Postpartum hemorrhage

Question 1

Definition primary vs secondary PPH

Answer 1

Primary: within first 24 hours, secondary 24 hrs to 12 weeks

Question 2

DDx primary PPH

Answer 2

Atony, retained products (cotyledon, succenturiate lobe, placenta accreta), lacerations, coagulopathy, uteirne inversion, uterine rupture

Question 3

DDx secondary PPH

Answer 3

Infection, placenta site sub-involution, retained placental fragments, coagulopathy (particularly VWD)

Question 4

6 pillars of PPH management

Answer 4

1) assessment and stabilization
2) mechanical treatment
3) pharmacologic treatment
4) blood component therapy
5) surgical treatment
6) emergency measures

Question 5

Steps of initial assessment/stabilization

Answer 5

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

Question 6

Mechanical treatment

Answer 6

• 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)

Question 7

oxytocin: dose/route/interval repeat/total repeat doses/contraindications

Answer 7

10-40 u/L LR over 1 hr, route: IV/IM/IMM, continuious IV infusion, fluid overload

Question 8

methergine - dose/route/interval repeat/total repeat doses/contraindications

Answer 8

0.2 mg, IM and IMM, q2 hours, hypertension, HIV/HAART

Question 9

PGF2alpha (hemate) dose/route/interval repeat/total repeat doses/contraindications

Answer 9

250 micgrograms, IM/IMM, q15 min, total repeat doses: 8, asthma

Question 10

PGE2 (prostin) dose/route/interval repeat/total repeat doses/contraindications

Answer 10

20 mg, rectally, q 2 hours, hypotension

Question 11

PGE1 (cytotec) -dose/route/interval repeat/total repeat doses/contraindications

Answer 11

1 mg, oral (onset of action 30 minutes), SL, rectally

Question 12

rPRBC - indication, volume, contents, effect, dose

Answer 12

Hgb < 7, 250-300 cc, RBC only, raise Hct 3%/Hgb 1 per unit

Question 13

Plt - indication, volume, contents, effect, dose

Answer 13

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)

Question 14

FFP - indication, volume, contents, effect, dose

Answer 14

DIC, 250 cc, 200 mg Fibrinogen + Antithrombin III, Factors V and VIII; given until fibrinogen >100 and normal PT; 3-5 units

Question 15

Cryopercipitate - indication, volume, contents, effect, dose

Answer 15

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

Question 16

what lab values should be considered to be monitored with massive transfusion

Answer 16

calcium, potassium, and repeat CBC/coags q5-7m

Question 17

Tranexemic acid

Answer 17

1 g IV within 3 hrs of birth for PPH; reduces risk of death, does NOT appear to increase VTE risk

Question 18

rFactor VIIa

Answer 18

New tx modality, 50-100 ug/kg q2hrs until hemoastasis; risk of subsequent VTE, expensive

Question 19

what is the definition of massive transfusion

Answer 19

> 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

Question 20

post PPH, what do you need to worry about

Answer 20

thromboembolic complications – need to mention ppx ; also transfusion rxn, hyperK, hypoCa

Question 21

How do you correct inverted uterus?

Answer 21

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.

Question 22

What order of surgical interventions will you do?

Answer 22

vertical midline for XL - quicker exposure, less bleeding

1. B lynch suture using 1 plain chromic
2. uterine artery ligation (oleary stitch) - bilateral with 1 chromic
3. utero-ovarian artery ligation

Question 23

Describe hypogastric artery ligation

Answer 23

Internal iliac ligation (anterior division only), place suture ligation lateral to medial, single ligature; no value if prior embolization

Question 24

What are your emergency agents for hypovolemia?

Answer 24

Ephedrine 10 mg
Epinephrine 5 micgrogram
Dopamine infusion - renal dose 1-3 microgram/kg/min;

Question 25

If there is hypotension and tahcycardia, how much % EBL of total blood volume?

Answer 25

25%

Question 26

What is active management of third stage entails?

Answer 26

Oxytocin (10 u ppx IV or IM is as effective as higher doses or in-conjunction with different meds), umbilical cord traction, and fundal massage. evidence is not clear cut

Question 27

what are success rates of UAE? What are risks?

Answer 27

ranges, but success ~ 80%. Uterine necrosis, peripheral neuropathy, and clot all risks < 5%

Question 28

what is the risk of repeat uterine inversion?

Answer 28

1/26

Question 29

When do you consider blood transfusion?

Answer 29

EBL 1500, vital sign changes