post partum hemorrhage Flashcards
what are the 4 best signs/ symptons of increased bleeding?
1/ (#1 vital signs)
- suction canister
- field
- sponge count
what patients (top 4) have highest chance of uterine hemorrhage (and death)?
- older parturiants (uterine atony)
- multiple gestation (twins etc.)
- previous ceasarean (scarred myometrium h/r for rupture (Vback)).
- patients receiving substandard care
what is meant by substandard care (during hemorrhage)?
- failure to recognize risk for bleed or
- inaccurate blood loss records
- failure to initiate prompt treatment
- twins represent ___% of births?
- carrying twins=higher risk of:
- what 2 medical conditions
- what 2 labor issues?
- 3% (increasing d/t assisted reproduction, delayed child beraring)
2.conditions: pre-eclampsia & anemia,
labor issues: premature labor & ante partum hemorrhage
multiple gestation at higher incidence of what CV issue?
supine hypotension d/t 2 placentas causing aorto-caval compression
- cardiac output for mother with multiple gestations (twins) increases ___ more than with singleton
- EBL is__more ?
- risk of premature birth is ___ greater?
- 10%
- 2x as much (1600-2000 ml blood loss)
- 6-10x more risk of premature birth
anesthesia for multiple gestation:
- what may happen to subsequent neonate once first one is delivered?
- how is this treated
- placenta may start to separate and cause anoxia to subsequent fetus
- emergency C section
- what 3 potential procedures do you need to prepare for if first child is delivered and second child is breech?
- what can be given to aid in version technique?
- what does it do?
- c section, forceps delivery or version technique (internal or external)
- nitro 400-800 mcg sl or nasal or 50-125 mcg iv
- allows for relaxation of uterus for version technique
2 risks of internal or external version
- abruptio placenta
2. cord entrapment
when woman is having twins, what should you have done?
type and cross
blood on hold
second iv setup
oxytocics
rapid sequence intubation and general set up for mom
uterine relaxation medications
double set up of everything (airway, isolette, etc.)
if you are going from regional to general, what should you do with the epidural
top it off
breech positioning:
- how often
- what type of delivery is it ? why?
- name most common breech?
- 3-4% (most common in premature-an anomaly)
- C-section; risk of maternal and neo morbitity (risk of hemorrhage, cervical lacerations, cranial damage)
- frank breecn
name the 3 breech positions:
- frank (butt down; feet up)
- footling (feet down into cervix)
- complete (butt down, legs curled up in fetal position)
what common anesthesia med can be given to relax uterine muscles?
volitile agents
- what is posterior presentation
- what problem does it cause (& what procedure may be needed)
- what might mother experience?
- when the fetal occiput is facing posterior and it jams into pelvis
- head getting stuck
- –may need to be c-section - causes severe back pain d/t head pinching spine nerves
- what is the leading cause of maternal mortality?
2. what may cause higher rates of this?
- hemorrhage (ante and post partum)
2. induction of labor associated with higher post partum hemorrhage numbers
why is post partum hemorrhage so deadly (besides the obvious)?
- underestimated blood losses
- failure to initiate treatment promptly
- failure to recognize risk factors
a. k.a. “substandard care”
what are the 3 most common causes of ante and post partum hemorrhage?
- placenta previa
- abruptio placenta
- uterine atony
what are the classifications of hemorrhage?
not the criteria, just the classes
classes I-IV
class I hemorrhage:
- blood loss:
- % loss:
- clinical findings:
- severity of shock:
class I hemorrhage: 1. blood loss: 900 ml 2. % loss: 15% loss 3. clinical findings: none 4. severity of shock: none considered "normal loss"
class II hemorrhage:
- blood loss (ml):
- % loss:
- clinical findings:
- severity of shock:
class II hemorrhage:
- blood loss (ml): 1200-1500
- % loss: 20-25%
- clinical findings: tachycardia >100, mild hypotension, peripheral vascular collapse
- severity of shock: mild
class III hemorrhage:
- blood loss (ml):
- % loss:
- clinical findings:
- severity of shock:
class III hemorrhage:
- blood loss (ml): 1800-2500 lm
- % loss: 30-35%
- clinical findings: tachycardia 100-120, hypotension 100 systolic,restlessness, oliguria
- severity of shock: moderate
class IV hemorrhage:
- blood loss (ml):
- % loss:
- clinical findings:
- severity of shock:
class IV hemorrhage:
- blood loss (ml): 2400
- % loss: 40%
- clinical findings: tachy >120, systolic < 60, anuria and altered consciousness
- severity of shock: severe
- what body function can be used to guage blood loss?
