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R2F > Obstetric Hemorrhage and Puerperal Sepsis > Flashcards

Obstetric Hemorrhage and Puerperal Sepsis Flashcards

1
Q

antepartum hemorrhage- if pts is bleeding profusely

A
  • 2 large bore IV lines
  • VS, amt of bleeding, mental status
  • labs- CBC, coag profile, H/H, type and crossmatch
  • PRBC
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2
Q

antepartum hemorrhage- if pts is bleeding profusely- exam

A
  • AVOID digital exam until placenta previa has been ruled out by US
  • sterile speculum exam- lacerations or cervical lesions
  • digital exam- cervical dilation
  • US
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3
Q

vaginal bleeding BEFORE 20 wks

A
  • abortions
  • ectopics
  • cervical/vaginal (cancer, trauma, polyps)
  • subchorionic hemorrhage/retroplacental clot
  • cervical insuff
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4
Q

vaginal bleeding AFTER 20 wks

A
  • upper genital tract- placental abruption/previa, uterine rupture, vasa previa
  • lower- “bloody show” labor, cervical polyps, infections, trauma, cancer, vulvar varicosities, blood dyscrasia
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5
Q

placenta previa

A
  • implantation of placenta over cervical os
  • most common type of placental placentation
  • 20% of all cases of antepartum hemorrhages
  • painless vaginal bleeding
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6
Q

placenta previa- risk factors

A
  • > 35 yo
  • multiparity
  • mult gestations
  • cocaine use, smoking
  • prior previa
  • prev c-section
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7
Q

placenta previa- classifications

A
  • 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
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8
Q

placenta previa- dx

A
  • painless vaginal bleeding!!
  • mean gestational age- 30 wks
  • US!!
  • some will have some degree of pervia at 24 wks- usually resolve!
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9
Q

placenta previa- management

A
  • 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
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10
Q

placenta accreta

A
  • abnormal firm attachment to superficial lining of myometrium
  • risk factors- prev c-section
  • cesarean hysterectomy
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11
Q

placenta increta

A

-invades myometrium

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12
Q

placenta percreta

A

-thru myometrium into uterine serosa

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13
Q

placental abruption

A
  • premature separation of normally implanted placenta
  • most common cause of 3rd trimester bleeding!!
  • painful bleeding, uterine tenderness, uterine hyperactivity, fetal distress and/or dirth
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14
Q

placental abruption- risk factrs

A
  • maternal HTN- most common!
  • cocaine
  • blunt trauma
  • polyhydramnios and multiparity
  • prev abruption
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15
Q

placental abruption- dx

A

-classic- painful bleeding, uterine tenderness, uterine hyperactivity, fetal distress and/or dirth

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16
Q

most common cause of DIC in pregnancy

A

placental abruption

-release of thromboplastin from disrupted placenta and subplacental decidua- consumptive coaguopathy

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17
Q

placental abruption- management

A
  • 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!!!
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18
Q

placental abruption- signs

A

-couvelaire uterus- extravasation of blood in to uterus- red and purple discoloration of serosa

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19
Q

uterine rupture

A
  • complete separation of uterine musculature

- spontaneous, traumatic, or assoc with prev uterine scar

20
Q

uterine rupture- risk factors

A
  • prior uterine incision (most common!!!)
  • injudicious use of oxytocin
  • trauma
21
Q

uterine rupture- dx

A
  • sudden onset of intense abd pain +/- vaginal bleeding
  • abnormal fetal HR pattern
  • regression of presenting part
22
Q

uterine rupture- management

A
  • laparotomy and delivery of fetus
  • repair ruptured site
  • FUTURE pregnancies- c-section
23
Q

fetal bleeding- cause of 3rd trimester bleding

A
  • 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!!
24
Q

postpartum hemorrhage

A
  • > 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!!
25
Q

postpartum hemorrhage- etiology

A
  • primary- uterine atony

- secondary- subinvolution of placental site, retained products of conception

26
Q

postpartum hemorrhage- Uterine atony

A
  • 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
27
Q

uterine atony- risk factors

A
  • enlargement of uterus
  • abnormal labor
  • conditions which interfere with contraction of uterus- leiomyomas, magnesium sulfate
28
Q

uterine atony- management

A
  • bimanual massage of uterus
  • oxytocin
  • methylergonovine (not in HTN pts)
  • 15-methyl prostaglandin F2a
  • dinoprostone
  • misoprostol
  • uterine packing or large volume balloon catheter
  • hysterectomy
29
Q

uterine atony- bimanual massage of uterus

A
  • confirms dx of uterine atony- “boggy”

- can diminish bleeding, expel blood clots

30
Q

uterine atony- uterine packing, radiology, surgery

A
  • packing- 4 in gauze, large volume balloon
  • interventional radiology- if stable vitals and persistent bleeding- arterial embolization
  • surgery- last resort- hysterectomy
31
Q

atonic uterine hemorrhage- surgery

A
  • Leary stitch- ligation of uterine a

- B-lunch suture

32
Q

2nd most common cause of postpartum hemorrhage

A
  • trauma during delivery

- common after operative vaginal deliveries, precipitous labor, macrosomia

33
Q

retained placenta

A
  • 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
34
Q

uterine inversion

A
  • top of fundus descends into vagina
  • copious bleeding and hypovolemic shock
  • tx- manually replace uterus, oxytocin
35
Q

amniotic fluid embolism

A
  • 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
36
Q

von willebrands dz

A
  • factor 8 def

- tx- factor 8 conc or cryoprecipitate

37
Q

idiopathic thrombocytopenia

A
  • plts fxn abnormally
  • antiplatelet ab’s of IgG type can cross placenta- fetal thrombocytopenia
  • tx- plt conc infusions
38
Q

puerperal sepsis

A
  • after delivery
  • febrile morbidity- T > 100.4 that occurs for > 2 days during the 1st 10 postpartum days
  • most due to endometritis
39
Q

puerperal sepsis- etiology

A
  • uterine cavity normally free of bacteria during pregnancy
  • after delivery, pH becomes more alkaline
  • anaerobic organisms (70%)
40
Q

puerperal sepsis- clinical features

A
  • postpartum fever and inc uterine tenderness on day 2-3- key!!
  • dx- history and physical
41
Q

puerperal sepsis- management

A
  • abx (anaerobic coverage)

- ampicillin + gentamicin

42
Q

persistent postpartum fever- other sources

A
  • infected hematoma
  • surgical site infection
  • Septic pelvic thrombophlebitis
  • drug fever
43
Q

septic pelvic thrombophlebitis

A

-virchow’s triad- enod damage, venous stasis, hypercoagulable state of pregnancy

44
Q

ovarian v thrombophlebitis

A
  • fever and abd pain 1 wk after delivery
  • appear clinically ill
  • 20% can see radiographically
45
Q

deep septic pelvic v thrombophlebitis

A
  • unlocalized fever in the 1st few days, nonresponsive to abx
  • do NOT appear clinically ill
  • no radiographic evidence
  • dx of exclusion
46
Q

septic pelvic thrombophlebitis- tx

A
  • anticoag

- unfractionated heparin or LMW heparin

R2F (18 decks)

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