Third Trimester Bleeding and Postpartum Hemorrhage Flashcards
What are simple things that can cause third trimester bleeding?
1) pelvic exam
2) intercourse
3) preterm labor
4) ectropion
What is placental abruption?
an abnormal premature separation of the placenta from the uterus
How does placental abruption classically present?***
Classically presents s painful contractions***
What are the risk factors for placental abruption?
1) hypertension
2) trauma
3) tobacco use
4) cocaine
5) multifetal gestation
What is the management of placental abruption?
1) > 34 weeks = deliver
2) < 34 weeks = may delay delivery is mother and fetus are stable
What is a feared complication of placental abruption?
DIC
What is placenta previa?
Placenta located over the internal os
complete, partial or marginal
How does placenta previa classically present?**
Classically presents as painless bleeding ***
How do you diagnos placenta previa?
ultrasound
What is the management for placenta previa?
1) pelvic rest (often hospitalization)
2) deliver as soon as fetal lungs are mature
What is vasa previa?
placental vessels cross over the internal os before the fetus
What can happen if vasa previa isn’t diagnosed quickly?
fetal exsanguination
What is placenta Accreta?
Abnormal Attachment of placenta to myometrium
What is the pathogenesis of placenta Accreta?
thin or absent decidua (endometrial lining)
What are the risk factors for placenta accreta?
1) previous C-sections
2) placenta previa
3) previous D&C
How do you manage placenta accrets?
C-section with hysterectomy with special considerations
What is placenta Increta?
the placenta Invades the myometrium
How do you manage placenta increta?
C-section
What is placenta Percreta?
placenta Penetrates the uterus
When does the uterus return to normal size after delivery and how?
1) starts resizing immediately after delivery and finished by 4 weeks post partum
2) do to contraction of myometrium stimulated by oxytocin and prostaglandins
What is the definitions of postpartum hemorrhage?
1) > 500ml blood loss for vaginal surgery
2) > 1,000ml blood loss for C-section
3) better def = excessive bleeding that makes the patient symptomatic or results in signs of hypovolemia
What percent of blood loss do you start to see signs and what are they?
1) 15-25% (1,000-15,000 ml)
2) weakness, tachycardia, sweating
** What are the four T’s of post partum hemorrhage**
1) Tone (uterine atony)
2) Tissue (retained placenta)
3) Trauma (lacerations and hematomas)
4) Thrombocytopenia (coagulation defects)
What causes most cases of PPH?
80% due to uterine atony
What is uterine atony?
poor “boggy” muscle tone allows for continued blood flow through the spiral arteries to the placental implantation site
How is uterine atony managed?
1) bimanual massage - stimulates oxytocin
2) Pitocin (oxytocin analog)
3) Methergine (not for HT pts, if doesn’t work
fast move on!)
4) Prostoglandins
5) Misoprostal
6) Caroprost tromethamine (PGF2alpha - a
long acting prostaglandin - not for
asthmatics)
7) Bakri Balloon = last straw before surgery!
What is the etiology of a retained placenta?
incomplete separation
What are the risk factors and treatment of a retained placenta?
1) fibroid, previous C-section or D&C
2) Tx = manual removal or D&C
What is a succenturiate placental lobe and why do we remove it?
1) an accessory lobe
2) if not removed can lead to PPH
When do most hematomas occur?
1) after forceps, vacuum or episiotomy
2) can occur without these
What is the management of hematomas?
1) non-expanding
a) compression and observe
2) expanding
b) surgical evacuation and repair
What maternal risk factors put her at risk for uterine atony?
1) prolonged labor
2) augmented labor
3) rapid labor
4) overdistended uterus
5) chorioamnionitis
What maternal risk factors put her at risk for coagulation defect?
1) history of PPH
2) preeclampsia/HELLP
3) asian or hispanic
What maternal risk factors put her at risk for trauma?
1) episiotomy
2) operative delivery
3) VBAC
How do you manage PPH?
1) evaluate bleeding and assess your patients overall status
a) signs and Sx of blood loss
b) inspect placenta
c) bimanual exam to assess atony
d) look for lacerations
2) review risk factors
3) assemble team
4) you may have to restart at step 1!!!
What puts a mom at risk for uterine rupture?
VBAC - vaginal birth after C-section
What is amniotic fluid embolism and what are the signs?
1) entry of amniotic fluid in maternal circulation
2) respiratory distress, cyanosis, CV collapse, hemorrhage, coma
