Postpartum Hemorrhage

Question 1

what is the most common cause of postpartum hemorrhage?

Answer 1

uterine atony

Question 2

What are risk factors for uterine atony?

Answer 2

precipitous labor, multiparity, general anesthesia, oxytocin use in labor, prolonged labor, macrosomia, hydramnios, twins, and chorioamnionitis

Question 3

What are the risks for genital tract lacerations?

Answer 3

Precipitous labor, macrosomia, or who have instrument assisted delivery or manipulative delivery(breech, etc)

Question 4

What is the most common etiology of uterine inversion?

Answer 4

excessive traction on umbilical cord during third stage of delivery

Question 5

What are uterotonics?

Answer 5

used to increase uterine contractions and decrease uterine bleeding

Question 6

what are used as uterotonics?

Answer 6

methergine(methylergonovine), prostaglandins, misoprostol and oxytocin

Question 7

What is MOA of methergine(methylergonovine) and when is it contraindicated?

Answer 7

it is an ergot alkaloid, which is a smooth muscle constrictor; it is also a vasoconstrictive agent and should be withheld from women with hypertension and/or preeclampsia

Question 8

What is prostaglandin E1(misoprostol) used for?

Answer 8

cervical ripening and labor inductoin; also a uterotonic frequently used for uterine atony although not FDA approved for this use

Question 9

What is Prostaglandin E2(Dinoprost) used for and when is it contraindicated?

Answer 9

a vaginal or rectal suppository used for uterine atony; avoid in hypotensive patients and must be stored in freezer so must be thawed before use

Question 10

What is prostaglandin F2-alpha(hemabate) used for and when should it be avoided?

Answer 10

IM injection that is potent smooth muscle constrictor used for uterine atony and should be avoided in asthmatic patients bc can cause bronchoconstriction; side effects are diarrhea, fever, tachycardia

Question 11

What is the MOA of oxytocin?

Answer 11

binds to receptors on uterine myocytes causing contractions

Question 12

How does uterine inversion present?

Answer 12

globular mass at introitus after delivery

Question 13

How is postpartum hemorrhage defined?

Answer 13

500cc after vaginal delivery or >1000cc after cesarean delivery

Question 14

What are the first steps in management of postpartum hemorrhage?

Answer 14

make sure uterus is well-contracted, there is no retained placental tissue and look for lacerations

Question 15

When is uterine artery embolization considered?

Answer 15

after other sources of bleeding such as lacerations are ruled out

Question 16

What is a B lunch suture?

Answer 16

used at time of laparotomy for uterine atony; has been shown to be effective in management of unresponsive uterine atony

Question 17

what is placenta accreta?

Answer 17

abnormally firm attachment of placenta to uterine wall; risk increased in women with previous c section; it is serious complication leading to retained placenta and severe postpartum hemorrhage; “placental lakes” on ultrasound

Question 18

Ligation of what pelvic vessels can lead to reduction in vascular pressure in the pelvis thus controlling hemorrhage?

Answer 18

uterine artery and internal iliac(hypogastric) ligation

Question 19

Von Willebrands disease can present for the first time in a patient with ___.

Answer 19

Delayed postpartum hemorrhage. Not uncommon to start bleeding 48-72hrs after delivery.

Question 20

What are some common findings in a patient with placental abruption?

Answer 20

vaginal bleeding accompanied by painful contractions and rapid progression of labor and finding of a clot on her placenta

Question 21

Patients undergoing abruption can progress into ___.

Answer 21

DIC and may require aggressive resuscitation with blood products