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MSc foetus exam > obstetric haemorrhage > Flashcards

obstetric haemorrhage Flashcards

1
Q

what is MBRACE?

A

its an audit

mothers and babies reducing risk through audits and confidential enquiries across the age

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2
Q

how common is death from obstetric haemorrhage?

A

remains a major cause of death in developing countries

not common in UK - still occurs though

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3
Q

what is PPH atony?

A

post party haemorrhage as uterus is completely relaxed - needs to contract to stop blood flow.

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4
Q

what is secondary post part haemorrhage?

A

defined as abnormal or excessive bleeding from the birth canna between 24 hours and 12 weeks after birth.

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5
Q

what happens to blood volume during pregnancy?

A

large increase in blood volume from 70ml/kg to 100ml/kg
- eg 70kg lady at booking = blood volume increase from 4900 to 7000ml
plasma volume increases 40-50%
red cell mass increases 20-30% produces relative anaemia.

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6
Q

how does clotting change in pregnancy?

A

pregnancy is a relatively hypercoagulable state, but during pregnancy neither clotting or bleeding times are abnormal

there is a decrease in fibrinolytic activity - these changes tend to prevent excessive bleeding at delivery

fibrinogen is markedly increased
clotting factors increase -

clotting factors increased = II, VII, VIII, X, XI, XII

platelets - the number rises within the normal range

DDimer levels are elevated in pregnancy

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7
Q

what changes in physiology during haemorrhage?

A

changes in HR an BP

  • HR increases
  • heart beats more forcefully
  • the blood vessels become constricted (increased systemic vascular resistance)
  • the body secretes less urine so the body loses less fluid.

only when you have lost 30% of your blood volume does you BP start to drop

woman may have lost a lot of blood before they become really unwell

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8
Q

during obstetric haemorrhage why is it hard to estimate blood loss?

A

its really hard to estimate blood loss accurately due to amniotic fluid mixed

you could look at the pre delivery Haemoglobin and then after/during haemorrhage to see if estimated blood loss is correct.

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9
Q

haemorrhage shock classification

A

Class 1 - up to 15% blood loss, normal heart rate BP RR and urine output, they may be slightly anxious. To replace fluid they are given crystalloid.

class 2 - 15-30% blood loss, mildly tachycardic, normal/slightly decreased BP, mildly tachypnea, urine out put = 0.5-1 ml/kg/hour, mildly anxious, give crystalloid.

class 3 - 30-40% blood loss moderate tachycardia, decreased blood pressure, moderate tachypnea, 0.25-0.5 ml/kg/hour, anxious and may be confused, give crystalloid and blood

class 4 ->40%, severe tachycardia, decreased BP, severe tachypnea, negligible urine output, they will be confused/lethargic. replace fluid loss with crystalloid and blood

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10
Q

what are the 4 causes of obstetric haemorrhage?

A
  • tone - abnormalities of uterine contraction (contraction will shut of all blood vessels and prevent bleeding)
  • Tissue - retain products of conception
  • Trauma - of the genital tract
  • Thrombin - abnormalities of coagulation
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11
Q

Tone - cause for obstetric haemorrhage

risk factors

A

risk factors for atonic bleeding

  • prolonged labour
  • over-distended uterus - twins, triplets, large baby, poly-hydramnios.
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12
Q

tissue - cause for obstetric haemorrhage

risk factors

A

main cause is retained placenta
may be because its stuck or takes a while to detach.

sometimes you get retained products of conception - means the uterus is not empty so can not contract properly .

Placenta Praevia - placenta is in the way - under the heads so baby can’t be delivered .

morbidly adherent placenta - when there has been previous scaring to the uterus which can lead to abnormal placentatio - acreta, increta, percreta.

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13
Q

trauma - cause for obstetric haemorrhage

risk factors

A

uterine trauma - inverted uterus (uterus passes through cervix), ruptured uterus (old c section scars), surgical damage e.g. broad ligament tears at c section.

genital tract trauma - vaginal tears - first through to 4th degree tears.

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14
Q

thrombin - cause for obstetric haemorrhage

risk factors

A

acquired coagulopathy in pregnancy

  • sepsis: PROM (premature rupture of membranes), endometritis(infection of the endometrium), chorio-amnionitis.
  • pre eclampsia/ eclampsia
  • placental abruption
  • HELLP syndrome
  • retained dead fetus
  • amniotic fluid embolus
  • DIC
  • liver disease: AFLP, pregnancy can cause fatty liver disease - so clotting factors not produced as well

Platelet abnormalities
- gestational thrombocytopenia
- idiopathic/immunological thrombocytopenia
idiopathic/immunological thrombocytopenic purpura
- HELLP syndrome
- sepsis
- DIC

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15
Q

thrombin - cause for obstetric haemorrhage

risk factors

A

acquired coagulopathy in pregnancy

  • sepsis: PROM (premature rupture of membranes), endometritis(infection of the endometrium), chorio-amnionitis.
  • pre eclampsia/ eclampsia
  • placental abruption
  • HELLP syndrome
  • retained dead fetus
  • amniotic fluid embolus
  • DIC
  • liver disease: AFLP, pregnancy can cause fatty liver disease - so clotting factors not produced as well

Platelet abnormalities

  • gestational thrombocytopenia
  • idiopathic/immunological thrombocytopenia purpura.
  • HELLP syndrome
  • sepsis
  • DIC from all the above causes
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16
Q

how is obstetric haemorrhage managed in theatre? what staff needed?

