Lecture 20: Obstetric Hemorrhage and Puerperal Sepsis Flashcards
How much will the Hct and Hgb be raised by 1 unti of PRBC’s?
Raise Hct by 3% and Hgb by 1g/dL
What should be avoided during the initial examination of antepartum hemorrhage?
- AVOID digital exam until placenta previa is ruled out
- Instead do sterile speculum exam
How many units of blood should you type and crossmatch for during antepartum hemorrhage?
4 untis of blood
Placenta previa classically presents how?
PAINLESS vaginal bleeding
Risk factors for placenta previa?
- Maternal age >35
- Multiparity
- Prior previa
- Previous C-section
What is the most serious type of placenta previa and is associated with the most blood loss?
COMPLETE
Placent previa is almost exclusively diagnosed how?
By U/S
How likely are placenta previas to resolve on their own?
90% will resolve by placental migration
What is goal of management of placenal previa in preterm pregnancy; can these patients go home?
- Goal is to attempt to obtain fetal maturation
- If bleeding not profuse, pt is managed on bed rest initially
- If stable and bleeding stops may send home on pelvic rest
What is the most common abnoraml placental implantation other than previa?
Placent ACCRETA; firm attachment ot the superficial linign of the myometrium
What is the most common cause of third trimester bleeding?
Placental Abruption
Which condition most often presents as painful third trimester bleeding, uterine tenderness, uterine hyperactivity, and fetal distress and/or death?
Placental abruption
What is the most common risk factor for placental abruption?
Maternal HTN
If pregnant mother presents after MVA or physical abuse how long should they be monitored for placental abruption?
Monitor for 4-6 hours
What is the most common cause of DIC in pregnancy?
Placental abruption
What is the proper management of placental abruption based on maternal and fetal stability?
- If both stable then proceed with vaginal delivery
- Often a rapid delivery ensues w/ abruption
- If remote from vaginal delivery w/ signs of fetal distress or uncontrolled bleeding then C-sections
What is couvelarire uterus?
Occurs during placental abruption with extravasation of blood into the uterus
Uterine rupture is associated with what signs/sx’s?
- Sudden onset of INTENSE abdominal pain +/- vaginal bleeding
- Abnormal FHR pattern or cessation of fetal heart tones
- Regression of the presenting part
How is uterine rupture managed?-
- Immediate laparotomy and delivery of fetus
- If feasible repair ruptured site
- If large rupture may have to do a cesarean hysterectomy
Fetal bleeding that occurs during the third trimester is most often due to what?
2’ to velamentous insertion of umbilical cord
Postpartum hemorrhage is defined as how much blood loss following a vaginal birth vs. C-section?
- >500cc following vaginal birth
- >1000cc following C-section
Differentiate primary vs. secondary postpartum hemorrhage?
- Primary is that which occurs within first 24 hours; often uterine atony
- Secondary occurs from >24 hours to 12 weeks
What will palpation of a uterus that fails to contract after delivery reveal (uterine atony)?
Will reveal “Boggy Uterus”
Effective hemostasis after separation of the placenta is dependent on what?
Myometrium to compress the severed vessels
What are some strategies to managin uterine atony?
- BIMANUAL MASSAGE of the uterus
- Start pharmacologic agents: oxytocin, etc…
- Uterine packing or large volume balloon catheter
- Interventional radiology
Methylergonovine can be given for tx of postpartum hemorrhage, but should be avoided in whom?
Avoid in HTN patients
15-methyl PGF2a (Hemabate) can be given for management of postpartum hemorrhage but should be avoided in which pt’s?
Avoid in asthmatics
Dinoprostone (PGE2) can be given for postpartum hemorrhage, but should be avoided in which pt’s?
Avoid if patient is HYPOtensive
What is the second most common cause of postpartum hemorrhage following vaginal delivery?
Trauma during delivery
What is the treatment for retained placenta?
- Manual removal if bleeding is profuse
- +/- uterine curettage with or without U/S guidance being careful not to perforate
How should uterine inverion be managed if placenta has not been delivered?
DO NOT remove placenta until the inversion is corrected
Uterine inversion is associated with what complications?
Copious bleeding and HYPOvolvemic shock can ensue
How much is the platelet count increased per unti of platelets given?
5000-10,000/mm3 per unit
What are the contents of fresh frozen plasma and how much does one unit increase the fibrinogen?
- Contains fibrinogen, antithrombin III,andFactors VandVIII
- Increases fibrinogen by 10 mg/dL
What are the blood components of Crypercipitate and how much does one unit increase the fibrinogen?
- Fibrinogen + vWF + Factors VIII and XIII
- Increases fibrinogen by 10 mg/dL
Febrile morbidity is defined as what?
Temp >100.4 (38 C) or higher occuring >2 consecutive days during the first 10 postpartum days
Majority of the postpartum fevers are due to what?
Endometritis
Organism with what oxygen dependence cause majority of puerperal infections; which organisms most commonly?
ANAEROBIC —> Peptostreptococcus, Peptococcus, and Streptococcus
What are the key clinical findings for puerpral sepsis?
Postpartum fever and ↑ uterine tenderness on postpartum day 2-3
What is an effective antibiotic regimen for puerperal sepsis; what if causative organism is Bacteroides fragilis?
- Ampicillin + Gentamicin
- Bacterioides fragilis is resistant to this combo, but sensitive to Clindamycin
Septic pelvic thrombophlebitis fufills the criteria for which pathogenesis of thrombosis?
- Virchow’s triad
- Endothelial damage + Venous stasis + hypercoagulable state of pregnancy
How does the presentation of ovarian vein thrombophlebitis differ from deep septic pelvic vein thrombophlebitis?
- Ovarian vein will have fever + abdominal pain within 1 week of delivery —> appear critically ill
- Pelvic vein will usually have unlocalized fever in first few days that is NON-responsive to Abx and pt’s do NOT appear critically ill
If ovarian vein thrombosis is seen radiographically anticoagulants should be continued for how long?
6 weeks
