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Obstetrics and Gynecology > Hemorrhage > Flashcards

Hemorrhage Flashcards

1
Q

Postpartum hemorrhage is defined as loss of blood of

A

> 500 ml after third stage of labor

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2
Q

Class 1 Blood loss

A

1000 ml
15%
Dizziness, palpitations

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3
Q

Class 2 blood loss

A 
1500 
20-25%
Tachycardia
Tachypnea
Sweating, weakness and narrowed pulse pressure
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4
Q

Class 3 blood loss

A 
2000 ml
30-35% 
Significant tachycardia and tachypnea
Restlessness
Pallor
Cool extremities
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5
Q

Class 4 blood loss

A

> /= 2500
40%
Shock
Air hunger

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6
Q

Hemodynamic adaptations in pregnant

A 
Inc BV 40-50% by 30th week
Inc RBC mass by 20-30th with good stores
Inc CO by 30-50% in 3rd trimester
Dec vascular resistance
Inc in fibrinogen and procoagulant factors
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7
Q

Anatomical change that promotes hemostasis at 3rd stage labor/post partum

A

Interlacing myometrial fibers

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8
Q

Dry lap sponges 18 x 18

A

25 ml - 50% saturation
50 ml - 75% saturation
75 ml - entire surface
100 ml - saturate and drip

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9
Q

Massive transfusion protocol

A

6 units pRBC: 4 FFP: 1 unit platelet

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10
Q

Position that improves hemodynamic status
Inc SV
Inc CO
dec HR

A

Trendelenburg

Left lateral decubitus

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11
Q

Common causes of hemorrhage in the antepartum period (maternal + fetal concerns)

A 
Ectopic pregnancy 
Abortion
GTN - before 20 weeks 
Abruptio placenta - most common 
Placenta previa
Vasa previa
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12
Q

Most common cause of hemorrhage in antepartum period

A

Abruptio placenta

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13
Q

Causes of hemorrhage in post-partum period

A 
Uterine atony
Genital tract laceration
Hematoma
Uterine inversion
Adherent placenta
Accreta, increta, percreta
Retained placenta, placental fragment
Coagulopathy
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14
Q

Most common significant post-partum cause of hemorrhage

A

Uterine atony

Genital tract laceration

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15
Q

Most frequent cause of obstetrical hemorrhage

A

Failure of uterus to contract sufficiently

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16
Q

Premature separation of normally implanted placenta from uterus prior to delivery after 20 weeks AOG

Placenta abruption initiated by hemorrhage into the decidua basalis

Decidua splits leaving a thin layer adhered to myometrium

Decidual hematoma expands and causes separation and compression of adjacent placenta

A

Abruptio placenta

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17
Q

40-60% of abruptio occur

A

prior to 37 weeks AOG

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18
Q

Abruptio is difficult to diagnose because

A

Concealed

Tetanic contraction of uterus

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19
Q

Hematoma formation from abruptio can

A

go inside sinuses and go into circulation releasing thrombin, thromboplastin material and cause DIC

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20
Q

Abruptio Dx

A

UTZ (retroplacental hematoma)
MRI
Histopath confirmation

Based on clinical picture

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21
Q

Vaginal bleeding with or without tetanic contractions
Sudden pain: trauma, vehicular accident, amniotomy (rapid change in pressure)

Sudden onset ABDOMINAL PAIN
uterine tenderness

Pallor
Baby tachycardic, bradycardic and no FTH

A

Abruptio placenta

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22
Q

PainLESS bleeding

A

Placenta previa

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23
Q

Separation of placenta, blood seeped into myometrium explaining bluish discoloration of the placenta

This uterus will not contract anymore because of blood in between which affects the contractility of muscles

A

Couvelaire uterus

24
Q

Abruptio Mx

A

Amniotomy - to release the pressure and blood will not be pushed to sinuses and thombin and thromboplastin will not be released and will not proceed into DIC

If near delivery, expedite quickly (vaginal)

If not in labor, proceed to CS or else DIC

25
Q

Degrees of abruptio

A

Mild
Moderate - baby fead
Severe - DIC

26
Q

Presence of placental tissue over or near internal cervical os

A

Placenta previa

27
Q

Restriction of activity in previa is only required if the condition persists more than

A

28 weeks

or if bleeding or contraction develops before this time

28
Q

Placenta previa resolves if detected in 2nd trimester due to formation of

A

lower uterine segment

placental migration

29
Q

PAINLESS vaginal bleeding appearing near end of 2nd trimester

10% if lowlying no bleeding

A

Placenta previa

Total - completely covering Os
Marginal - portion of placenta near os
Low-lying - edge of placenta quite close but does not overlap

