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OB hemorrhage and thromboembolism Flashcards

1
Q

3 ways to prevent maternal death from hemorrhage

A

-recognize risk factors
-timely ID abnormal bleeding
-prompt initiation of appropriate Tx

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2
Q

normal amounts blood loss with:
-vaginal birth
-C/S, forceps/vacuum, 3rd/4th degree tear
-C/S hysterectomy

A

vaginal: 500 mL
C/S, forceps/vacuum, 3rd/4th tear: 1000 mL
C/S hysterectomy: 1500 mL

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3
Q

causes OB hemorrhage in early pregnancy

A

-spontaneous abortion (miscarriage)
-ectopic pregnancy (tubal)
-molar pregnancy (gestational trophoblastic disease)

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4
Q

causes OB hemorrhage in late pregnancy/intrapartum (6)

A

-placental abruption
-placenta previa
-vasa previa
-uterine rupture
-abnormal placental implantation (placenta accreta spectrum - PAS)
-amniotic fluid embolism

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5
Q

when placenta implants over os of cervix (complete or marginal - <2.5 cm through transvaginal ultrasound)

A

placenta previa

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6
Q

moms at increased risk for placenta previa

A

-previous C/S or uterine surgery
-maternal age >35 yo
-multiparity
-h/o suction curettage (miscarriage/abortion)
-previous placenta previa
-smoking

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7
Q

determinants for medical Tx of placenta previa (3)

A

-gestational age (>36 weeks = C/S)
-amount of bleeding
-maternal and fetal status

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8
Q

premature separation of placenta

A

placental abruption

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9
Q

risk factors placental abruption

A

-previous abruption
-maternal HTN (all types)
-cocain
-blunt external abdominal trauma
-smoking

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10
Q

classification placental abruption

A

grade 0: completely asymptomatic

grade 1 (mild): 10-20% placental surface area detached, blood los <500 mL, uterine tone normal, no pain

grade 2 (moderate): 20-50% placental surface area detached, blood loss 1000-1500 mL, uterine tenderness and pain, abnormal FHR pattern

grade 3 (severe): >50% surface area detached, blood loss >1500 mL, “board-like” abdomen, mother in shock w/ coagulopathy (DIC), severe pain, abnormal FHR pattern and fetal death possible

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11
Q

will mom or baby show S+S of hemorrhage first

A

baby
mom’s body shunts blood to vital organs

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12
Q

2 types vasa previa

A

-velamentous insertion of cord (fetal arteries running through amniotic membrane)
-succenturiate placenta (extra lobe)

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13
Q

what FHR might you see with vasa previa

A

variable decels

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14
Q

big risk with vasa previa and amniotic fluid rupture

A

-large volume bloody amniotic fluid
-baby FHR variable decels, then no HR
-baby exsanguinates

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15
Q

S+S vasa previa

A

-palpation FHR pulsation with vaginal exam
-ROM with bright red bleeding and variable decels
-fetal exsanguination
-PPH w retained lobe (w succenturiate placenta)

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16
Q

Tx vasa previa

A

-C/S immediately (if discovered intrapartum)
-C/S at 34-35 weeks EGA (if diagnosed prenatally)

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17
Q

S+S amniotic fluid embolism

A

sudden acute onset:
-phase 1: resp distress (hypoxia, pulm edema)
-phase 2: circulatory collapse (hypoTN, tachy, shock)
-phase 3: hemorrhage (DIC)

(anaphylactoid syndrome of pregnancy)

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18
Q

Tx amniotic fluid embolism

A

-Sbp>90
-UOP>30 mL/hr
-SaO2>95% and pO2>60%
-correct coagulopathies
-CPR prn
-intubate prn
-IV fluids, then blood
-vasopressors
-possible inotropic meds if L HF
-C/S if CPR for 4 mins w/o response

