Obstetric Hemorrhage Flashcards
Initial evaluation of antepartum hemorrhage
Initiate 2 large bore IV lines
Assess vitals, amount of bleeding, pt’s mental status
Review PMH for known bleeding disorders, liver disease, anatomic abnormalities (vaginal septum), and abnormal placentation
Labs: CBC and coag profile, serial H/H, type and crossmatch for 4 units of blood
Physical exam, US, continuous fetal monitoring
When performing a physical exam on a pt with antepartum hemorrhage, it is important to AVOID digital exam until ____ ___ has been ruled out by US; once that has been ruled out, you can proceed with sterile speculum exam for genital lacerations or cervical lesions, and a digital exam for cervical dilation
Placenta previa
Causes of vaginal bleeding before 20 weeks gestation
Abortions Ectopics Cervical/vaginal etiology Subchorionic hemorrhage/retroplacental clot Cervical insufficiency
Causes of antepartum hemorrhage (bleeding after 20 wks)
Upper genital tract causes: placental abruption, placenta previa, uterine rupture, vasa previa
Lower genital tract causes: “bloody show” labor, cervical polyps, infection, trauma, cancer, vulvar varicosities, blood dyscrasia
Most common type of abnormal placentation
Placenta previa — implantation of the placenta over the cervical os
How does placenta previa typically present? How is it diagnosed?
Painless vaginal bleeding (mean gestational age this occurs is 30 wks)
Almost exclusively dx by ultrasound
Risk factors for placenta previa
Maternal age >35
Multiparity
Multiple gestations
Cocaine use and smoking
Prior previa
Previous C section
Classifications of placenta previa
Marginal: edge of placenta extends to margin but does NOT cover cervical os
Partial: partial occlusion of cervical os
Complete: complete occlusion of os; most serious type — associated with greater blood loss
Management of placenta previa in a preterm pregnancy
Attempt to obtain fetal maturation; if bleeding is not perfuse, pt is managed in hospital on bed rest initially
If stable and bleeding stops, may send home on pelvic rest (most pts will have recurrence of bleeding)
[note: if unstoppable labor, fetal distress, or life threatening hemorrhage, proceed with C section immediately regardless of gestational age]
Management of placenta previa beyond 36 weeks
Deliver via C section with documented fetal lung maturity
3 other types of abnormal placentation besides placenta previa
Placenta accreta — abnormal firm attachment to superficial lining of myometrium (more common than increta and percreta)
Placenta increta — invades myometrium
Placenta percreta — invades through myometrium into uterine serosa (least common)
Risk factors for placenta accreta/increta/percreta
Previous C section(s)
Management for placenta accreta/percreta/increta
Cesarean hysterectomy
Most common cause of third trimester bleeding
Placental abruption = premature separation of normally implanted placenta
Presentation of placental abruption
Painful bleeding, uterine tenderness, uterine hyperactivity, and fetal distress and/or death
Risk factors for placental abruption
Maternal HTN (most common risk factor)
Cocaine use
External maternal blunt trauma (monitor 4-6 hrs after event)
Polyhydramnios and multiparity
Previous abruption
Ultrasonography can detect some abruptions but are better at diagnosing previas. How is a placental abruption managed?
Monitor maternal and fetal conditions — if both are stable may proceed with vaginal delivery. If there are signs of fetal distress or uncontrolled bleeding, proceed with C section
[similar overall management to previa: get IV access, labs include H/H, type and cross, PT, PTT, fibrinogen, platelets, if RH negative get Kleihauer-Betke test and give rhogam if indicated, get serial blood draws, NPO status, prepare for preterm delivery]
Most common cause of DIC in pregnancy
Placental abruption
What is a couvelaire uterus?
Results from extravasation of blood into uterus following placental abruption causing red and purple discoloration of the serosa
Risk factors for uterine rupture
Prior uterine incision (most common risk factor)
Injudicious use of oxytocin
Trauma
External cephalic version
Multiparity
Presentation and diagnosis of uterine rupture
Presents with sudden onset of intense abdominal pain +/- vaginal bleeding
Abnormal fetal heart rate pattern or cessation of fetal heart tones
Regression of presenting part
Fetal parts may be easily palpable on abdominal exam
Management of uterine rupture
Immediate laparotomy and delivery of fetus
If feasible, repare ruptured site
If large rupture, may have to do a cesarean hysterectomy
How should someone with previous uterine rupture plan to deliver in future pregnancies?
If they had a previous lower uterine segment rupture, recommendation is to deliver by C section
If they had a previous upper uterine segment rupture, recommend against future pregnancies
A rare but important cause of third trimester bleeding is that associated with rupture of a fetal vessel. What is this usually secondary to?