2. what else can be a sign?
- urine output
2. hypotension and tachycardia after delivery
goals for hemorrhaging parturient:
- fluid recussitation
- deliver placenta quickly
- stimulate contraction of uterus to stop bleeding
placenta previa:
what are the 3 classifications & (% of occurence)?
- marginal (partially blocking outlet) (30%)
- complete (40%)
- low lying (near the opening) (30%)
- how is placenta previa defined
- risk factors for placenta previa:
- what happens to the uterus to causes this?
- when the placenta presents before the fetus
- risk factors: previous placenta previa, smoking, prior uterine trauma or scarring, multiparity, older maternal age, previous abortion, prior uterine surgery
- all cause defective vascularization of decidua or atrophic changes
- s/s of placenta previa:
2. Clinical diagnosis (what characteristics will be seen)?
- painless and possibly profuse vaginal bleeding (previa=painless)
- relaxed lower uterine segment with fetus in upper portion of uterus
Placenta previa:
what is a double set up
set up for vag exam and c-section with general (just in case placenta previa is present and bleeding starts)
placenta previa:
what are emergent C-section medications?
- etomidate .3 mg/kg of ketamine 0.5-1 mg/kg
- sux with RSI
- large bore IV or cvp
- blood warmer with fluids or expanders
- foley
- sub arachnoid or epidural is stable
placenta previa:
3 reasons why there will there be alot of bleeding (and therefore may need general with ETT)?
- incision may go thru placenta if placenta is anterior uterus
- magnesium may contribute to hypotension
- poor contraction of lower uterine segment
placenta accreta:
- when most common in patients that have had…?
- what is it?
- what are the other types?
- most common after previous c-section or placenta previa (24-31%)
- invasion of placenta into uterine wall in which placenta fails to separate from wall after birth
- placenta increta and percreta
placenta increta:
what is it?
placenta grows deep into myometrium
think of “in” as inside of myometrium
placenta percreta:
what is it?
placenta grows thru uterine wall and into surrounding organs
think as “per” as through
abruptio placenta:
- what is it?
- how common?
- what does it lead to?
- abnormal separation of normally implanted placenta between 20 weeks and birth of fetus
- rare-1% of pregnancies
- IUGR, decidual necrosis, placental infarcts
abruptio placenta:
1. associated with what issues/diseases (6)?
- hypertensive disorders (#1)
- increased parity
- uterine abnormalities
- previous abruption
- maternal cocaine use
- trauma
abruptio placenta:
- clinincal manifestations:
- diagnosed via:
- etiology?
- painFUL bleeding, uterine tenderness, possible increased uterine activity
- ultrasound
- rupture of spiral arteries causing hemorrhage and hematoma formation between placenta and endometrium causing to further separate (shearing more vessels).
- the uterus becomes distended and cannot contract to stop bleeding from torn vessels
- increased intrauterine pressure causes anticlotting agents (placenta tissue thromboplastin) and amniotic debris to be forced thru open venous sinuses into maternal circulation.
abruption:
- how much blood loss can be concealed in the uterus?
- what deadly condition is abruption the most common cause of? –especially in what situations?
- what is mortality rate with abruption?
- treatment (definitive):
- 4000 mL
- most common cause of DIC
- -increases with intrauterine fetal demise - mortality as high as 50% (higher fetal mortality than mother)
- deliver the baby (vaginally (preferred) if fetus is dead)
abruption: mild to moderate abruption:
1. symptoms:
2. diagnosed how?
