Clotting & things...

Question 1

Common causes (not including meds) of thrombocytopenia during pregnancy

Answer 1

Gestational thrombocytopenia
Severe preeclampsia or HELLP syndrome
DIC

Question 2

List uncommon causes of thrombocytopenia

Answer 2

HIV
SLE (lupus)
Antiphospholipid antibody syndrome
Immune thrombocytopenic purpura 
ITP

Question 3

List rare causes of thrombocytopenia

Answer 3

Folic acid deficiency
Thrombotic thrombocytopenic purpura
Hemolytic uremic syndrome
Type 2b von Willebrand syndrome
Hematologic malignancies
May-Hegglin anomaly 
Wiskott-Aldrich syndrome
Hemoglobin SC crisis with splenic sequestration

Question 4

Medications that can cause thrombocytopenia

Answer 4

H2-blockers
Heparin
Some abx

Question 5

Define Idiopathic thrombocytopenia (ITP)

Answer 5

Autoimmune disease where platelts are <100, platelet associated IgG may show up (but it may show up for other things too, so it helps to rule in, but not to r/o)
Diagnosis based on exclusion, no meds or other diseases

Question 6

Treatment for ITP

Answer 6

Not necessary, unless bleeding is present
Glucocorticoids (methylprednisolone)
IV gamma globulins
Transfusion (Plts)
Splenectomy

Question 7

Define von Willebrands Disease

Answer 7

Impaired function of vWF, a carrier prtoein that extends life of factor 8 and helps platelets aggregate and adhere to walls of vessel. Congenital bleeding disorder that could be Type 1 (dominant) or 2 or 3 (recessive)1% of the population

Question 8

S/sx of von Willebrands disease

Answer 8

Epistaxis, bleeding of gums, bruises easily

Question 9

Mgmt/Tx of von Willebrands disease

Answer 9

Prepare for possible PPH
If <50% in labor or h/o PPH, give IV desmopressin immediately after birth and 24 hrs later
If <50% before c/s, give desmopressin to Type I and factor VIII +vWF concentrate to Type 2 and 3
Know levels of factor VIII before d/c

Question 10

Why might someone with von Willebrands Disease hemorrhage later in the PP period?

Answer 10

Because VIII and vWF increase during pregnancy and decrease after birth.

Question 11

Most common causes of DIC in pregnancy

Answer 11

PPH, HELLP, Preeclampsia, pretained products of conception, placental abruption, acute fatty livver disease
AF embolism, sepsis

Question 12

S/Sx of DIC

Answer 12

Bleeding, shock, renal/hepatic impairment, thromboembolism, respiratory impairment, CNS impairment
Look for hematomas in vagina

Question 13

Labs to confirm DIC

Answer 13

CBC w/plts and diff
Coag studies: aPTT, fibrinogen, PT/INR
BUN
LFTs
Blood and urine cultures (r/o spesis)
If red-top tube does not stay clotted in 8-10 mins --> possible DIC

Question 14

Mgmt/Tx of DIC

Answer 14

HELP! (anesthesia, transfusion, neonatology)
Treat underlying cause
O2, fluids, warmth, airway protection
Monitor blood loss and VS
Assess status of fetus–support if fetal loss

Question 15

What is DIC?

Answer 15

Blood gets exposed to procoagulant → coagulation cascade → Firbin & plts cause thrombi → fibrinolysis –> continuous bleeding → decreased perfusion +/- thrombi → damage to organs

Question 16

What is an amniotic fluid embolism?

Answer 16

When AF enters maternal circulation

Question 17

What is thought to happen during an AF embolism?

Answer 17

severe pulmonary hypertension, sudden right ventricular failure, then left ventricular impairment → respiratory failure, CV collapse → systemic inflammation and noncardiogenic pulmonary edema

Question 18

What are the s/sx of an AF embolism?

Answer 18

N/V, chills, fever
change in mental status +/- anxiety
CV collapse
Respiratory compromise: Decrease O2, dyspnea, tachypnea, cyanosis
Seizures
Fetal compromise

Question 19

Mgmt during AF embolism (for the midwife)

Answer 19

GET help
Position in left lateral position
Immediate delivery
O2, fluids, blood
Labs (CBC, gases, cardiac enzymes, natriuretic peptide, CMP)
ECG
Bedside U/S
Chest x-ray
Airway
Assist with ACLS
Communicate w/family and document!