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Endo Repro Exam II > Obstetric Hemorrhage > Flashcards

Obstetric Hemorrhage Flashcards

1
Q

Initial evaluation of antepartum hemorrhage

A

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

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2
Q

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

A

Placenta previa

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3
Q

Causes of vaginal bleeding before 20 weeks gestation

A 
Abortions
Ectopics
Cervical/vaginal etiology
Subchorionic hemorrhage/retroplacental clot
Cervical insufficiency
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4
Q

Causes of antepartum hemorrhage (bleeding after 20 wks)

A

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

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5
Q

Most common type of abnormal placentation

A

Placenta previa — implantation of the placenta over the cervical os

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6
Q

How does placenta previa typically present? How is it diagnosed?

A

Painless vaginal bleeding (mean gestational age this occurs is 30 wks)

Almost exclusively dx by ultrasound

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7
Q

Risk factors for placenta previa

A

Maternal age >35

Multiparity

Multiple gestations

Cocaine use and smoking

Prior previa

Previous C section

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8
Q

Classifications of placenta previa

A

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

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9
Q

Management of placenta previa in a preterm pregnancy

A

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]

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10
Q

Management of placenta previa beyond 36 weeks

A

Deliver via C section with documented fetal lung maturity

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11
Q

3 other types of abnormal placentation besides placenta previa

A

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)

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12
Q

Risk factors for placenta accreta/increta/percreta

A

Previous C section(s)

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13
Q

Management for placenta accreta/percreta/increta

A

Cesarean hysterectomy

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14
Q

Most common cause of third trimester bleeding

A

Placental abruption = premature separation of normally implanted placenta

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15
Q

Presentation of placental abruption

A

Painful bleeding, uterine tenderness, uterine hyperactivity, and fetal distress and/or death

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16
Q

Risk factors for placental abruption

A

Maternal HTN (most common risk factor)

Cocaine use

External maternal blunt trauma (monitor 4-6 hrs after event)

Polyhydramnios and multiparity

Previous abruption

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17
Q

Ultrasonography can detect some abruptions but are better at diagnosing previas. How is a placental abruption managed?

A

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]

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18
Q

Most common cause of DIC in pregnancy

A

Placental abruption

19
Q

What is a couvelaire uterus?

A

Results from extravasation of blood into uterus following placental abruption causing red and purple discoloration of the serosa

20
Q

Risk factors for uterine rupture

A

Prior uterine incision (most common risk factor)

Injudicious use of oxytocin

Trauma

External cephalic version

Multiparity

21
Q

Presentation and diagnosis of uterine rupture

A

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

22
Q

Management of uterine rupture

A

Immediate laparotomy and delivery of fetus

If feasible, repare ruptured site

If large rupture, may have to do a cesarean hysterectomy

23
Q

How should someone with previous uterine rupture plan to deliver in future pregnancies?

A

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

24
Q

A rare but important cause of third trimester bleeding is that associated with rupture of a fetal vessel. What is this usually secondary to?

A

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

25
Q

Presentation of fetal vessel rupture

A

Acute vaginal bleeding and change in fetal heart rate (initial tachycardia followed by bradycardia)

Need to dx rapidly and proceed to delivery

26
Q

Define and classify postpartum hemorrhage

A

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

27
Q

Leading cause of maternal death worldwide

A

Postpartum hemorrhage

28
Q

Most common cause of primary postpartum hemorrhage

A

Uterine atony

[other causes of primary include uterine atony, retained placenta (especially accreta), defects in coagulation, uterine inversion]

29
Q

Etiologies of secondary postpartum hemorrhage

A

Subinvolution of placental site

Retained products of conception

Infection

Inherited coag defects

30
Q

Risk factors for postpartum hemorrhage

A 
Prolonged labor
Augmented labor
Precipitous labor (<3hrs)
Hx of postpartum hemorrhage
Placental abruption
Placenta previa
Operative vaginal delivery
Overdistention of uterus
Chorioamnionitis
31
Q

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

A

Enlargement of the uterus (multiples, polyhydramnios, macrosomia)

Abnormal labor (precipitous, prolonged, augmented)

Conditions which interfere with contraction of uterus (fibroids, magnesium sulfate)

32
Q

Management of uterine atony

A

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

33
Q

Signs/symptoms of amniotic fluid embolism

A

Respiratory distress, intense bronchospasm

Cyanosis

Cardiovascular collapse

Hemorrhage

Coma

Consumptive coagulopathy (DIC)

[tx: respiratory support, correct hypovolemic shock, replace coag factors]

34
Q

Inherited factor VIII deficiency that results in prolonged bleeding times; usually not an issue during pregnancy, but may complicate delivery

A

Von Willebrands disease

35
Q

Abnormal platelet function and lifespan requiring platelet concentration infusions

A

Idiopathic thrombocytopenia (antiplatelet antibodies may cross placenta and result in fetal and neonatal thrombocytopenia)

36
Q

How do the following blood products affect a pt’s values when given?

PRBCs, platelets, FFP, cryprecipitate

A

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

37
Q

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 _____

A

Endometritis

[usually d/t enterococci, hemolytic and nonhemolytic streptococci, anaerobic streptococci, enteric bacilli, pseudodiphtheria bacteria, and Neisseria spp.]

38
Q

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

A

Alkaline; aerobic (most common is e.coli)

Anaerobic (most are anaerobic cocci — peptostreptococcus, peptococcus, and streptococcus)

39
Q

Predisposing factors to the development of puerperal sepsis

A 
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
40
Q

Clinical presentation of peurperal sepsis

A

Postpartum fever and increasing uterine tenderness on day 2-3

May see purulent lochia, chills, malaise, and anorexia

41
Q

Management of puerperal sepsis

A

Antibiotics — should provide anaerobic coverage since these cause 70% of puerperal infections (ampicillin+gentamicin+clindamycin)

Continue abx until afebrile x48 hrs

42
Q

Sources of persistent postpartum fever after tx for puerperal sepsis

A

Infected hematoma
Surgical site infection
Septic thrombophlebitis
Drug fever

43
Q

2 types of septic pelvic thrombophlebitis

A

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

44
Q

Tx of septic pelvic thrombophlebitis

A

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

Endo Repro Exam II (28 decks)

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