Third Trimester Bleeding - Sheiner Flashcards
What are the possible causes of antepartum hemorrhage and what is their likelihood?
- Placenta Previa (1/200)
- Placental Abruption (1/200)
- Uterine Rupture (<1% in scarred uterus)
- Vasa Previa (1/2000-3000)
What is the management for placenta previa?
C-section if:
-in active labor
-documented lung maturity (wait if possible if not)
->=37 weeks gestational age
-excessive bleeding
0development of another complication mandating delivery
If fetus is not mature and can delay, do. But if any of these are present, do a c-section.
Airway, primary fluid manage (IV), check Hct, Hgb, platelets, etc.
May have to cut into placenta- increased bleeding risk
High risk of placenta accreta (invaded uterine wall), especially if prior c-section, the major cause of c-hysterectomy
Regional (spinal) anesthesia preferred if not in labor or if in labor and not hemorrhaging
What are the risk factors for placental abruption?
History of Abruption
Hypertension
Prolonged PROM
Cocaine
Trauma
Multiparity
Smoking
What is the management of placental abruption?
C-section:
-depends on gestational age, fetal distress and general condition
No regional anesthesia if hypovolemia or coagulopathy
What is the difference between uterine rupture and dehiscence?
Dehiscence:
-fetal membranes remain intact, fetus no extruded intraperitoneally
Separation within old scar (not more)
Peritoneum overlying is intact
Thin uterus can tear from contractions
Usually no fetal distress nor maternal hemorrhage
Rupture:
Separation of scar and extension, rupture of fetal membranes with extrusion (fetal parts into abdominal cavity)
Results in fetal distress/maternal hemorrhage
Fetal mortality is 35%
Features:
Vaginal bleeding, hypotension, cessation of labor/contractions, fetal distress, change in fetal station (disengagement)
Pain in only 10%
Critical condition, may result in postpartum hemorrhage
What are the causes of uterine rupture?
Traumatic (Iatrogenic):
Abdomninal trauma
Labor induction (especially with prostaglandins-15x higher, causes polysystolia/tachysystole)
Internal podalic version
Assisted breech delivery
Instrumental deliveries
Increased with classical C-section/VBAC
Single-layer closure
Spontaneous:
Grand multiparity
Congenital abnormality of the uterus
Invasive mole
Abnormal placentation
Malpresentation
Highest chance of rupture with classical or T-shaped scar (4-9% rupture). Low vertical has 1-7%, low transverse has least chance (<1%).
What fetal heart rate patterns are common in uterine rupture?
Uterine tachysystole (<6 contractions/10 minutes)
Disappearance of contractions
Reduced baseline variability
Fetal tachycardia
Fetal bradycardia
What is the management of uterine rupture?
- Prompt detection
- Rapid surgical intervention with a surgeon, anesthesiologist (for mom and baby reuscitation), hematologist, neonatal team
Repair if possible
Future fertility possible
Hysterectomy if extension into broad ligament or myometrium or placenta accreta
How do placenta abrupta, previa and uterine rupture present differently?
Previa is least likely to have abdominal pain
Abruption has older blood than previa or rupture
DIC is most common in abruption
Acute fetal distress is least common in placenta previa
What are the management options for placenta accreta?
Uterine curettage
Oversweing of placental bed
Hysterectomy (accreta is the most common indication for C-hysterectomy)
What are the classifications of postpartum hemorrhage?
What are possible etiologies?
Blood loss >500cc after vaginal delivery or 1L after c-section
10% of deliveries
Primary if within 24 hours of delivery
Secondary if between one day and 6 weeks
Highest risk for maternal mortality
Primary etiology is uterine atony
Genital trauma (episiotomy)
Retained placenta/placenta accreta
Uterine inversion
What is the treatment of uterine atony?
Uterine massage
Oxytocin
Ergot derivatives (alpha adrenergics-vasoconstriction)
Prostaglandins
If drugs fail there can be embolization of arterial supply (uterine artery), ligation or hysterectomy
Laparotomy
B-lynch (suture of uterus)
Cause contractions
What is the treatment for retained placenta?
Manual removal, oxtocin
Need to give epidural or spinal anesthesia if not hypovolemic
What are invasive treatment options for obstetric hemorrhage?
Angiographic embolization
Bilateral surgical ligation of uterine, ovarian, internal iliacs (preseves fertility): 42% success
Cesarean- or postpartum hysterectomy
(Done emergently with blood loss is about 2500ccs or electively with 1300cc)
What are the risk factors for uterine inversion?
What is the treatment?
Uterine atony
Inappropriate fundal pressure
Umbilical cord traction (pull the placenta before it separates completely)
Uterine anomaly
Oxytocin is primary treatment, also replace the uterus and can use methergine or NTG IV or halogenated agent
