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OBGYN > Postpartum Hemorrhage > Flashcards

Postpartum Hemorrhage Flashcards

1
Q

How is postpartum hemorrhage defined?

A

a cumulative blood loss of more than 1 L or blood loss accompanied by signs and symptoms of hypovolemia within 24 hours of delivery

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2
Q

How do we define primary and secondary postpartum hemorrhage?

A
  • primary is within 24 hours of delivery

- secondary is delayed, usually between 24 hours and 12 weeks after delivery

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3
Q

What are the most significant risk factors for postpartum hemorrhage?

A
  • prolonged, augmented, or rapid labor
  • history of PPH
  • pre-eclampsia
  • over distended uterus
  • abnormal uterine placentation
  • operative delivery
  • chorioamnionitis
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4
Q

Describe the symptomatic progression following blood loss.

A
  • signs are first apparent with 15-20% of blood loss, including tachycardia, tachypnea, and delayed capillary refill
  • orthostatic changes and narrowed pulse pressure follow
  • with 30% blood loss, overt hypotension develops
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5
Q

What is the most common cause of PPH?

A

uterine atony

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6
Q

What does the differential include for PPH?

A
  • uterine atony is most common
  • retained placenta, genital tract trauma, lacerations, and coagulation disorders are less common
  • ruptured uterus and inverted uterus are rare but serious
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7
Q

One unit of packed RBCs is expected to have what effect on a patient’s CBC? What about one unit of random donor platelets?

A
  • pRBCs increase Hct by 3% and hemoglobin by 1 g/dL

- RDPs increase platelet count by 5K-10K

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8
Q

What normally prevents excessive bleeding after delivery?

A

uterine contraction, which constricts the spiral arteries, more so than coagulation

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9
Q

Uterine Atony

A
  • a failure of the uterus to contract and constrict the spiral arteries following delivery
  • risk factors include enlargement of the uterus, abnormal labor, and conditions that interfere with contraction such as uterine leiomyomata or magnesium sulfate
  • risk is reduced by active management of the third stage of labor, usually with oxytocin infusion, uterine massage, and gentle traction on the cord
  • diagnosis is based on palpation of the uterus which is softer and boggy rather than firm
  • treated first with bimanual uterine massage; then attempt uterotonic agents, uterine compression with packing or balloon compression, or surgical management
  • these include oxytocin, methylergonovine maleate, misoprostol, B-lynch sutures, sequential arterial ligation, arterial embolization, or hysterectomy
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10
Q

How is the third stage of labor actively managed and why do we do this?

A
  • normal management includes 20 units oxytocin in 1L normal saline at 200-500 mL/hour initiated after delivery of the infant along with gentle cord traction and uterine massage
  • used to prevent atony
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11
Q

What uterotonic agents are available for the treatment of uterine atony?

A
  • oxytocin
  • methylergonovine maleate
  • misoprostol (PGE1)
  • dinoprostone (PGE2)
  • 15-methyl prostaglandin F2a
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12
Q

What surgical options are available for treating uterine atony?

A
  • uterine compression sutures, either B-lynch or multiple squares
  • sequential arterial ligation of the ascending or descending branches of the uterine, utero-ovarian, then internal iliac arteries
  • selective arterial embolization
  • hysterectomy
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13
Q

Describe a B-lynch suture.

A
  • a stitch is placed inferior to the c-section cut and comes out superior to the cut
  • the suture is run over the top and around to the back of the uterus and comes through on the posterior uterine surface opposite the c-section incision
  • the suture is run out the back of the uterus, horizontally across the posterior surface of the uterus
  • the suture is run over the top and around to the front of the uterus where it is run through superiorly and the inferiorly to the c-section incision
  • there, it is tied
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14
Q

What is the advantage and disadvantage of methylergonovine maleate as a uterotonic agent?

A
  • it works very fast, inducing contraction within minutes

- it can lead to dangerous hypertension and is avoided in those with hypertensive disorders

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15
Q

What risk factors exist for lacerations of the lower genital tract which may then lead to postpartum hemorrhage?

A
  • instrumented delivery
  • manipulative delivery such as a breech extraction
  • precipitous labor
  • presentations other than occiput anterior
  • macrosomia
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16
Q

The placenta and uterus separate between what layers?

A

the zona basalis and zona spongiosa

17
Q

What risk factors exist for retained placenta?

A

previous cesarean delivery, uterine leiomyomata, prior uterine curettage, accessory placental lobe

18
Q

What finding would indicate the presence of a retained accessory placental lobe?

A

sheared or abruptly ending surface vessels on the delivered portion of the placenta

19
Q

Why is retained placental tissue problematic?

A

it can interfere with contractions, leading to atony and excessive bleeding, and is a nidus for infection

20
Q

What are placenta accreta, increta, and percreta?

A
  • accreta: placenta attaches to the myometrium without penetrating it
  • increta: placenta penetrates into the myometrium
  • percreta: placenta penetrates through the myometrium and into the uterine serosa
21
Q

Placenta Accreta

A
  • improper implantation of the placenta onto the myometrium with little or no intervening decidua
  • placenta increta and percreta are varying degrees of penetration
  • risk factors are placenta previa, previous uterine surgery, prior endometrial ablation, Asherman’s syndrome, and maternal age greater than 35
  • presents with difficult delivery of the placenta and life-threatening postpartum hemorrhage
  • typically managed with planned preterm cesarean hysterectomy with the placenta left in situ
22
Q

Retained Placental Tissue

A
  • risk factors include previous cesarean delivery, uterine leiomyomata, prior uterine curettage, accessory placental lobe
  • retained accessory lobe may be indicated by sheared or abruptly ending surface vessels on the delivered portion of the placenta
  • presents with inadequate uterine contraction and postpartum hemorrhage
  • often requires hysterectomy if the tissue can’t be removed manually or via curettage
23
Q

How does lower genital tract hematoma present?

A

it is a possible cause of postpartum hemorrhage which is likely to presents with exquisite pain with or without signs of shock

24
Q

What obstetric conditions are associated with DIC?

A
  • placental abruption
  • amniotic fluid embolism
  • acute fatty liver
  • sepsis
  • severe pre-eclampsia
25
Q

Amniotic Fluid Embolism

A
  • a potential cause of postpartum hemorrhage
  • presents with a sequence of respiratory distress, cyanosis, cardiovascular collapse, hemorrhage, and coma
  • often also results in a severe coagulopathy or DIC
26
Q

Uterine Inversions

A
  • a potential cause of severe postpartum hemorrhage
  • likely to occur if more than gentle traction is applied to the cord before the placenta has separated from the uterus
  • avoid by applying suprapubic counterpressure while delivering the placenta to secure the fundus
  • initial treatment includes manual replacement, typically after administering a medication to relax the uterus such as sublingual nitroglycerine
  • surgical management may be required
27
Q

What is the difference between a uterine rupture and uterine dehiscence?

A
  • rupture is a frank opening between the uterine cavity and abdominal cavity
  • dehiscence is a window covered by the visceral peritoneum
28
Q

What risk factors exist for uterine rupture?

A
  • abnormal labor
  • operative delivery
  • placenta accreta
29
Q

Uterine Rupture

A
  • a frank opening between the uterine cavity and the abdominal cavity; in contrast to a dehiscence which is a window covered by the visceral peritoneum
  • risk factors include abnormal labor, operative delivery, and placenta accreta
  • presents with acute abdominal pain, change in abdominal contour, non reassuring fetal heart patterns, and loss of fetal station
  • surgical repair is required

OBGYN (21 decks)

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