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19
Q

at how many minutes does a C/S happen if mom has cardiac arrest

A

4 minutes

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20
Q

difference SaO2 and SpO2

A

saturation hemoglobin molecules with oxygen
SpO2 = pulse ox
SaO2 = blood

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21
Q

risk factors uterine rupture

A

-*previous uterine surgery (scar)
-labor induction with prostaglandins (cytotec) followed by oxytocin
-labor augmentation with oxytocin
-antepartum fetal death
-previous first trimester miscarriages
-<16 month interdelivery interval
-previous C/S with severe PPH

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22
Q

what meds are contraindicated with previous uterine scar

A

prostaglandins (cytotec)

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23
Q

S+S uterine rupture

A

-abdominal pain/tenderness (wide range)
-sharp, tearing pain (if complete rupture)
-vomiting/syncope
-vaginal bleeding
-tachycardia, hypoTN/shock, pallor
-loss fetal station (can’t reach presenting part)
-contractions - decreased frequency or tachy
-tense, acute abdomen with shoulder pain (abdominal bleeding)

fetus:
-abnormal FHR pattern
-no FHR variation
-decels (recurrent late/variable, prolonged)
-brady

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24
Q

Tx uterine rupture

A

prevention:
-no cytotec in 3rd trimester w uterine scar
-repeat C/S if high vertical/T-shaped uterine incision
-birth at appropriate facility
_____________________
-continuous EFM
-C/S
-hemodynamic stabilization

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25
Q

definition PPH

A

cumulative blood loss >1000 mL OR
blood loss accompanied by S+S hypovolemia
within 24 hrs following birth process

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26
Q

classification PPH

A

primary (early):
-birth to placental separation
-between placental separation and expulsion (retained placental fragment)
-expulsion of placenta to 24 hours after birth (uterine atony)

secondary (late):
->24 hours after birth up to 6 weeks PP (retained placental fragment, infection)

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27
Q

causes primary PPH (4 Ts + 1)

A

-tone (uterine atony)
-tissue (retained placenta)
-trauma (genital tract lacerations)
-thrombin (clotting abnormality)
-uterine inversion

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28
Q

causes secondary PPH

A

-infection
-subinvolution placental site (failure to heal to prepregancy state)
-retained placenta
-inherited coagulation defect

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29
Q

Tx uterine atony

A

-call for help
6 M’s:
-massage fundus and empty bladder
-monitor VS, O2, I&O
-measure (quantified blood loss)
-medicate (IV fluids, oxytocin/uterotonics)
-maintain warmth (blankets)
-mobilize team

-position if hypovolemic: trendelenburg
-administer blood prn

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30
Q

how to know how to position pt w PP complications

A

“face is red, lift up head”
“face is pale, lift up tail”

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31
Q

meds for PPH

A

-prophylaxis oxytocin in IV fluids (3rd/4th stage labor, then after birth)

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32
Q

side effects oxytocin admin

A

-uterine contractions (afterbirth pains)
-IVP contraindicated (hypoTN, MI)
-prolonged admin: N/V, hyponatremia, water intoxication

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33
Q

uterine stimulant med: methergine
-nursing implications
-contraindications
-side effects

A

methergine (methylergonovine/ergonovine)
=uterotonic
-don’t give PRIOR to delivery of placenta
-take BP prior to admin (hold if BP 140/90)
-contraindicated: HTN, heart disease
-side effects: N/V
-adverse effects: HTN
(PO/IM med)

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34
Q

uterine stimulant med: hemabate
-nursing implications
-contraindications
-side effects

A

hemabate (prostaglandin F2; carboprost)
=prostaglandin for PPH
-don’t give PRIOR to delivery of placenta
-don’t exceed 8 doses
-contraindication: asthma, hypersensitivity, acute PID
-side effects: headache, N/V, fever, flushing
-adverse effect: bronchospasm/wheezing
-ausculatate breath sounds frequently
-check temp q1-2 hrs

