PPH Flashcards
methergine
- compound
- dosing
- contraindications
- compound (methyl-ergonovine)
- dosing: 0.2 mg IM q2-4 hours
- contraindications: hypertensive disease, cardiovascular disease
hemabate
- compound
- dosing
- contraindications
- compound: methyl prostaglandin 2 alpha F analogue
- dosing: 250 microgram IM or IU (q15 minutes for maximum of 8 doses)
- contraindications: asthma, renal or hepatic dysfunction, pulmonary
pitocin
- compound
- dosing
- contraindications
- compound: oxytocin
- dosing: 10-40 units in 500-1000 mL IV fluid or 10 u IM
- contraindications
deifnition of PPH
1000 mL EBL in 24 hours after delivery
def’n and ddx of primary PPH
def’n and ddx of secondary PPH
Primary PPH - within first 24 hours
- atony
- trauma
- coagulopathy
- retained products
- uterine inversion
Secondary PPH - 24 hours - 12 weeks
- bleeding disorder
- placental site subinvolution
- endometritis
- retained placenta/clot
principles in management of unsuspected accreta?
- don’t try to deliver whole placenta if adherent
- move to OR, counsel patient about possibility of hysterectomy
- assess extent of ongoing bleeding, depth and width of abnormal placentation
- options for management: D&C, hysterectomy, medical management, wedge resection
- if medical management: 40% risk of needing emergent hysterectomy, 42% chance of serious morbidity, 20% abnormal placentaiton in future pregnancy
principles in managing uterine inversion?
classic exam finding: absence of uterine fundus with mass below cervix
- try to reduce manually (open palm or closed fist) circumferentially upward
- can use uterine relaxants or halogenated anesthetics for help
- if cannot reduce manually, need to proceed surgically:
1. laparotomy
2. huntington manuever (serially pull traction on uterus with Allis clamps)
3. Haultain procedure - posterior cervical incision; manually reduce into regular position
what objective measures exist to begin prepare for transfusion?
- 1500 ml EBL with ongoing blood loss
- vital sign changes
what should prompt massive transfusion protocol?
10 u pRBC in 24 hours or 4 u pRBC in 1 hour
what is massive transfusion protocol?
pRBC:FFP:platelets 1:1:1, with cryo
- different protocols exist
- more than ratio, important to have a protocol with fixed ratios
risks of blood transfusion
- anaphylaxis
- TRALI
- hyperkalemia
- hypocalcemia (due to citrate in blood products)
- acidosis
- hypothermia
when should TXA be given?
- PPH, due to any cause of hemorrhage after first line medications have failed
- within 3 hours of birth
- can reduce maternal death by 30%
how is TXA dosed?
- 1 g in 10 mL, infused at 1 mL per min (i.e. total of 10 minutes)
- repeat after 30 minutes if needed
what order of surgical procedures would you do for atony?
1) B- Lynch
2) O’Leary (uterine artery ligation)
3) utero-ovarian ligations
what options do you have for uterine packing?
- Bakri tampanode balloon (instill 300-500 cc saline)
- Multiple foley catheters
- Gauze swabs
blood components
- volume:
- contents:
- effect:
- dose:
pRBC
- volume: 250 cc
- contents: RBC
- effect: 1 unit increases Hct 3% or Hgb 1 gm
FFP
- volume: 250 cc
- contents: fibrinogen (200 mg), Factor V, Factor VIII, antithrombin III
Platelets
- volume: ~ 300 cc
- contents: 1 unit has 50 million, a 6 pack has ~ 300 x 10^9 plts
- effect: increases plts by ~ 30 K (6 pack or single donor)
- dose: single donor/1- 6 pack (
cryo
- volume: 50 cc
- contents: 200 mg fibrinogen, factor VIII, factor XIII, VWF
- does not need ABO/Rh typing
