section, Multipartiy, multiple gestation, advancing maternal age, previous placenta previa.

Question 17

Diagnosis for Placenta Previa

Answer 17

Classical presentation in painless, bright, red bleeding

Question 18

Uterine Abruption

Answer 18

hard, contraction, dark blood loss

Hallmark is “painful vaginal bleeding in association with uterine tenderness, hyperactivity and increased tone.”

Question 19

uterine rupture

Answer 19

intense pain and then temporarily relief.

Question 20

Management of Placenta Previa

Answer 20

Mom: IVs, CBC, type and cross
Fetus: monitor, us, determine gestational age/maturity

Question 21

Management Preterm infant and mother stable

Answer 21

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.

Question 22

Placenta Abruptio Risk Factors

Answer 22

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.

Question 23

Complicating factors for Placenta Abruptio

Answer 23

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

Question 24

MOA for Placenta Abruptio

Answer 24

• 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.

Question 25

Diagnosis for Placenta Abruptio

Answer 25

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%

Question 26

Management of Placenta Abruptio

Answer 26

• 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.

Question 27

Uterine Rupture

Answer 27

• “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.

Question 28

Uterine Rupture Risk Factors

Answer 28

• 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.

Question 29

Diagnosis of Uterine Rupture

Answer 29

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.

Question 30

Management of Uterine Rupture

Answer 30

• 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.

Question 31

Postpatrum hemorrhage

Answer 31

The uterus fails to contract around the myometrial spiral arterioles and decidual veins at the attachment site after placental separation.

Question 32

Postpatrum hemorrhage causes

Answer 32

Uterine Atony
Genital Tract Trauma
Retained placental fragments
Uterine Inversion
Low Placental Implantation
Coagulation disorders (abruption, retained dead fetus, inherited coagulopathy, 	amniotic fluid embolism)

Question 33

Uterine Atony Predisposition

Answer 33

Overdistension of the uterus (multiple gestation, polyhydramnios, fetal macrosomia)
Prolonged Labor
Grand Multip (>5)
Pitocin stimulation/ Magnesium Sulfate Tx.
Chorioamnionitis

Question 34

Diagosis of Postpatrum hemorrhage

Answer 34

Inspection/palpation is the diagnosis for all causes of postpatrum hemorrhage except coagulation defects

Question 35

Management of Postpartum hemorrhage

Answer 35

IV Pictocin, Massage, methergrine, • Prostaglandin F2-Alpha, Cytotec, Embolization of Uterine Arteries, Ligation of Uterine or Hypogastric arts., B-Lynch Stitch, Supracervical hysterectomy

Question 36

Genital Tract Trauma

Answer 36

2nd most common cause of postpartum hemorrhage. lacerations of vagina/cervix, common following operative deliveries. Diagnosis- exploration