35
Q

uterine stimulant med: misoprostol

A

misoprostol (prostaglandin E; cytotec)
-cautiously with asthma
-SE: fever, chills, shivering

36
Q

antifibrinolytic agent for uterine atony: TXA

A

tranexamic acid (TXA)
-reduces bleeding by interfering with breakdown of clots
-not first line Tx for PPH
-contraindication: h/o thrombosis, active thromboembolic disease (DVT/PE)
-1st dose given within 3 hrs birth

37
Q

expulsion of all products of conception has not occurred within 30-60 mins of birth

A

retained products of conception

38
Q

risk factors retained placental fragments

A

-2nd tri birth
-chorioamnionitis
-accessory placental lobes (succenturiate placenta)

39
Q

S+S retained placental fragments

A

-uterine bleeding
-atony

(could lead to placental entrapment, uterus is contracting and traps placenta)

40
Q

Tx retained placental fragments

A

-uterine tonics/TXA
-exploration uterus
-curetage

41
Q

3 types abnormal placental implantation

A

-accreta: adheres/attaches to myometrium
-increta: invades uterine wall and myometrium
-percreta: penetrates myometrium (and invades nearby organs)

42
Q

risk factors placenta accreta spectrum

A

-previous C/S or uterine surgery
-placenta previa
-advanced maternal age
-fibroids, uterine anomalies

43
Q

Tx placenta accreta spectrum

A

-prenatal Dx at risk women
-referral to level 3/4 facility
-consider antenatal corticosteroids and scheduled preterm C/S (34-35 weeks EGA)
-multidisciplinary team
-prepare for hemorrhage and initiation of massive transfusion protocol

44
Q

types uterine inversion

A

-complete
-incomplete/partial
-forced
-spontaneous

45
Q

S+S uterine inversion

A

-large red/bluish gray mass visualized in vagina
-profuse bleeding
-nonpalpable fundus
-pelvic pain
-vaginal fullness

46
Q

Tx uterine inversion

A

-reposition (push it back up)
-tocolytics (terbutaline - relaxes uterus so it can be pushed back up)
-stimulate uterine tone (oxytocin and uterine tonics)
-treat hypovolemic shock
-hysterectomy if unable to replace
-Abx

47
Q

3 coagulopathies

A

-von willebrands disease
-idiopathic thrombocytopenia purpura (ITP)
-disseminated intravascular coagulation (DIC)

48
Q

Dx of ITP

A

-low platelets
-purpura
-increased bleeding time

49
Q

risks with ITP

A

-maternal hemorrhage
-neonatal thrombocytopenia

50
Q

Tx ITP

A

-prenatal: corticosteroids, IV immunoglobulin
-if significant bleeding: platelet transfusion
-splenectomy (if severe case)

51
Q

S+S von willebrands disease

A

-deficiency in von willebrand factor (clotting factor 8)
-menorrhagia (heavy periods)
-recurrent bleeding (nosebleeds, gums)
-bruise easily
-excessive bleeding w surgeries or trauma

52
Q

when does risk for PPH increase with von willebrands disease

A

3-5 days PP

53
Q

Tx von willebrands disease

A

-desmopressin (IV)
-cryoprecipitate
-concentrates of factor 8
-keep in hospital a little longer

54
Q

pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external or internal bleeding or both

A

disseminated intravascular coagulation (DIC)

55
Q

triggers of DIC

A
  1. release of tissue thromboplastin:
    -placental abruption
    -retained dead fetus syndrome
    -amniotic fluid embolism
  2. damage to vascular integrity:
    -severe preeclampsia and HELLP
    -sepsis
56
Q

S+S DIC

A

-hemorrhage
-tissue hypoxia and ischemic necrosis
-renal failure
-ARDS (acute resp distress syndrome)

57
Q

Tx DIC

A

-fix underlying cause
-volume expansion
-rapid transfusion blood and clotting factors
-O2
-maintain body temp

