OB hemorrhage and thromboembolism Flashcards
3 ways to prevent maternal death from hemorrhage
-recognize risk factors
-timely ID abnormal bleeding
-prompt initiation of appropriate Tx
normal amounts blood loss with:
-vaginal birth
-C/S, forceps/vacuum, 3rd/4th degree tear
-C/S hysterectomy
vaginal: 500 mL
C/S, forceps/vacuum, 3rd/4th tear: 1000 mL
C/S hysterectomy: 1500 mL
causes OB hemorrhage in early pregnancy
-spontaneous abortion (miscarriage)
-ectopic pregnancy (tubal)
-molar pregnancy (gestational trophoblastic disease)
causes OB hemorrhage in late pregnancy/intrapartum (6)
-placental abruption
-placenta previa
-vasa previa
-uterine rupture
-abnormal placental implantation (placenta accreta spectrum - PAS)
-amniotic fluid embolism
when placenta implants over os of cervix (complete or marginal - <2.5 cm through transvaginal ultrasound)
placenta previa
moms at increased risk for placenta previa
-previous C/S or uterine surgery
-maternal age >35 yo
-multiparity
-h/o suction curettage (miscarriage/abortion)
-previous placenta previa
-smoking
determinants for medical Tx of placenta previa (3)
-gestational age (>36 weeks = C/S)
-amount of bleeding
-maternal and fetal status
premature separation of placenta
placental abruption
risk factors placental abruption
-previous abruption
-maternal HTN (all types)
-cocain
-blunt external abdominal trauma
-smoking
classification placental abruption
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
will mom or baby show S+S of hemorrhage first
baby
mom’s body shunts blood to vital organs
2 types vasa previa
-velamentous insertion of cord (fetal arteries running through amniotic membrane)
-succenturiate placenta (extra lobe)
what FHR might you see with vasa previa
variable decels
big risk with vasa previa and amniotic fluid rupture
-large volume bloody amniotic fluid
-baby FHR variable decels, then no HR
-baby exsanguinates
S+S vasa previa
-palpation FHR pulsation with vaginal exam
-ROM with bright red bleeding and variable decels
-fetal exsanguination
-PPH w retained lobe (w succenturiate placenta)
Tx vasa previa
-C/S immediately (if discovered intrapartum)
-C/S at 34-35 weeks EGA (if diagnosed prenatally)
S+S amniotic fluid embolism
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)
Tx amniotic fluid embolism
-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
at how many minutes does a C/S happen if mom has cardiac arrest
4 minutes
difference SaO2 and SpO2
saturation hemoglobin molecules with oxygen
SpO2 = pulse ox
SaO2 = blood
risk factors uterine rupture
-*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
what meds are contraindicated with previous uterine scar
prostaglandins (cytotec)
S+S uterine rupture
-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
Tx uterine rupture
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
definition PPH
cumulative blood loss >1000 mL OR
blood loss accompanied by S+S hypovolemia
within 24 hrs following birth process
classification PPH
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)
causes primary PPH (4 Ts + 1)
-tone (uterine atony)
-tissue (retained placenta)
-trauma (genital tract lacerations)
-thrombin (clotting abnormality)
-uterine inversion
causes secondary PPH
-infection
-subinvolution placental site (failure to heal to prepregancy state)
-retained placenta
-inherited coagulation defect
Tx uterine atony
-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
how to know how to position pt w PP complications
“face is red, lift up head”
“face is pale, lift up tail”
meds for PPH
-prophylaxis oxytocin in IV fluids (3rd/4th stage labor, then after birth)
side effects oxytocin admin
-uterine contractions (afterbirth pains)
-IVP contraindicated (hypoTN, MI)
-prolonged admin: N/V, hyponatremia, water intoxication
uterine stimulant med: methergine
-nursing implications
-contraindications
-side effects
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)
uterine stimulant med: hemabate
-nursing implications
-contraindications
-side effects
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
uterine stimulant med: misoprostol
misoprostol (prostaglandin E; cytotec)
-cautiously with asthma
-SE: fever, chills, shivering
antifibrinolytic agent for uterine atony: TXA
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
expulsion of all products of conception has not occurred within 30-60 mins of birth
retained products of conception
risk factors retained placental fragments
-2nd tri birth
-chorioamnionitis
-accessory placental lobes (succenturiate placenta)
S+S retained placental fragments
-uterine bleeding
-atony
(could lead to placental entrapment, uterus is contracting and traps placenta)
