Obstetric Hemorrhage and Puerperal Sepsis Flashcards
antepartum hemorrhage- if pts is bleeding profusely
- 2 large bore IV lines
- VS, amt of bleeding, mental status
- labs- CBC, coag profile, H/H, type and crossmatch
- PRBC
antepartum hemorrhage- if pts is bleeding profusely- exam
- AVOID digital exam until placenta previa has been ruled out by US
- sterile speculum exam- lacerations or cervical lesions
- digital exam- cervical dilation
- US
vaginal bleeding BEFORE 20 wks
- abortions
- ectopics
- cervical/vaginal (cancer, trauma, polyps)
- subchorionic hemorrhage/retroplacental clot
- cervical insuff
vaginal bleeding AFTER 20 wks
- upper genital tract- placental abruption/previa, uterine rupture, vasa previa
- lower- “bloody show” labor, cervical polyps, infections, trauma, cancer, vulvar varicosities, blood dyscrasia
placenta previa
- implantation of placenta over cervical os
- most common type of placental placentation
- 20% of all cases of antepartum hemorrhages
- painless vaginal bleeding
placenta previa- risk factors
- > 35 yo
- multiparity
- mult gestations
- cocaine use, smoking
- prior previa
- prev c-section
placenta previa- classifications
- marginal- edge of placenta extending to margin of cervical os- does NOT cover os
- partial- partial occlusion of cervical os
- complete- os completely covered; assoc with greater blood loss
placenta previa- dx
- painless vaginal bleeding!!
- mean gestational age- 30 wks
- US!!
- some will have some degree of pervia at 24 wks- usually resolve!
placenta previa- management
- preterm- obtain fetal maturation; if bleeding not profuse, pt on bed rest, 70% will have recurrence of bleeding
- c-section at 36-37 wks with documented fetal lung maturity
- if unstoppable labor, fetal distress, or life threatening hemorrhage- c-section regardless of gestational age
placenta accreta
- abnormal firm attachment to superficial lining of myometrium
- risk factors- prev c-section
- cesarean hysterectomy
placenta increta
-invades myometrium
placenta percreta
-thru myometrium into uterine serosa
placental abruption
- premature separation of normally implanted placenta
- most common cause of 3rd trimester bleeding!!
- painful bleeding, uterine tenderness, uterine hyperactivity, fetal distress and/or dirth
placental abruption- risk factrs
- maternal HTN- most common!
- cocaine
- blunt trauma
- polyhydramnios and multiparity
- prev abruption
placental abruption- dx
-classic- painful bleeding, uterine tenderness, uterine hyperactivity, fetal distress and/or dirth
most common cause of DIC in pregnancy
placental abruption
-release of thromboplastin from disrupted placenta and subplacental decidua- consumptive coaguopathy
placental abruption- management
- monitor maternal and fetal conditions
- if stable- vaginal delivery
- if signs of fetal distress or uncontrolled bleeding- c-section
- most common cause of DIC in pregnancy!!!
placental abruption- signs
-couvelaire uterus- extravasation of blood in to uterus- red and purple discoloration of serosa
uterine rupture
- complete separation of uterine musculature
- spontaneous, traumatic, or assoc with prev uterine scar
uterine rupture- risk factors
- prior uterine incision (most common!!!)
- injudicious use of oxytocin
- trauma
uterine rupture- dx
- sudden onset of intense abd pain +/- vaginal bleeding
- abnormal fetal HR pattern
- regression of presenting part
uterine rupture- management
- laparotomy and delivery of fetus
- repair ruptured site
- FUTURE pregnancies- c-section
fetal bleeding- cause of 3rd trimester bleding
- secondary to velamentous insertion of umbilical cord
- vasa previa- if unprotected vessels pass over cervical os
- if vessels rupture- vaginal bleeding and change in fetal HR- dx and delivery!!
postpartum hemorrhage
- > 500 cc after vaginal birth, >1000 cc after c-section
- primary- occurs within 24 hrs- secondary to uterine atony (80% of time)
- secondary- 24 hrs- 12 wks- subinvolution of uterus, sloughing of eschar or retained products
- leading cause of maternal death worldwide!!
postpartum hemorrhage- etiology
- primary- uterine atony
- secondary- subinvolution of placental site, retained products of conception
postpartum hemorrhage- Uterine atony
- immediately preceding or after delivery of placenta
- common when uterus fails to contract after delivery of placenta- “boggy uterus” on palpation
- hemostasis after separation of placenta- dep on myometrium to compress the severed vessels
uterine atony- risk factors
- enlargement of uterus
- abnormal labor
- conditions which interfere with contraction of uterus- leiomyomas, magnesium sulfate
uterine atony- management
- bimanual massage of uterus
- oxytocin
- methylergonovine (not in HTN pts)
- 15-methyl prostaglandin F2a
- dinoprostone
- misoprostol
- uterine packing or large volume balloon catheter
- hysterectomy
uterine atony- bimanual massage of uterus
- confirms dx of uterine atony- “boggy”
- can diminish bleeding, expel blood clots
uterine atony- uterine packing, radiology, surgery
- packing- 4 in gauze, large volume balloon
- interventional radiology- if stable vitals and persistent bleeding- arterial embolization
- surgery- last resort- hysterectomy
atonic uterine hemorrhage- surgery
- Leary stitch- ligation of uterine a
- B-lunch suture
2nd most common cause of postpartum hemorrhage
- trauma during delivery
- common after operative vaginal deliveries, precipitous labor, macrosomia
retained placenta
- 50% of pts with secondary postpartum hemorrhages
- inability of uterus to maintain a contraction and involute normally around placental tissue mass
- risk factors- prev c-section, leiomyomas, prior D&C
- tx- manual removal if bleeding profuse, uterine curettage
uterine inversion
- top of fundus descends into vagina
- copious bleeding and hypovolemic shock
- tx- manually replace uterus, oxytocin
amniotic fluid embolism
- 80% mortality rate
- infusion of amniotic fluid into maternal circulation
- resp distress, bronchospasm, cyanosis, CV collapse, hemorrhage, coma, consumptive coagulopathy
- tx- resp support, correct hypovolemic shock, replace coag factors
von willebrands dz
- factor 8 def
- tx- factor 8 conc or cryoprecipitate
idiopathic thrombocytopenia
- plts fxn abnormally
- antiplatelet ab’s of IgG type can cross placenta- fetal thrombocytopenia
- tx- plt conc infusions
puerperal sepsis
- after delivery
- febrile morbidity- T > 100.4 that occurs for > 2 days during the 1st 10 postpartum days
- most due to endometritis
puerperal sepsis- etiology
- uterine cavity normally free of bacteria during pregnancy
- after delivery, pH becomes more alkaline
- anaerobic organisms (70%)
puerperal sepsis- clinical features
- postpartum fever and inc uterine tenderness on day 2-3- key!!
- dx- history and physical
puerperal sepsis- management
- abx (anaerobic coverage)
- ampicillin + gentamicin
persistent postpartum fever- other sources
- infected hematoma
- surgical site infection
- Septic pelvic thrombophlebitis
- drug fever
septic pelvic thrombophlebitis
-virchow’s triad- enod damage, venous stasis, hypercoagulable state of pregnancy
ovarian v thrombophlebitis
- fever and abd pain 1 wk after delivery
- appear clinically ill
- 20% can see radiographically
deep septic pelvic v thrombophlebitis
- unlocalized fever in the 1st few days, nonresponsive to abx
- do NOT appear clinically ill
- no radiographic evidence
- dx of exclusion
septic pelvic thrombophlebitis- tx
- anticoag
- unfractionated heparin or LMW heparin
