Postpartum hemorrhage Flashcards
Definition primary vs secondary PPH
Primary: within first 24 hours, secondary 24 hrs to 12 weeks
DDx primary PPH
Atony, retained products (cotyledon, succenturiate lobe, placenta accreta), lacerations, coagulopathy, uteirne inversion, uterine rupture
DDx secondary PPH
Infection, placenta site sub-involution, retained placental fragments, coagulopathy (particularly VWD)
6 pillars of PPH management
1) assessment and stabilization
2) mechanical treatment
3) pharmacologic treatment
4) blood component therapy
5) surgical treatment
6) emergency measures
Steps of initial assessment/stabilization
Assessment of EBL and etiology, 2nd large bore IV, catherization of bladder, Labs: CBC/T+S/Fibrinogen/FSP/clotting time, communicate, for additional OBGYN/extra RN/anestehsia/good real time documentation
Mechanical treatment
- Fundal massage
- bimanual massage
- examination of placenta
- remove products in uterus
- correct inversion
- repair lacs (in OR if needed),
- uterine packing (bakri 300-500 cc, gauze swabs can soak in thrombin, multple foley catheters, svengstaken blakemore tube)
oxytocin: dose/route/interval repeat/total repeat doses/contraindications
10-40 u/L LR over 1 hr, route: IV/IM/IMM, continuious IV infusion, fluid overload
methergine - dose/route/interval repeat/total repeat doses/contraindications
0.2 mg, IM and IMM, q2 hours, hypertension, HIV/HAART
PGF2alpha (hemate) dose/route/interval repeat/total repeat doses/contraindications
250 micgrograms, IM/IMM, q15 min, total repeat doses: 8, asthma
PGE2 (prostin) dose/route/interval repeat/total repeat doses/contraindications
20 mg, rectally, q 2 hours, hypotension
PGE1 (cytotec) -dose/route/interval repeat/total repeat doses/contraindications
1 mg, oral (onset of action 30 minutes), SL, rectally
rPRBC - indication, volume, contents, effect, dose
Hgb < 7, 250-300 cc, RBC only, raise Hct 3%/Hgb 1 per unit
Plt - indication, volume, contents, effect, dose
If surgery imminent < 50K, if not then 10-15K, 50 cc, 50 million plt, plt rise 5-10K, 5-10 units (i.e. 6 pack)
FFP - indication, volume, contents, effect, dose
DIC, 250 cc, 200 mg Fibrinogen + Antithrombin III, Factors V and VIII; given until fibrinogen >100 and normal PT; 3-5 units
Cryopercipitate - indication, volume, contents, effect, dose
VWD, hemophilia A, 25 cc, 200 mg Fibrinogen + Factor VIII, XIII, von willebrand factor; until fibrinogen >100/normal PT, 1u-/5-10 kg wt. ABO TYPING NOT IMPORTANT
what lab values should be considered to be monitored with massive transfusion
calcium, potassium, and repeat CBC/coags q5-7m
Tranexemic acid
1 g IV within 3 hrs of birth for PPH; reduces risk of death, does NOT appear to increase VTE risk
rFactor VIIa
New tx modality, 50-100 ug/kg q2hrs until hemoastasis; risk of subsequent VTE, expensive
what is the definition of massive transfusion
> 10 u pRBC in 24 hours, 4 u within 1 hour with ongoing bleeding; goal to have ratio of FFP: plt (6 pack): RBCs 1:1:1
post PPH, what do you need to worry about
thromboembolic complications – need to mention ppx ; also transfusion rxn, hyperK, hypoCa
How do you correct inverted uterus?
Last portion to invert is the first to be reduced, consider giving tocolytic or inhaled/halogenated anesthesia to relax the uterus. Huntington procedure is where you give progressive traction with Babcock or Allis clamps on fundus. Haultain procedure is where you incise the cervical ring posteriorly to assist in replacement of the fundus.
What order of surgical interventions will you do?
vertical midline for XL - quicker exposure, less bleeding
- B lynch suture using 1 plain chromic
- uterine artery ligation (oleary stitch) - bilateral with 1 chromic
- utero-ovarian artery ligation
Describe hypogastric artery ligation
Internal iliac ligation (anterior division only), place suture ligation lateral to medial, single ligature; no value if prior embolization
What are your emergency agents for hypovolemia?
Ephedrine 10 mg
Epinephrine 5 micgrogram
Dopamine infusion - renal dose 1-3 microgram/kg/min;