Tx retained placental fragments
-uterine tonics/TXA
-exploration uterus
-curetage
3 types abnormal placental implantation
-accreta: adheres/attaches to myometrium
-increta: invades uterine wall and myometrium
-percreta: penetrates myometrium (and invades nearby organs)
risk factors placenta accreta spectrum
-previous C/S or uterine surgery
-placenta previa
-advanced maternal age
-fibroids, uterine anomalies
Tx placenta accreta spectrum
-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
types uterine inversion
-complete
-incomplete/partial
-forced
-spontaneous
S+S uterine inversion
-large red/bluish gray mass visualized in vagina
-profuse bleeding
-nonpalpable fundus
-pelvic pain
-vaginal fullness
Tx uterine inversion
-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
3 coagulopathies
-von willebrands disease
-idiopathic thrombocytopenia purpura (ITP)
-disseminated intravascular coagulation (DIC)
Dx of ITP
-low platelets
-purpura
-increased bleeding time
risks with ITP
-maternal hemorrhage
-neonatal thrombocytopenia
Tx ITP
-prenatal: corticosteroids, IV immunoglobulin
-if significant bleeding: platelet transfusion
-splenectomy (if severe case)
S+S von willebrands disease
-deficiency in von willebrand factor (clotting factor 8)
-menorrhagia (heavy periods)
-recurrent bleeding (nosebleeds, gums)
-bruise easily
-excessive bleeding w surgeries or trauma
when does risk for PPH increase with von willebrands disease
3-5 days PP
Tx von willebrands disease
-desmopressin (IV)
-cryoprecipitate
-concentrates of factor 8
-keep in hospital a little longer
pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external or internal bleeding or both
disseminated intravascular coagulation (DIC)
triggers of DIC
- release of tissue thromboplastin:
-placental abruption
-retained dead fetus syndrome
-amniotic fluid embolism - damage to vascular integrity:
-severe preeclampsia and HELLP
-sepsis
S+S DIC
-hemorrhage
-tissue hypoxia and ischemic necrosis
-renal failure
-ARDS (acute resp distress syndrome)
Tx DIC
-fix underlying cause
-volume expansion
-rapid transfusion blood and clotting factors
-O2
-maintain body temp
normal MAP in 2nd tri and 3rd tri
2nd = 80
3rd = 90
when might you want a Pulmonary Artery Catheter (swan-ganz)
-oliguric after fluid resuscitation
-sepsis
-cardiac/pulmonary disease
-severe HTN w preeclampsia
usually 1st changes in maternal VS with hemorrhage
-tachypnea
-tachycardia
fetal signs hemorrhage
1st indicator = significant changes in FHR
-tachycardia/bradycardia
-decreased/loss FHRV
-repetitive late/variable decels
uterine signs hemorrhage
tachysystole
hypertonus
loss contractions
nursing interventions for hemorrhage (general)
-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
type and amount blood products to give are determined by
-QBL
-continued bleeding
-clinical assessments
-responses to interventions
-labs
initial volume replacement interventions for hemorrhage
-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
how long does thawing FFP take
about 30 mins
when to give PRBC
hgb <8 w active bleeding
hgb <6 w/o active bleeding but symptomatic
when to give FFP
-if PT/PTT>1.5 times normal range
when to give platelets
(microvascular bleeding)
-plt count <50-70k
when to give whole blood
hgb<8
complications hypovolemia and massive transfusion
“TRIAD OF DEATH”:
-hypothermia
-coagulopathy
-acidosis
______
-electrolyte imbalance
definition hypothermia
<95 F
Tx acidosis (with hypovolemia and massive transfusion)
-restore volume
-transfuse PRBCs
-art line
electrolyte imbalances with hypovolemia and massive transfusion
-Tx
-hyperchloremic acidosis
-hypomag
-hypocalcemia
-hyperkalemia
*monitor values, EKG
management of coagulopathies with hypovolemia and massive transfusion (DCR)
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)
what causes increased risk thrombus formation (3)
-venous stasis
-hypercoagulability
-endothelial damage
DVT Tx for thromboembolism during pregnancy
-no warfarin until after birth
-use lovenox or heparin
-monitor for PE
S+S PE
-dypsnea, SOB
-cough, hemoptysis
-tachycardia, chest pain, apprehension
Tx PE
-oxygen
-IV
-raise hob
-activate rapid response team
type of acquired thrombophilia during pregnancy
antiphospholipid syndrome (APS)
antibodies attack cels
risks with antiphospholipid syndrome (APS) during pregnancy
-fetal loss
-fetal IUGR
-preeclampsia
prophylactic intervention against complications with APS
baby aspirin
risk factors that require extra surveillance of thrombophilia
APS +
2 or more early pregnancy losses
1 or more late losses, IUGR, abruption, or preeclampsia
how many weeks EGA do you want to do left hip tilt with trauma situations
> 20 weeks EGA
