Obstetric Hemorrhage Flashcards by tcarlso 3

By the 30th week of pregnancy, what is the expansion in blood volume?

40%

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What is the significance of the increase blood in pregnancy?

large blood losses can occur w/o clinical evidence

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What Is the normal blood loss with a SVD? C/s?

SVD = 500ml

- C/S = 1000ml

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What is the initial change that is used to maintain bp with hemorrhage?

Increased TPR

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After what percent of blood loss is there a fall in CO such that SVR can no longer maintain BP?

20%

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How do BP and CO decrease in relation to one another?

in parallel to each other

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What is placental abruption?

Premature separation of the normally implanted placenta from the uterus

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What is the clinical triad of placental abruption?

Painful Uterine bleeding
Hypertonic uterus
fetal distress/death

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Inspection of the vagina with placental abruption shows what?

Adherent retroplacental clot with depression of the the underlying placental tissue

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What is a grade I placental abruption? 
(-vaginal bleeding
-Uterine s/sx
-maternal BP
-maternal fibrinogen
-FHT)?

Slight vaginal bleeding
Uterine irritability
Unaffected BP
normal fibrinogen
FHT normal

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What is a grade II placental abruption? 
(-vaginal bleeding
-Uterine s/sx
-maternal BP
-maternal fibrinogen
-FHT)?

Mild to moderate uterine bleeding
Uterine irritable, tetanic, or frequent ctx
BP maintained, but orthostatic
Tachycardia
Fibrinogen decreased
FHT show distress

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What is a grade III placental abruption?
(-vaginal bleeding
-Uterine s/sx
-maternal BP
-maternal fibrinogen
-FHT)?

Moderate to severe bleeding
Uterine tetanic and painful
Hypotension
Fetal death
Fibrinogen less than 150
Coag abnormalities

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What percent of placental abruption occurs before the onset of labor?

80%

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What is the etiology of placental abruption? (5)

Cocaine use
maternal smoking
poor nutrition
trauma
maternal HTN

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What is the hallmark presentation of placental abruption?

Painful bleeding in the 3rd trimester

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True or false: placental abruption rarely occurs more than once

False– significant rate of recurrence (5-17%)

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What is the treatment for a grade I placental abruption?

-Observe

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What is the treatment for a grade II or more placental abruption?

Continuous fetal monitoring
Tocolysis (?)
Delivery
volume resuscitation

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What is placenta previa?

Implantation of the placenta over the cervical os

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What are the three variations of placenta previa?

Total
Partial
Marginal

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What type of placenta previa is the worst? What fraction of previas are these?

Total

30% ish are these

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What is the complication of partial placenta previa?

Dilation causes detachment

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What is a marginal previa?

Placenta encroaches a bit onto the os

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How do you differentiated between marginal and partial placenta previa?

US and the degree of cervical dilation and method of diagnosis

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What is the leading cause of third-trimester hemorrhage?

Placenta previa

What is the classic presentation of placenta previa?

*painless* vaginal bleeding

What are the three major risk factors for placenta previa?

- Advanced maternal age - Minority - Previous C-section

Why are previous cesarean deliveries a risk for placenta previa?

implantation can get caught in the irregular scarred area

When are most placenta previas found, when they are? Why?

2nd trimester d/t anatomy scan

When is vaginal delivery appropriate for placenta previa? Why should be done for this?

if marginal previa Do double set up

If you diagnose placenta previa a long time from delivery, what should you do?

Expectant management with avoidance of sexual intercourse d/t contraction induction

What are accreta, increta, and percreta?

- Accreta = attachment onto the myometrium - Increta = invades the myometrium - Percreta = penetrates the myometrium

What is the decidua basalis?

the area of endometrium between the implanted chorionic sac and the myometrium, which develops into the maternal part of the placenta

What is abnormal placentation?

formation of an abnormally firm attachment to the uterine wall with *loss of the deciruda basalis* and incomplete development of the fibrinoid layer

What is the incidence of abnormal placentation with previa without prior surgery? WIth precios c/s with multiple c/s?

W/o = 4% with 1 = 10-35% with multiple = 60-65%

How long does the bleeding last for with placenta previa? Placental abruption?

Previa = Stops within 2 hours Abruption, Continuous bleeding

Which presents with painful bleeding: Placenta previa/abruption? Painless?

``` Painful = Abruption Painless = Previa ```

What happens to FHT with placenta previa? Placental abruption?

Normal with previa | Variable with abruptio

Which commonly has coagulation defects: placenta previa or placental abruption?

Abruption has coagulation defects Previa does not

What is vasa previa?

Fetal vessels traverse the membranes and cover the os

What is the classic presentation of vasa previa?

SROM, laceration of the fetal vessel, and rapid fetal death

What is the the fetal mortality rate with vasa previa?

more than 50%

Effective hemostasis after separation of the placenta is dependent on what?

The myometrium to compress the vessels

Failure of the myometrium to compress the myometrial vessels is usually attributed to what?

Myometrial dysfunction or retained POS

What are the risk factors for myometrial dysfunction? (3)

Overdistention of the uterus 2/2: - Multiple gestations - Polyhydramnios - Fetal macrosomia

How do you prevent or minimize PP hemorrhage?

Establish IV access just prior to labor, and prep for possible blood transfusion

Why do you want to avoid excessive traction on the umbilical cord during delivery?

possibility of hemorrhage

How do you manage hemorrhage PP?

Continue oxytocin/prostaglandins -Frequently palpate fundus and monitor VS

How is misoprostol administered to treat PP hemorrhage?

1 unit of pRBC increase HCT and Hb by what? 1 unit of platelets?

- pRBCs = 3% and 1g | - Platelets = 5000-10000

What is a first degree vaginal laceration?

vaginal mucosa and perineal skin

What is a second degree vaginal laceration?

Also includes the muscles of the perineal body.

What is a third degree vaginal laceration?

Also include the anal sphincter

What is a fourth degree vaginal laceration?

Extends through rectal mucosa

What are the three major pelvic hematomas?

- Vulvar - Vaginal - Retroperitoneal

What is a vulvar hematoma? Are these painful or painless?

Laceration of vessel in superficial fascia of anterior or posterior pelvic triangle Painful

What is the treatment for a vulvar hematoma?

Volume support | -incise and evacuate clost

What causes vaginal hematomas?

Results from trauma to soft tissues during delivery, causing blood to accumulate in the plane above the pelvic diaphragm

What are the s/sx of vaginal hematoma?

Severe rectal pain or feels like she still has to push

How do you treat vaginal hematomas?

Take to OR, I+D, pack

What causes a retroperitoneal hematoma?

Laceration of a vessel originating from the hypogastric artery, and can dissect up to the renal vasculature

How do you detect a retroperitoneal hematoma?

Uterus will be displaced d/t hematoma, and s/sx of shock

What is the treatment for a retroperitoneal hematoma?

- Surgical excision | - ligation of hypogastric vessels

True or false: A previous oxytocin-stimulated labor is a risk factor for the development of myometrial dysfunction

True

True or false: Prolonged or rapid labor is a risk factor for myometrial dysfunction

True

What are the two ethnicities that have an increased risk for postpartum hemorrhage?

Asians | Hispanics

Cryoprecipitate replaces which coagulation factors? What else?

8 and 12 | Fibrinogen

Fresh frozen plasma replaces which coagulation factors?

5, 8, and antithrombin III

What is a succenturiate lobe? What is the significance of this?

- Accessory lobe of the placenta | - Increases the risk of leaving behind part of the placenta after delivery