Postpartum hemorrhage Flashcards
What is hemabate?
Carboprost tromethamine (15 methyl-PGF2alpha) - prostaglandin E2 receptor agonist.
Dose is 0.25mg q15 min x 8 doses max
What is methergine?
Ergot alkaloids are serotonergic receptor agonists in smooth muscle, weak antagonists of dopaminergic receptors, and partial agonists of alpha-adrenergic receptors. They induce fast rhythmic uterine contractions
dose is 0.2mg IM q2 hours
What is misoprostol?
prostaglandin E1, no contraindications
What is TXA?
anti-fibrinolytic, 1g IV, best when used within 3 hours of delivery
- reduces risk of death!
- contra-indications: renal dz, coagulopathy
What are types of transfusion reactions?
Simple febrile: 1% risk. Use leuko-reduced products. Reaction against donor leukocytes. Self-limited, give tylenol
Allergic reaction: 0.2% of RBC. allergy to plasma protein, tx anti-histamine, continue transfusion
Anaphylactic: 1/20,000: tx epi IM
Hemolytic: very rare. Recipient antibodies induce hemolysis of donor RBC, due to ABO incompatibility. High mortality. Induces DIC. stop transfusion, support renal function, give iVF
TRALI: recipient neutrophil has anti-HLA affecting pulm vasculature. Find the donor bc can lead to TRALI in other recipients! That donor cannot donate again.
What are causes of PPH?
Atony, lacerations, retained products, uterine inversion.
What increases the risk of PPH?
Multiparity, hx PPH, multiple gestation, prolonged labor, macrosomia, chorio, use of magnesium
What is a PPH?
EBL>1L or signs/symptoms of hypovolemia within the first 24hrs of delivery.
Confirm that you have a type and cross. Initial management: empty bladder, uterine massage, pitocin
What are second line things to do in PPH if uterotonics aren’t helping?
UAE, bilateral uterine artery ligation. B-lynch (2-0 chromic), hysterectomy
When to active MTP?
EBL >1500cc, continued bleeding, unstable vital signs, suspect DIC.
What is indication and effect/dose of pRBC in hemorrhage?
use for Hgb < 7
- volume: 250cc
- AIM: Hgb rises 1gm, Hct rises 3%
Dose: >2 units
What is indication and effect/dose of platelets in hemorrhage?
Indication: Plt < 50K (if going to surgery)
- volume 50cc
- contents: 50 million pLT
- AIM: platelets rise 5K-10K
- Dose 5-10 units
What is indication and effect/dose of FFP in hemorrhage?
Indication: DIC
- volume 250cc
- contents: 200mg fibrinogen + antithrombin 3, factors 5 & 8
- AIM: fibrinogen rise >100, normal PT
- Dose: 3-5 units
What is indication and effect/dose of cryoprecipitate in hemorrhage?
Indication: vWD, hemophilia A
- volume 25cc
- contents: 200mg fibrinogen + factor 8, 13, vWF
- AIM: fibrinogen rise >100, normal PT
What is massive transfusion protocol?
> 10u pRBC in 24hrs or 4 units in 1 hr
- survival improved if ratio is 1:1:1 for pRBC: platelets:FFP
- need VTE ppx afterwards bc high risk thromboembolic complications w/ hemorrhage!
What is emergency treatment of hypovolemia?
Ephedrine 10mg
Dopamine infusion
Epinephrine
What is PAS?
pathologic adherence of placenta
Hypothesis: defect of endometrial-myometrial interface and failure of normal decidualization in area of uterine scar.
Rate 1:272 pregnancies.
What are risk factors for PAS?
- prior CD
- AMA
- multiparity
- prior uterine surgeries or curretage
- Asherman syndrome
- placenta previa
What are ultrasound features of PAS
- presence of placenta previa (80% of cases)
- multiple vascular lacunae within placenta
- loss of normal hypo echoic zone btw placenta and myometrium
- decreased retroplacental myometrial thickness (< 1mm)
- abnormalities of uterine-serosa bladder interface
- extension of placenta into myometrium, serosa or bladder.
- color dopplers w/ turbulent lacunar flow
C-hyst w/ placenta in situ after delivery at 34 0 /7-35 6/7
- BMZ, deliver at level 3-4 center, optimize blood count pre-op.
What are changes in clotting system in normal pregnancy?
- increase in thrombotic activity
– increased factor 5,7,8,10, 12, fibrinogen
decrease in fibrinolytic activity
- resistance to protein C, S
*designed to INCREASE thrombotic tendency and reduce blood loss at delivery
What is lovenox?
most commonly used agent for VTE prophylaxis in pregnancy
- inhibits factor Xa
- doesn’t cross placenta
- monitored with anti Xa q4-6wks
- decreased risk of thrombocytopenia, osteoporosis and post-op bleeding compared to UFH.
DISADVANTAGES
- no reversal agent
- ionic risk epidural hematoma
- can’t use w/ prosthetic valves.
What is dosing for IM Pitocin?
10units IM
What are options for emergency contraception?
Options: plan B (levonorgestrel) x 2 doses. BEST when within 72hr. inhibits/delays ovulation. Failure rate 3%
Ullipristal/Ella: Selective progesterone modulator: 30mg PO x1. Effective up to 5d, inhibits ovulation. Failure rate 1.4%
Paraguard: up to 5d. Failure rate 0.2%
What is an O’leary stitch?
bilateral ligation of uterine arteries.
- 0-vicryl stitch starting 22cm from lateral margin of uterus. going through myometrium from anterior to posterior and then coming back through an avascular area in the broad ligament. then tie down.
What is management of vaginal hematoma?
- conservative: observation, analgesics, foley
- serial exam and serial CBC for Hgb/Hct
- do not explore it immediately. unconfined space
- if >4cm, may need evacuation. in oR. take down repair and see if bleeding vessel identified/ligated. Otherwise evacuate clot and close defect in layers
- pack vagina for 12-24 hrs and place foley.
- if pt hemodynamically unstable, order CBC, coags, blood products. Get stat CTAP. then IR.
