UW postpartum uterine atony 02-20 (1) Flashcards
UW table. postpartum uterine atony. Risk factors? 5
Uterine fatigue from prolonged, induced or precipitous labor
Intraamniotic infection
Uterine overdistension (multiple gestation, macrosomia, polyhydramnios)
Retained placenta
Grand multiparity (>=5 prior deliveries)
UW table. postpartum uterine atony. CP? 2
MCC of postpartum hemorrhage
Enlarged, soft, boggy, poorly contracted uterus
UW table. postpartum uterine atony. Intervetions list
Bimanual uterine massage
Correction of bladder distension
High dose oxytocin, misoprostol
Tranexamic acid
Carboprost, methylergonovine
Intrauterine ballon tamponade
Possible surgical intervention (is atony unresolved)
UW. Some patients may not have an immediate PPH (eg 1 hour after delivery). why?
because blood can gradually accumulate in the lower uterine segment (the least contractile portion of the uterus).
UW. When atony manifests + cause hemorrhage. time?
withint 24hours post delivery
UW. Postpartum hemorrhage (PPH) is defined as an estimated blood loss ???? ml or Cp
≥1,000 mL OR bleeding with signs/symptoms of hypovolemia.
UW. step-wise approach. Initial Mx?
placement of 2 large-bore intravenous lines for volume resuscitation.
UW. step-wise approach. After initial, first step? 2
Bimanual uterine massage (and bladder catheterization) are performed to improve uterine tone.
UW. step-wise approach. after massage next step? drug
High-dose oxytocin, the first-line uterotonic agent, is administered.
UW. step-wise approach. persists after oxytocin?
best next step in management is tranexamic acid
UW. step-wise approach. persists after tranexamic acid?
second-line uterotonic medications, including carboprost tromethamine, methylergonovine, and misoprostol.
UW. step-wise approach.
in what patients contraindicated Carboprost tromethamine ?
in patients with asthma due to the risk of bronchospasm
UW. step-wise approach. Methylergonovine is contraindicated in what patients?
hypertension (regardless of the patient’s current blood pressure) due to an increased risk of stroke
UW. step-wise approach. not resolved after all drug therapy?
an intrauterine balloon tamponade can be used
UW. step-wise approach. not resolved after an intrauterine balloon tamponade?
patients with PPH refractory to medical and minimally invasive techniques require either uterine artery embolization or surgical management with laparotomy (and possible hysterectomy).
UW. For what is used Dilation and curettage if PPH?
for PPH due to retained products of conception
Although this patient’s (case) placenta was extracted in pieces, an ultrasound revealed no evidence of retained products of conception (eg, a thin endometrial stripe).
UW. when used sterile gauze?
to apply pressure to bleeding vaginal mucosa (eg, after vaginal sulcal laceration repair) to allow for clot formation
UW. kita table for PPH. retained products. risk facotrs?
succenturiate placenta
manual extraction of placenta
Hx of previous uterine surgey
UW. kita table for PPH. retained products. CP?
enlarged, boggy uterus
Placenta missing cotyledons
RETAINED PLACENTAL FRAGMENTS ON UG
UW. kita table for PPH. retained products. Mx?
Manual extraction
UW. kita table for PPH. genital trauma. Risk factors?1
operative vaginal delivery
UW. kita table for PPH. genital trauma. examination 2
laceration of cervix or vagina
enlarging hematoma
UW. kita table for PPH. genital trauma. Mx?
Laceration repair
UW. kita table for PPH. inherited coagulopathy. risk factors?
Hx of abnormal bleeding in patients of family members
UW. kita table for PPH. inherited coagulopathy. examination?
Continued bleeding despite contracted uterus
UW. kita table for PPH. inherited coagulopathy. Mx?
correction of coagulopathy
UW. buvo case su vWD. Pagimde pries 2 sav, turi kraujavima from os. aPTT normal, plt normal, PT normal, prolonged bleeding time.
WHY aPTT NORMAL? mild-moderate disease
Patients with mild to moderate VWF deficiency may have adequate factor VIII levels to maintain aPTT within normal range (most common reason).
UW. buvo case su vWD. Pagimde pries 2 sav, turi kraujavima from os. aPTT normal, plt normal, PT normal, prolonged bleeding time.
WHY aPTT NORMAL? inflammation/stress
VWF and factor VIII are acute-phase reactants; inflammation and stress (eg, hemorrhage) can acutely raise levels.
UW. buvo case su vWD. Pagimde pries 2 sav, turi kraujavima from os. aPTT normal, plt normal, PT normal, prolonged bleeding time.
WHY aPTT NORMAL? hormones/pregnancy
- VWF synthesis is increased by estrogen and thyroid hormones; pregnancy, oral contraceptives, and thyroid hormone replacement can raise VWF levels and normalize aPTT.
UW. buvo case su vWD. diagnostic studies?
Diagnostic studies include VWF antigen level, VWF activity (ristocetin cofactor activity), and factor VIII levels.
UW. buvo case su vWD. if bleeding does not stop, what drug to Mx?
Desmopressin (DDAVP) potentiates the release of VWF from endothelial cells and can be used in the management of acute bleeding or for prophylaxis.
UW. vWD vs vaginal hematoma’?
Vaginal hematoma typically presents with hypotension and anemia due to concealed bleeding into the retroperitoneum. In addition, patients have severe vaginal pain and a vaginal mass on examination. This patient has a normal pelvic examination.
UW. Educational objective:
Patients with von Willebrand disease may have postpartum hemorrhage and prolonged bleeding time. Activated PTT may be normal or prolonged, and platelet count and PT are normal. Treatment of acute bleeding includes desmopressin.
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