Velamentous insertion of umbilical cord — cord inserts at a distance away from the placenta, and its vessels must traverse between the chorion and amnion without protective Wharton’s jelly
If unprotected vessels pass over the cervical os, it is termed vasa previa
Presentation of fetal vessel rupture
Acute vaginal bleeding and change in fetal heart rate (initial tachycardia followed by bradycardia)
Need to dx rapidly and proceed to delivery
Define and classify postpartum hemorrhage
Defined as estimated blood loss of >500 cc following vaginal birth, or >1000cc after C section
Can be classified as primary if occurs w/i first 24 hours, or secondary if occurs 24 hrs-12 weeks postpartum
Leading cause of maternal death worldwide
Postpartum hemorrhage
Most common cause of primary postpartum hemorrhage
Uterine atony
[other causes of primary include uterine atony, retained placenta (especially accreta), defects in coagulation, uterine inversion]
Etiologies of secondary postpartum hemorrhage
Subinvolution of placental site
Retained products of conception
Infection
Inherited coag defects
Risk factors for postpartum hemorrhage
Prolonged labor Augmented labor Precipitous labor (<3hrs) Hx of postpartum hemorrhage Placental abruption Placenta previa Operative vaginal delivery Overdistention of uterus Chorioamnionitis
Uterine atony results when uterus fails to contract after delivery of placenta; palpation will reveal a “boggy uterus”. What are risk factors for uterine atony
Enlargement of the uterus (multiples, polyhydramnios, macrosomia)
Abnormal labor (precipitous, prolonged, augmented)
Conditions which interfere with contraction of uterus (fibroids, magnesium sulfate)
Management of uterine atony
Bimanual massage of uterus
Pharmacologic methods: oxytocin (often given prophylactically after delivery of infant or placenta), methylergonovine (contraindicated in HTN), 15-methylprostaglandin F2a (contraindicated in asthma), dinoprostone, misoprostol
Uterine packing or large volume balloon catheter
Intervential radiology
Surgical measure/hysterectomy
Signs/symptoms of amniotic fluid embolism
Respiratory distress, intense bronchospasm
Cyanosis
Cardiovascular collapse
Hemorrhage
Coma
Consumptive coagulopathy (DIC)
[tx: respiratory support, correct hypovolemic shock, replace coag factors]
Inherited factor VIII deficiency that results in prolonged bleeding times; usually not an issue during pregnancy, but may complicate delivery
Von Willebrands disease
Abnormal platelet function and lifespan requiring platelet concentration infusions
Idiopathic thrombocytopenia (antiplatelet antibodies may cross placenta and result in fetal and neonatal thrombocytopenia)
How do the following blood products affect a pt’s values when given?
PRBCs, platelets, FFP, cryprecipitate
PRBCs — increase Hct by 3%, Hgb by 1g/dL
Platelets — increase platelet count 5000-10,000
FFP — increase fibrinogen by 10 mg/dL
Cryprecipitate — increase fibrinogen by 10 mg/dL
Following delivery, mom can develop a febrile morbidity — defined as temp >100.4 that occurs for more than 2 consecutive days (exclusive of first 24 hrs) during the first 10 postpartum days. Most of the fevers are due to _____
Endometritis
[usually d/t enterococci, hemolytic and nonhemolytic streptococci, anaerobic streptococci, enteric bacilli, pseudodiphtheria bacteria, and Neisseria spp.]
After delivery, the pH of the vagina becomes more ______, which favors an increase in growth of _____ organisms
After about 48 hrs, the endometrial and placental remnants produce a favorable intrauterine environment for the production of ______ bacteria, which cause the majority of puerperal infections/sepsis
Alkaline; aerobic (most common is e.coli)
Anaerobic (most are anaerobic cocci — peptostreptococcus, peptococcus, and streptococcus)
Predisposing factors to the development of puerperal sepsis
Poor nutrition and hygiene Anemia PROM Prolonged ROM Prolonged labor Frequent vaginal exams during labor C-section (nonelective>elective) Operative vaginal delivery Cervical or vaginal lacerations Manual extraction of placenta Retained products of conception
Clinical presentation of peurperal sepsis
Postpartum fever and increasing uterine tenderness on day 2-3
May see purulent lochia, chills, malaise, and anorexia
Management of puerperal sepsis
Antibiotics — should provide anaerobic coverage since these cause 70% of puerperal infections (ampicillin+gentamicin+clindamycin)
Continue abx until afebrile x48 hrs
Sources of persistent postpartum fever after tx for puerperal sepsis
Infected hematoma
Surgical site infection
Septic thrombophlebitis
Drug fever
2 types of septic pelvic thrombophlebitis
Ovarian vein thrombophlebitis — Appear clinically illl with fever and abd pain w/i 1 week after delivery, may be dx radiographically
Deep septic pelvic vein thrombophlebitis — do NOT appear clinically ill, no radiographic evidence of thrombosis, dx of exclusion
Tx of septic pelvic thrombophlebitis
Anticoagulation w/ unfractionated heparin or LMWH
Can discontinue after resolution of fever x48 hrs (if no further documented thrombosis)
If ovarian v. thrombosis is seen radiographically, anticoagulate x6weeks then repeat imaging