30
Q

Placenta previa risk factors

A 
Inc parity
Advanced age
Maternal cigarette smoking - carbon monoxide hypoxemia causing placental hypertrophy
Placenta previa
In vitro fertilization 
Cocaine
Infertility
Multiple gestation
Malpresentation
IUGR
Preterm labor
Congenital anomalies
Previous history of previa
Prior uterine surgeries
31
Q

Cigarette smoking causes placental hypertrophy because

A

Carbon monoxide hypoxia promotes hypertrophy
Placenta edge may reach the lower part of the uterus ans cover the entire cervical canal
Atrophy or inflammation of decidua may cause defective vascularization

32
Q

CI in Placenta previa

A

IE

TVS is not because it doesn’t touch cervix

33
Q

Placenta previa Dx

A

Transabdominal UTZ - identifies implantation site, confirms the
diagnosis of placenta previa
TVS - accurate in assessing distance, measures how much of the placenta overlaps
MRI

34
Q

Placenta previa Tx

A 
CS 
Preterm: Steroids (lung maturity)
MgSO4 (neuroprotection)
Tocolytic
Bed rest
No coitus
Repeat UTZ 32-35 weeks 
Deliver 36-37 w
35
Q

Presence of fetal vessels (velamentous cord insertiong over cervical os

Prone to compression leading to anoxia and laceration leading to fetal hemorrhage

Fetal death instantaneous hence warrants immediate CS

A

Vasa previa

36
Q

Vasa Previa risk factors

A 
Bilobed or succenturiate-lobed placenta
Vilamentous insertion of umbilical cord 
Placenta succenturiata 
IVF pregnancy
Multiple gestation
Second tri placenta previa or low-lying placenta
37
Q

Branching off of umbilical cord before reaching the placenta therefore exposed within the membrane

The cord and vessels go upright up to surface of the placenta before branching off

A

Velamentous insertion of umbilical cord

38
Q

Velamentous insertion Dx

A

Color Doppler Ultrasound

Blue - flow away from sonologist
Red - flow towards sonologist
Yellow - turbulent flow

39
Q

Placenta consists of large lobe and smaller one connected together by a membrane

Umbilical cord is inserted into the large lobe branches of its vessels cross the membrane to the small succenturiate (accessory lobe)

Accessory lobe may be retained in the uterus after delivery leading to postpartum hemorrhage

There could be fetal hemorrhage

A

Placenta succenturiata

40
Q

Placenta previa Dx

A

UTZ with Doppler flow
History of vaginal bleeding after rupture of the membrane due to laceration of thr fetal vessels
IE: pulsations of fetal vessels in the membrane that overlie the cervical OS

41
Q

Vasa Previa Tx

A

If prior term and not bleeding: NST to check for cord compression
CS at 34-35 weeks
If during labor: Immediate CS

42
Q

Most important and most preventable cause of postpartum hemorrhage

A

Disseminated intravascular coagulation

43
Q

Hemostatic mechanisms to prevent hemorrhage

A 
Platelet aggregation and platelet plug formation
Local vasoconstriction
Clot polymerization
Fibrous tissue fortification of clot
Uterine contraction
44
Q

Most common cause of postpartum hemorrhage (80%)

A

Uterine atony

45
Q

If atony is prior to placental delivery

A

manually extract placental

46
Q

If atony is after placental delivery

A

medical management + bimanual compression of uterus

47
Q

If pure atony but stable patient,

A

tamponade (uterine packing) with gauze or balloon
selective embolization
surgical intervention

48
Q

Uterine atony sx

A

Ligation of uterine and internal iliac artery

Hysterectomy

49
Q

Medical Management (Uterotonic)

A

Oxytocin
Carbetocin -long acting oxytocin agonist
Ergot derivatives (Methylergometrine maleate, Methergine, Ergonavine) - rapid if oxytocin not working
PGE1 (Misoprostol) - transrectal
PGEF2a (Carboprost) - not given in asthmatics
PGE2 (Dinoprostone)

50
Q

Uterine atony ligation is done in

A 
Internal iliac/hypogastric artery
Uterine artery (branch) at isthmus for lateral laceration
51
Q

Abnormal attachment of placenta to the uterine lining due to absence of decidua basalis and an incomplete development of fibrinoid layer

A

Placenta accreta

52
Q

Placenta on myometrium

A

Accreta

53
Q

Penetrates deep into myometrium

A

Increta

54
Q

Beyond the myometrium and possibly in neighboring structures

A

Percreta

55
Q

Risk factor for Placenta Accreta

A 
Placenta previa and prior CS
Increased parity and age
Myoma uteri (submucous)
Previous uterine surgery
Previous curettage leading to endometrial defects
56
Q

Placenta accreta Tx

A

CS Hysterectomy at 34-35 weeks

57
Q

If uterine preservation is requested with focal accrete, give

A

methotrexate

Obstetrics and Gynecology (18 decks)

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