Obstetric Hemorrhage Flashcards by Sarah Gillen

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

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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

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Causes of vaginal bleeding before 20 weeks gestation

Abortions
Ectopics
Cervical/vaginal etiology
Subchorionic hemorrhage/retroplacental clot
Cervical insufficiency

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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

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Most common type of abnormal placentation

Placenta previa — implantation of the placenta over the cervical os

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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

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Risk factors for placenta previa

Maternal age >35

Multiparity

Multiple gestations

Cocaine use and smoking

Prior previa

Previous C section

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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

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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]

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Management of placenta previa beyond 36 weeks

Deliver via C section with documented fetal lung maturity

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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)

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Risk factors for placenta accreta/increta/percreta

Previous C section(s)

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Management for placenta accreta/percreta/increta

Cesarean hysterectomy

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Most common cause of third trimester bleeding

Placental abruption = premature separation of normally implanted placenta

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Presentation of placental abruption

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

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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

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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]

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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