Postpartum hemorrhage

Question 1

What is hemabate?

Answer 1

Carboprost tromethamine (15 methyl-PGF2alpha) - prostaglandin E2 receptor agonist.

Dose is 0.25mg q15 min x 8 doses max

Question 2

What is methergine?

Answer 2

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

Question 3

What is misoprostol?

Answer 3

prostaglandin E1, no contraindications

Question 4

What is TXA?

Answer 4

anti-fibrinolytic, 1g IV, best when used within 3 hours of delivery

• reduces risk of death!
• contra-indications: renal dz, coagulopathy

Question 5

What are types of transfusion reactions?

Answer 5

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.

Question 6

What are causes of PPH?

Answer 6

Atony, lacerations, retained products, uterine inversion.

Question 7

What increases the risk of PPH?

Answer 7

Multiparity, hx PPH, multiple gestation, prolonged labor, macrosomia, chorio, use of magnesium

Question 8

What is a PPH?

Answer 8

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

Question 9

What are second line things to do in PPH if uterotonics aren’t helping?

Answer 9

UAE, bilateral uterine artery ligation. B-lynch (2-0 chromic), hysterectomy

Question 10

When to active MTP?

Answer 10

EBL >1500cc, continued bleeding, unstable vital signs, suspect DIC.

Question 11

What is indication and effect/dose of pRBC in hemorrhage?

Answer 11

use for Hgb < 7
- volume: 250cc
- AIM: Hgb rises 1gm, Hct rises 3%
Dose: >2 units

Question 12

What is indication and effect/dose of platelets in hemorrhage?

Answer 12

Indication: Plt < 50K (if going to surgery)
- volume 50cc
- contents: 50 million pLT
- AIM: platelets rise 5K-10K
- Dose 5-10 units

Question 13

What is indication and effect/dose of FFP in hemorrhage?

Answer 13

Indication: DIC
- volume 250cc
- contents: 200mg fibrinogen + antithrombin 3, factors 5 & 8
- AIM: fibrinogen rise >100, normal PT
- Dose: 3-5 units

Question 14

What is indication and effect/dose of cryoprecipitate in hemorrhage?

Answer 14

Indication: vWD, hemophilia A
- volume 25cc
- contents: 200mg fibrinogen + factor 8, 13, vWF
- AIM: fibrinogen rise >100, normal PT

Question 15

What is massive transfusion protocol?

Answer 15

> 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!

Question 16

What is emergency treatment of hypovolemia?

Answer 16

Ephedrine 10mg

Dopamine infusion

Epinephrine

Question 17

What is PAS?

Answer 17

pathologic adherence of placenta

Hypothesis: defect of endometrial-myometrial interface and failure of normal decidualization in area of uterine scar.

Rate 1:272 pregnancies.

Question 18

What are risk factors for PAS?

Answer 18

• prior CD
• AMA
• multiparity
• prior uterine surgeries or curretage
• Asherman syndrome
• placenta previa

Question 19

What are ultrasound features of PAS

Answer 19

• 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.

Question 20

What are changes in clotting system in normal pregnancy?

Answer 20

• 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

Question 21

What is lovenox?

Answer 21

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.

Question 22

What is dosing for IM Pitocin?

Answer 22

10units IM

Question 23

What are options for emergency contraception?

Answer 23

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%

Question 24

What is an O’leary stitch?

Answer 24

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.

Question 25

What is management of vaginal hematoma?

Answer 25

• 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.