58
Q

normal MAP in 2nd tri and 3rd tri

A

2nd = 80
3rd = 90

59
Q

when might you want a Pulmonary Artery Catheter (swan-ganz)

A

-oliguric after fluid resuscitation
-sepsis
-cardiac/pulmonary disease
-severe HTN w preeclampsia

60
Q

usually 1st changes in maternal VS with hemorrhage

A

-tachypnea
-tachycardia

61
Q

fetal signs hemorrhage

A

1st indicator = significant changes in FHR
-tachycardia/bradycardia
-decreased/loss FHRV
-repetitive late/variable decels

62
Q

uterine signs hemorrhage

A

tachysystole
hypertonus
loss contractions

63
Q

nursing interventions for hemorrhage (general)

A

-mobilize team
-airway, O2 through NRB mask 10L
-2 large bore IV caths (LR or NS)
-uterine massage (if PP)
-labs (CBC, clotting studies)
-type and crossmatch blood
-meds per protocol orders
-foley cath
-manage pain and anxiety
-anticipate surgical interventions

64
Q

type and amount blood products to give are determined by

A

-QBL
-continued bleeding
-clinical assessments
-responses to interventions
-labs

65
Q

initial volume replacement interventions for hemorrhage

A

-1000-1500 mL of QBL w active bleeding
-2 large bore IV
-volume expansion (2 L crystalloid solutions - NS)
*avoid solutions containing glucose when transfusion blood

66
Q

how long does thawing FFP take

A

about 30 mins

67
Q

when to give PRBC

A

hgb <8 w active bleeding
hgb <6 w/o active bleeding but symptomatic

68
Q

when to give FFP

A

-if PT/PTT>1.5 times normal range

69
Q

when to give platelets

A

(microvascular bleeding)
-plt count <50-70k

70
Q

when to give whole blood

A

hgb<8

71
Q

complications hypovolemia and massive transfusion

A

“TRIAD OF DEATH”:
-hypothermia
-coagulopathy
-acidosis

______
-electrolyte imbalance

72
Q

definition hypothermia

A

<95 F

73
Q

Tx acidosis (with hypovolemia and massive transfusion)

A

-restore volume
-transfuse PRBCs
-art line

74
Q

electrolyte imbalances with hypovolemia and massive transfusion
-Tx

A

-hyperchloremic acidosis
-hypomag
-hypocalcemia
-hyperkalemia
*monitor values, EKG

75
Q

management of coagulopathies with hypovolemia and massive transfusion (DCR)

A

damage control resuscitation (DCR):

-permissive hypoTN (maintain minimum bp to perfuse organs, Sbp=90)
-limit crystalloids (limit fluid overload)
-balanced ratio blood products (1:1:1 platelets, plasma, PRBCs)
-goal directed correction of coagulopathy (test: thromboelastography measure clotting)

76
Q

what causes increased risk thrombus formation (3)

A

-venous stasis
-hypercoagulability
-endothelial damage

77
Q

DVT Tx for thromboembolism during pregnancy

A

-no warfarin until after birth
-use lovenox or heparin
-monitor for PE

78
Q

S+S PE

A

-dypsnea, SOB
-cough, hemoptysis
-tachycardia, chest pain, apprehension

79
Q

Tx PE

A

-oxygen
-IV
-raise hob
-activate rapid response team

80
Q

type of acquired thrombophilia during pregnancy

A

antiphospholipid syndrome (APS)
antibodies attack cels

81
Q

risks with antiphospholipid syndrome (APS) during pregnancy

A

-fetal loss
-fetal IUGR
-preeclampsia

82
Q

prophylactic intervention against complications with APS

A

baby aspirin

83
Q

risk factors that require extra surveillance of thrombophilia

A

APS +
2 or more early pregnancy losses
1 or more late losses, IUGR, abruption, or preeclampsia

84
Q

how many weeks EGA do you want to do left hip tilt with trauma situations

A

> 20 weeks EGA

high risk OB (14 decks)

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