Keeler: Obstetrical hemorrhage, GDM and PPROM Flashcards
preggo crazy bleeding, still have fetal heartbeat, dx?
Placenta previa
Abruptio placentae
Vasa previa
US = total placenta previa
(no evidence for “invasive” placenta)
gal has placenta previa and lots of bleeding. What do we do for it?
Steroids given Bleeding slowed/stopped Admitted for prolonged antepartum stay @ 36 weeks, amniocentesis = + FLM Low vertical cesarean delivery
Placenta previa info- risk factors, types, signs
Multiparity, adv maternal age, infertility Tx
Non-white, smoking, cocaine, male baby??
Prior C/S - red light red light red light
Partial, total, marginal, low lying
Second trimester US will find it
No digital exam unless results of 2nd tri US are known
Painless bleeding after 20 weeks
preggo in car accident, abdomen diffusely and markedly tender, no rebound. 30 minutes later– prolonged FHR deceleration with increase in pain and more bleeding
what do we do?
immediate c section under gen anesthesia
50% of maternal surface of placenta ended up being occupied by clotted blood
this was abruptio placentae
Abruptio placentae (Abruption) associated stuff
Associated with HTN/PIH, trauma, smoking, cocaine abuse, some - etiology = unclear
Varying degrees
Delivery – it depends on the case
Can have DIC, massive blood loss
gal has great normal delivery. after placenta 1 L of blood, what’s the possible ddx?
Uterine atony
Retained placental fragment
Obstetrical laceration
The four T’s
Tone, trauma, tissue, thrombus
post partum hemorrhage (PPH) – atony – a different physiology
“Hemostasis” after birth is achieved because the MYOMETRIUM contracts and closes off the SPIRAL ARTERIES that feed the placental bed.
Thus is a “mechanical” event and not a “biochemical” event (coagulation = biochemical)
what we can do for post-partum hemorrhage
Massage/evacuate clots Intrauterine exam Bimanual massage Extra oxytocin Methylergonovine (Methergine®) IM Inspect for lacerations (above perineum) – none are found
what to do when usual measures fail for postpartum hemorrhage
Bleeding continues, or abates only to resume
Curettage for fragment
Code “White”
Prostaglandin agonists (Cytotec PO/PR, Hemabate IM) see 2 slides hence……..
Bakri balloon
Embolization in radiology ????? - NOT for massive acute PPH
finally: Ligation hypogastric (internal iliac) arteries
“B-Lynch” suture
HYSTERECTOMY - have the COURAGE to do this in time !!!!!!!!!!!!!!!!!!!!!!!!!
Prostaglandins for PPH
Cytotec (misoprostol) = analog of prostaglandin E
Hemabate (carboprost) = analog of prostaglandin F2α. ** Do not use this one if patient has asthma. This one can also cause fever and diarrhea. **
PPH risk factors….
Multiparity IOL Prolonged labor – or rapid labor (<3 hrs) Prior hx of PPH Use of oxytocin, esp prolonged Older maternal age Large infant, overdistended uterus Multiple gestations Magnesium sulfate Chorioamnionitis Leiomyomata (fibroids) Halogenated anesthetics
“Uneventful” labor and delivery then... As placenta delivers, mother…….. Takes a deep breath, coughs up a little blood Turns dusky and pale Eyes roll back in head Becomes unintelligible BP = 80/P P = 140 SAO2 = 83% on RA – O2 immediately started
most likely dx?
AFE =
Amniotic fluid embolism
Anaphylactoid reaction of pregnancy
Exact pathophysiology is unclear!!
AFE
Sudden hypoxia + CV collapse
Profound DIC
Massive blood loss
90+% mortality
AFE - Tx
Get help – a LOT of help
Second IV line/central line
Massive transfusion protocol (1:1:1 of packed red cells, platelets, FFP)
** “Rescues” have been reported with HEART-LUNG MACHINE. Busy OB units have pre-arranged with CV Dept for this
** Early recognition is vital
eklampsis means
a shining forth or
strikes like lightning
Maternal physiology gone off the rails!
some terminology about eclampsia
Toxemia (no “toxin” ever discovered)
Pre-eclampsia
Pregnancy-induced hypertension = “PIH”
17 y/o preggers with high BP, pretibial edema, narrowing of arterioles in retina
PIH, pre-eclampsia, etc.
admit, induce labor.
expect post partum hemorrhage due to MgSO4
Pre-eclampsia - facts
Leading cause of maternal morbidity/mortality worldwide
Up by 25% in US in past 20 years
At risk for future CVD + metabolic disorders
risk factors for pre-eclampsia
Nulliparity Hx of PIH Age < 18, >40 \+ FHx Chronic HTN/renal dis Thrombophilias Vascular/CT diseases Diabetes/ high BMI Multiple gestation African-Am race Male history Fetal hydrops IUGR/ mom was LBW Long interval between Molar pregnancy ? Genetic mutation ? Partner factors Suggestive hx in prior Pg
Diagnosis of HTN
Pre-eclampsia / Eclampsia
(aka “Pregnancy-Induced Hypertension” = PIH)
Chronic HTN (existed before Pg, or < 20 wks)
Chronic HTN w/ “superimposed” pre-eclampsia
“Gestational hypertension”
Triad of Pre-eclampsia
Hypertension > 140/90 after 20 weeks
Proteinuria > 0.3gm/24H (~ 1+ dip)
Edema
