Hemorrhage

Question 1

Define a compensated PPH?

Answer 1

<1000mL, (10-15%) with normal vital signs, normal or increased pulse pressure, urinary output is >/=30cc/hr and AxOx4

Question 2

Define mild PPH

Answer 2

1000-1500 (15-30%), HR >100, pulse pressure is narrowed, resp rate 20-30/min & urinary output 20-30/hr.
Mental status: weakness, anxiety, agitation, and sweating

Question 3

Define moderate PPH

Answer 3

1500-2000, (30-40%)
HR >/= 120
BP: Hypotension with narrowed pulse pressure
RR: 30-40
urinary output: 5-15mL/hr
Mental status: restless, pallor, confusion

Question 4

Define severe PPH

Answer 4

> /=2000 (>/=40%)
HR: >/=140
BP: profound Hypotension with narrowed PP
RR: >40
UO: slight or anuria
Mental status: air hungry, lethargy, collapse

Question 5

Management plan for a parturient with moderate to high RISK of PPH

Answer 5

1. provide anticipatory guidance to woman, family, and hospital staff
2. Order type and screen and cross-match blood if needed & place 16 to 18g IV
3. Empty bladder frequently
4. Consider pain mgmt methods that will support parturient if PPH does occur
5. Administer uterotonic agent during anterior shoulder
6. Maintain uterine massage after placental expulsion and closely monitor.

Question 6

How is the 1st line therapy, Oxytocin (Pitocin) given (IV & IM route)

Answer 6

IV: 10-80U in (250 or 500cc) of NS or LR
IM: 10 U

Question 7

What are the contraindications for & SE of oxytocin?

Answer 7

CI: hypersensitivity
SE: cramping & HYPOnatremia
ADE: hypotension and cardiac collapse if undiluted

Question 8

Onset & duration of action of oxytocin

Answer 8

Onset: 2-3 mins, but effectiv in 15-30mins
Duration: 2-3 hours IF given IM

Question 9

How can the 2nd line, Methylergonovine maleate (Methergine) given?

Answer 9

0. 2mg IM, repeat in 5 mins, and q2-4 hours OR

0. 2mg PO TID for prophylaxis

Question 10

CIs and SEs to methergine

Answer 10

CI: HTN, PEC (&causes vasospasm if given IV)
SE: cramping, N/V, HTN, seizure, headache

Question 11

Onset of action, plasma peak concentration, and 1/2 life of methergine

Answer 11

Onset: 2-5mins
Plasma peak concentration: 20-30 mins
1/2 life: 3-4hrs

Question 12

What does Methergine’s BBW say?

Answer 12

Don’t BF for first 12 hours of NBs life

Question 13

How to give Carboprost tromethamine (Hemabate)–aka 15 methyl protaglandin F2a analogue

Answer 13

250mcg IM q15-90mins, up to 8 doses

Question 14

CI & SE & BBW for Hemabate

Answer 14

CI: ashtma, cardiac, pulmonary, renal, or hepatic dz
SE: N/V/D, bronchospasm, HTN, pyrexia (common)
BBW: avoid BF for first 12 hours

Question 15

Peak serum concentration of Hemabate

Answer 15

30 mins, but LESS effective than methergine

Question 16

How to give Misoprostol (Cytotec)

Answer 16

sublingual: 600-800mcg (can give BID)
Rectum: 800-1000mcg x 1

Question 17

SE of cytotec

Answer 17

N/V/D, abdominal pain, pyrexia

Question 18

Onset of action, peak concetration (rectal and SL)

Answer 18

onset: 3-5mins
Peak SL: 30 mins
Peak rectal: 40-60 mins

Question 19

How to give Dinoprostone (Prostin E2)?

Answer 19

20mg vaginal or rectal, may repeat every 2 hours

Question 20

CI, SE, and BBW of Dinoprostone (Prostin E2)?

Answer 20

CI: Hypotension and cardiac dz
SE: N/V/D & pyrexia
BBW: ONLY use in hospital settings (??)

Question 21

Onset of action of Dinoprostone (Prostin E2)?

Answer 21

10 mins (slower than others(

Question 22

When and how to give Tranexamic acid (Cyklokapron)?

Answer 22

When other measures fail, give TXA, which inhibits fibrinolysis
1g in 10mL syringe –IV push over 1 min
Can be repeated after 30 mins

Question 23

SE & ADE of tranexamic acid

Answer 23

Mild GI distress, potential risk of thrombosis

Question 24

What’s the difference between primary and secondary PPH?

Answer 24

Primary, also known as “early,” PPH is defined as a PPH occurring the first 24 hours, while secondary (late) PPH occurs between 24 hours and 6 weeks PP

Question 25

Incidence of PPH and % of maternal mortality attributed to PPH.

Answer 25

2-3% of all births will r/i a PPH (often r/t oxytocin use & c-section)
20% of maternal deaths are attributed to hemorrhage, and 1/2 of these are preventable.
PPH is the leading cause of maternal mortality in this nation.

Question 26

Define PPH

Answer 26

Blood loss of 1000mL or more
OR
Blood loss that is accompanied by s/sx of hypovolemia within 24 hours of birth.

Question 27

Signs and symptoms of uterine rupture

Answer 27

Loss of station
Sharp, continuous pain
Bleeding 
Hematuria 
FHR changes

Question 28

T or F: dehiscence of uterine scar requires immediate surgery

Answer 28

False; it doesn’t involve the serosa layer and patients are typically asymptomatic