3. anesthesia type:
4. delivery:
- painful vag bleed, coagulopathy, fetal distress, usually NO maternal hypotension,
- dx done by EXCLUDING previa
- epidural or SAB ok if no hypotension, hypovolemia, and only if very small abruption
- vag if possible
abrption: severe:
1. s/s:
2. treatment:
3. treatment if bleeding continues:
- severe hemorrhage (along with pain) d/t blood extravisation preventing uterine contraction
- deliver baby, give Ergots (methergine) IM or prostaglandin F2a intrauterine injection to stop bleeding
- internal iliac artery ligation or gravid hysterectomy
abruption:
what causes the DIC
abruption causes activation of circulating tissue plasminogen which destroys fibrinogen (hypofibrinogenemia) and causes fibrinolysis.
there is also defeciency in platelets and factors 5 & 8
abruption:
DIC-
1. what appears in circulation?
2. what is the treatment?
- FSPs (fibrin split (or degredation) products) or elevated D-dimer
- platelets, FFP, cryo
what is the anesthetic management of an abruption mother (especially with DIC??)
- regional CONTRAINDICATED d/t hypovolemia and clotting abnormalities
- treat like active bleeding previa (large bore IV, blood warmers etc.)
- aggressive volume replacement
- extensive recussitation usually required for infant
- what is the dose of oxytocin?
2. what is the max dose? why?
- 10 units in 500 or 20 units in 1000;
2. 60 units (it begins to act like vasopressin (ADH) causing fluid retention
uterine rupture:
- occurance:
- mortality (mother and fetal)
- causes:
- uncommon (<1%)
- catastrophic mortality (especially to fetus (50-75%)
- causes: separation at uterine scar d/t :
- -rare in patient without uterine scar
- -myomectomy hx
- -#1 cause: c-section (especially if classic incision)
- -previous difficult deliveries
- -rapid, spontaneous or tumultuous labor
- -prolonged labor with excessive oxytocin or cephalopelvic disproportion
- -weak or stretched uterine muscles from multiparity or grand multipara
- -traumatic rupture caused by iatrogenic (intrauterine manipulation, difficult delivery with forceps, supra fundal pressure)
- -VBAC (though 70-80% are successful)
when should a vbac be attempted (theoretically)
if uterine scar is low and transverse
uterine rupture:
- s/s depend on what?
- s/s:
- depend on degree of rupture
- vaginal bleeding
- severe abdomen pain
- disappearance of fetal heart tones (#1 most reliable in conj. with other symptoms)
- hypotension and shock
anesthetic management:
laparotomy
same as for hypovolemic abruption (no spinal, GETA with RSI)
uterine rupture: treatment: 1. first step? 2. second step? if still bleeding? 3. third step if still bleeding and fertilty is not being preserved? 4. fourth step? 5. fifth step? 6. fourth step if fertility is to be preserved
uterine rupture: treatment:
- deliver baby and placenta
- surgical ligation
- -if still bleeding– - uterine artery ligation
- -if still bleeding– - hypogastric artery ligation
- -if still bleeding– - hysterectomy and or cuff packing
- 4 th step if fertility is to be preserved: over sew bleeding areas and lower segment packing
uterine inversion:
- cause:
- predisposing factors:
- s/s:
- anesthesia choice:
- iatrogenic or overzealous traction on the umbilical cord in 3rd stage of labor
- retained placenta, prolonged labor, precipitous labor
- pain, hypovolemia, bleeding,
- GETA with volitile agents
postpartum hemorrhage:
- how long after birth? Primary? secondary?
- causes:
- 3-5% are minutes after
- -primary: within first 24 hours
- -secondary: from 24 hours to 6 weeks after - retained products of conception, uterine atony, cervical/vaginal/uterine lacerations
retained placenta:
- treatment:
- anesthetic choice 1
- anesthetic choice 2
- if more anesthesia needed -choice #3
- what does GA do to the uterus?
- requires manual exploration of uterus
- epidural top of (if you have one); high risk for sympathectomy and low blood pressure from hypovolemia
- oxygen, nitrous, ketamine 15-20 mg, and versed
- crash induction or saddle block
- relaxes the uterus
uterine atony:
- occurance:
- how much blood can be lost?
