OB HEMORRHAGES Flashcards
Postpartum Hemorrhage
Cumulative blood loss > 1000 mL accompanied by signs and symptoms of HYPOVOLEMIA
NSD > 500 mL
CS > 1000 mL
4 Ts
Tone
Trauma
Tissue
Thrombin
Bleeding during pregnancy
Antepartum Hemorrhage
Frequent causes of Postpartum Hemorrhage
uterine atony with placental site bleeding
genital tract trauma
Most frequent cause of obstetrical hemorrhage
Uterine Atony
Antimicrobial prophylaxis after manual removal of placenta
Ampicillin or Cefazolin
Uterotonic agents – UTERINE CONTRACTION
Oxytocin Ergot Derivative - Methylergonovine (Methergine), Ergonovine Carboprost Prostaglandin E2 - Dinoprostone Misoprostol - Cytotec
Degrees of Uterine Inversion
1st Degree
Inverted fundus extends to but not through the cervix
Degrees of Uterine Inversion
2nd Degree
Inverted fundus extends through the cervix but remains within the vagina
Degrees of Uterine Inversion
3rd Degree
Inverted fundus extends outside the vagina
Degrees of Uterine Inversion
Total Inversion
Vagina and uterus are inverted
Occurs more commonly in patients with previous caesarian delivery (classical CS)
Uterine Rupture
Risk Factors for Uterine Rupture
Prior uterine surgery/uterine scar Injudicious use of oxytocin Grand multiparity Marked uterine distension Abnormal fetal lie Large fetus External version Trauma
Treatment of choice when intractable uterine bleeding occurs or when the uterine rupture sites are multiple, longitudinal or low lying
HYSTERECTOMY
Premature separation of the placenta from the uterine wall
Placental Abruption
vaginal bleeding (3rd trimester) sudden onset abdominal pain uterine tenderness
Maternal sequelae of placental abruption
DIC shock transfusion hysterectomy renal failure death
Fetal complications of placental abruption
nonreassuring fetal status
growth restriction
death
Neonatal outcomes
death
preterm delivery
growth restriction
Risk factors for placental abruption
prior abruption increased age and parity preeclampsia chronic HPN chorioamnionitis preterm ruptured membranes multifetal gestation low birthweight hydramnios cigarette smoking single umbilical artery cocaine use uterine leiomyoma
Placental abruption
hypovolemic shock consumptive coagulopathy Couvelaire uterus end organ injury Sheehan syndrome
Classic sign of placental abruption that can be seen at the time of cesarean delivery
life threatening condition
Couvelaire uterus
bluish purple myometrium
Abnormally implanted placenta
Placenta goes before the fetus into the birth canal
Placenta Previa
Describe the apparent movement of the placenta AWAY from the INTERNAL OS
Placental migration
Internal os is covered partially or completely by placenta
PLACENTA PREVIA
complete/totalis
partial/partialis
marginalis
low-lying
Implantation in the lower uterine segment
placental edge does not cover the internal os but lies within a 2 cm wide perimeter around the os
Low Lying Placenta
The most characteristic event with placenta previa
PAINLESS BLEEDING
Predisposing factors for placenta previa
prior CS and uterine surgery multiparity multiple gestation erythroblastosis smoking hx of placenta previa increasing maternal age
Fetal complications associated with Placenta previa
preterm delivery and its complications preterm premature rupture of membranes intrauterine growth restriction malpresentation vasa previa congenital abnormalities
Recommended delivery in placenta previa
b/w 34 and 37 weeks
Abnormal placental adherence to the myometrium
partial or total absence of decidua basalis
imperfect devt of fibrinoid or Nitabuch layer
Frequent and serious complication associated with placenta previa
morbidly adherent placentas
Villi are attached to the myometrium
Placenta ACCRETA
Total placenta accreta
Focal placenta accreta
Villi INVADE the myometrium
Placenta INCRETA
Villi that PENETRATE through the myometrium and to or through the serosa
Placenta PERCRETA
Confirmation of a percreta or increta almost always mandates
Hysterectomy
2nd MC severe maternal morbidity indicator
Disseminated Intravascular Coagulation (DIC)
Classic triad of amniotic fluid embolism
abrupt hemodynamic
respiratory compromise
DIC
For treatment of hypovolemia from catastrophic hemorrhage
Compatible Whole Blood
Massive Transfusion Protocol
Cryoprecipitate
Fresh frozen plasma
Packed RBCs
Platelets
EFM tracing associated with abruptio
recurrent late or variable decelerations
reduced variability
bradycardia
sinusoidal pattern
Complications of Placental Abruptio
Perinatal mortality (25-30%) Hemorrhage Couvelaire uterus (Uteroplacental apoplexy) Acute renal failure (23 %) DIC
Risk Factors for massive bleeding during CS with previa
advanced maternal age
previous CS
(+) sponge like US findings in the cervix
Widespread systemic activation of coagulation –> thrombotic obstruction of small and midsize vessels –> tissue ischemia and bleeding from consumption of platelets and coagulation factors
Disseminated Intravascular Coagulation (DIC)
Intrinsic pathway (Endothelial damage)
septic abortion
chorioamnionitis
Extrinsic pathway (massive tissue injury)
abruptio placenta
amniotic fluid embolism
retained dead fetus
saline induced abortion
Risk factors of DIC
pregnancy abruptio placenta preeclampsia/eclampsia intrauterine fetal demise (> 1 mo) septic abortion amniotic fluid embolism