A
  • midwife
  • labour ward coordinator
  • neonatal team
  • 2 obstetric surgeons
  • 2 anaesthetists
  • 2 theatre nurses
  • 2 anaesthetic assistants
  • support worker to take blood tests to labs and fetch blood and blood products.
17
Q

what equipment is there to help with obstetric haemorrhage?

A
  • rapid infuser - rapidly induces and importantly warms crystalloid, celluloid and blood: ability to keep up with rapid blood loss. Can give 1L of fluid in 2 minutes.
  • red cells salvage - collects and processes maternal blood from surgical site, centrifuges, washes and returns red cells to patient.
  • point of care testing - ROTEM thromboeslastomerty tests whole blood clotting: guides blood product. Blood gas analyser; guides resuscitation and blood. - allows to individualise whether to give blood products or not.
18
Q

what pharmacological agents can manage obstetric haemorrhage?

A

uterotonic agents (syntocinon IV (synthetic oxytocin), ergometrine IV/IM (very good but has side effects, causes vasoconstriction so if have pre eclampsia can cause stroke|), carboprost (can cause broncho-constriction so don’t give to asthmatics) , misoprostol

19
Q

what is a cheap drug that is effective to stop bleeding?

A

tranexamic acic

found on the woman trial

20
Q

what surgical treatments are there for obstetric haemorrhage?

A

for tone - uterine massage, B lynch suture (dissolving sutures hold the uterus together contacted), Bakri balloon insertion (the balloon compresses placental bed and stops bleeding)

Tissue - remove retained products, manual removal of placenta

Trauma - surgical repair

21
Q

haematological managegement of obstetric haemorrhage

A
  • replace circulating volume - Hartmans solution
  • replace blood: cell salvage/ allogenic
  • correct coagulation with blood products. (platelets, FFP, cryoprecipitates, fibrinogen concentrate)
22
Q

what blood products are made from centrifuged blood?

A

Fresh Frozen Plasma.
FFP contains all of the clotting factors normally found in blood at the normal concentrations

Cryoprecipitate is prepared from FFP and contains clotting factors in higher concentrations.

Platelets are prepared by centrifuging the blood more slowly and pooling them together

23
Q

what are the aims for haematological parameters when managing obstetric haemorrhage?

A

Maintain Hb > 8g/dl (normal range 10 to 15g/dl)
Haemotocrit > 0.3 (normal range 0.28 – 0.4)
Prothrombin time < 1.5 times normal (12-13 seconds)
Activated prothrombin time < 1.5 times normal
Platelets > 75 X 109/ litre (normal range 150-400)
Fibrinogen > 2 g/litre (normal range 3.7 – 6.2)

24
Q

what bedside test and laboratory tests are done when managing obstetric haemorrhage?

A 
Bedside testing: Serial blood gases
Hb / Hct
Lactate / PH / HCO3
Bedside coagulation testing: ROTEM
Laboratory tests: FBC / coag (take 1 hour)
25
Q

what is major and minor obestetric haemorrhage

A

Minor obstetric haemorrhage (500–1000 ml) or
Major Obstetric Haemorrhage MOH (more than 1000 ml).

Major can be further subdivided into moderate (1001–2000 ml) and severe (more than 2000 ml)

26
Q

what can obstetric haemorrhage be divided into?

A

ante partum

post partum

27
Q

what is antepartum haemorrhage?

A
  • bleeding from the genital tract occurring from 24 weeks of pregnancy and prior to the birth of the baby. It is usally caused by placenta praevia or placental abruption and is a significant cause of maternal and fetal morbidity and mortality

Minor : blood loss less than 50 ml
Major : blood loss of 50-1000ml
Massive : blood loss > 100ml and or signs of clinical shock

28
Q

what is post partum haemorrhage?

A

Primary Post partum haemorrhage: is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby.
PPH can be
Minor obstetric haemorrhage (500–1000 ml) or
Major Obstetric Haemorrhage MOH (more than 1000 ml).
Major can be further subdivided into moderate (1001–2000 ml) and severe (more than 2000 ml)
Secondary Post Partum Haemorrhage: is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally.
Women are designed to tolerate blood loss at delivery to ensure the human race survives!

29
Q

what happens during primary and secondary haemostats and in fibrinolysis?

A

primary haemostats –> vasoconstriction, platelet adhesion and platelet aggregation (formation of white blood clot or platelet plug)

Secondary homeostasis - activation of coagulation factors, formation of fibrin (formaition of stable red blood clot)

fibrinolysis - activation of fibrinolysis (lysis of the clot)

30
Q

what are the physiological compensatory changed during obstetric haemorrhage?

A

The heart rate increases
The heart beats more forcefully
The blood vessels become constricted (increased systemic vascular resistance)
The body secretes less urine so that the body loses less fluid

The patients are young and fit
They compensate very well
They may have lost a lot of blood before they become really unwell
It is hard to estimate blood loss accurately

MSc foetus exam (19 decks)

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