- causes:
- can occure immediately or several hours after birth
- can lose 2L in 5 min
- high parity, multiple births, polyhydramnios, large infants, retained placenta, internal or external version
uterine atony:
rank of mortality in maternal death?
one of the leading causes of maternal death
uterine atony:
- treatment:
- monitoring:
- bimanual fundal massage
- -pitocin
- -methergine
- -oxygen
- -fluid and blood
- -hemabate directly into uterus
- -hysterectomy
- -internal iliac or hypogastric artery ligation - monitor with art line and or cvp
methergine:
- IM dose:
- infusion:
- 0.2 mg IM
2. 0.2 mg/250cc infusion
hemabate:
dose:
2.5 mcg intra uterine muscle injection
cytotec crystals:
dose: route:
800-1000 mcg given intra rectal if hemorrhage unresponsive to oxytocin and methergine
surgical management of hemorrhage:
1-bilateral surgical ligation of uterine, ovarian and internal iliac arteries (85% effective)
2-intrauterine balloon tamponade (80% effective)
3-Lynch procedure uterine compression suture technique to control surgical bleeding
4-postpartum hysterectomy-definitive treatment for uterine atony and placenta acreta (especially increta and percreta) or when other measures are unsuccessful
5-angiographic arterial embolization
what is angiographic arterial embolization?
a temporary occlusive gelatin sponge is used to block the arteries
what is the anesthetic management of uterine hemorrhage
general is best (even with functional epidural); ketamine induction
amniotic fluid emboli:
- occurance/ mortality:
- cause
- risk factors:
- s/s
- rare (4-6 of 100,000), but often fatal (60-80% mortality) makes up 12% of maternal deaths (40% survival rate-15% with intact neuro)
- uterine contractions cause a sudden infusion of amniotic fluid into maternal circulation thru lacerated endercervical veins (#1) or thru abnormally open sinusoids at the utero placental site
- risk higher in multiples, placental abnormalities, eclampsia, uterine rutptue, labor inductions
- dyspnea, cyanosis, cv collapse, coma, coagulation disorders
- amniotic emboli als called:
- what is in amniotic fluid
- what is amniotic emboli described as?
- anaphylactoid syndrome of pregnancy
- lanugo, meconium, squamous cells, hair, amniotic debris
- the most dangerous and untreatable conditon in ob
- what are the phases to amniotic emboli (biphasic response)
- early and second phases
amniotic embolus:
what happens in the “first” phase? mortality?
early phase:(< 30 minutes)
- -transient and intense pulm artery vasospasm
- -right heart dysfunction
- -decreased C.O.
- -hypoxia; pulmonary vasospasm or obstruction
- -hypotension
- -hyperventilation with VQ changes/ ARDS
- -50% of deaths occur here
amniotic emboli:
3. what happens in the “second” phase?
second phase: (only if surviving the first phase)
- -left ventricular failure
- -pulmonary edema
- -coronary and organ ischemia
- -cerebral ischemia, liver and kidney failure
what 3 major events come from amniotic embolus:
- pulmonary embolism
- DIC
- uterine atony
Amniotic emboli: effects-
pulmonary artery vasoconstriction cause what?
- decreased blood to left heart , pulmonary vasculature collapse, hypotension, hypoxemia and blood shunting
amniotic emboli-effects: DIC
caused by what?
- liberation of thromboplastin into maternal circulation (which are found in high concentrations in amniotic fluid and placental tissue)
- destruction of fibrinogen and fibrin by plasma fibrinolysis
- release of “heparin like” substances present in amniotic fluid which blocks conversion of prothrombin to thrombin
effects of amniotic emboli: uterine atony
cause:
- due to hypotension and decreased perfusion to uterus
- amniotic fluid has direct depressant effect on uterine muscle
what are clinical features of amniotic emboli:
s/s
- resp distress
- cyanosis
- cardiovascular collapse
- coma
- hemorrhagic tendency (if survive first hour)
Classifications of hemorrhage: EBL(mL & %); symptoms; degree of shock Class I: Class II: Class III: Class IV:
- CLASS I: EBL: 900 ml(15%); no s/s; no shock
- CLASS II: EBL: 1200-1500(20-25%), tachy, mild hypoTN, pv collapse; mild shock
- CLASS III: EBL:1800-2300(30-35%), tachy(100-120), hypoTN (100 systolic), restlessness, oliguria, moderate shock
- CLASS IV: EBL:2400(40%), tachy (>120), hypoTN (systolic < 60), anuria, altered LOC, severe shock
