Columbus & ACOG PB: obstetrical hemorrhage and transfusion Flashcards
What percentage of abruptions are associated with underlying hypertension?
50%
Among causes of hemorrhage related mortality, which is associated with the highest risk of maternal death?
Placental abruption, almost 20%
What is the incidence of abruption in Caucasians and African-Americans?
0.5%
What are risk factors for abruption?
Prior abruption, smoking, trauma, cocaine use, multiple gestation, hypertension, thrombophilia, advanced maternal age, PPROM, polyhydramnios
How does abruption clinically present?
Vaginal bleeding 80% Uterine tenderness 60% Tachysystole 20% Hypertonus 20% Stillbirth 15%
Describes the “30-30 rule” used to avoid acute kidney injury?
Aggressive treatment of hypovolemia to maintain hematocrit above 30% and urine output above 30 mL per hour
What lab testing should be performed for evaluation of abruption?
CBC, creatinine, PT/PTT, fibrinogen, type & screen
How long does fresh frozen plasma take to prepare?
What is the volume of fluid?
How much does one unit increase fibrinogen by?
What are the other contents?
30-40 minutes
250 mL
10 mg/dL
Antithrombin III, factors V & VIII
What is the volume of one unit of packed RBCs?
How much would this be expected to raise hemoglobin?
300 mL
1 g/dL or hematocrit by 3%
At what fibrinogen threshold should fresh frozen plasma be administered?
150 mg/dL
When should platelets be transfused?
What is the volume of one units?
How much would a six pack be expected to raise platelet count?
Platelet count less than 50,000 with clinical bleeding
50 mL
30,000 per microliter
What are the general principles of management of DIC?
Treat underlying cause
Restore circulating blood volume
Timely and appropriate use of blood products
No heparin or anti-fibrinolytics
What are causes of DIC in obstetrics?
Dilution from any cause of hemorrhage Abruption: 33% incidence if stillborn Amniotic fluid embolism Acute fatty liver Retained dead fetus greater than four weeks Sepsis or septic abortion Preeclampsia, eclampsia, HELLP syndrome
What is the most common cause of postpartum hemorrhage?
What are risk factors?
Uterine atony
Rapid or prolonged labor Over-distended uterus Oxytocin General anesthetic Chorioamnionitis High parity History of atony: 10% recurrence Hypotension from hemorrhage or regional anesthesia
How should uterine atony be initially managed?
Uterine massage or compression Oxytocin IV access Labs including CBC, coags, type and screen or crossmatch Methergine or Hemabate Foley
What is the IM dosing for oxytocin? IV dosing?
Why is rapid IV infusion contraindicated?
10 units
10-40 units in 1 L of NS or LR
Hypotension
What are the causes of postpartum hemorrhage?
Causes of delayed postpartum hemorrhage?
Uterine atony Retained placenta, including placenta accreta Coagulation disorders Obstetrical laceration Uterine inversion
Subinvolution of placental site
Retained products of conception
Infection
Inherited coagulation defects
What is the generic name for Methergine?
What is the IM dosage?
How often can do it be administered?
In what patients is it contraindicated?
Methylergonovine
200 µg
Every 2-4 hours
Hypertension
What class of medication is misoprostol?
How is it dosed?
PGE1
800-1000 mcg rectally
What is the generic name for Hemabate?
What is the dosage?
How often can it be given? What is the maximum dosage?
What are the contraindications?
What are common side effects?
15-methyl PGF2alpha
250 µg
Every 15-90 minutes, eight doses maximum
Asthma; relative contraindications are hepatic, renal, or cardiac disease.
Diarrhea, fever, tachycardia can occur
What is the secondary management of uterine atony if initial management has failed?
Transfusion
Uterine packing or Bakri balloon
Uterine artery embolization
Surgical management such as compression sutures or hysterectomy
Described technique for uterine packing?
4 inch gauze soaked in 5000 units of thrombin and 5 mL of sterile saline
Packing is then carefully layered back-and-forth from one cornu to the other using a sponge stick until extension of the gauze through the cervical os
What volume is instilled in the Bakri balloon?
300-500 mL of NS
What patients are good candidates for arterial embolization?
What factors predict failed embolization?
Stable vital signs with persistent bleeding or continued bleeding after hysterectomy
EBL greater than 1500 mL or greater than 5 units RBC’s transfused
What surgical techniques can be used for management of postpartum hemorrhage?
Uterine curettage Uterine artery ligation or O'Leary stitch B-Lynch sutures Hypogastric artery ligation Hysterectomy
How is uterine inversion managed?
Replacement of the uterine corpus by placing the hand against the fundus as if holding a tennis ball.
Terbutaline, magnesium sulfate, general anesthetic, or nitroglycerin maybe necessary for uterine relaxation.
What is the Huntington procedure?
Progressive traction on the inverted corpus using Babcock or Allis forceps at laparotomy.
How does recombinant factor VIIa work?
How is it dosed?
What are the primary concerns with its use?
Activation of extrinsic clotting pathway
50-100 µg per kilogram every two hours. Cessation of bleeding occurs in 10-40 minutes
Increased risk of VTE and high cost
Describe massive transfusion protocol.
1:1:1 FFP, platelets, RBCs
Based on trauma literature from Iraq war
How should anemia following excessive blood loss be managed?
Prenatal vitamins with 60 mg of elemental iron, 1 mg of folate and two iron tablets with ferrous sulfate 300 mg or 60 mg of elemental iron each
