UW uterine inversion + vagina hematoma 02-20 (1)

Question 1

UW. uterine inversion CP?

Answer 1

postpartum hemorrhage + possible hemorrhagic shock + vaginal mass + abdominal pain

Question 2

UW. uterine inversion. what type of shock apart hemorrhagic?

Answer 2

Neurogenic shock, due to the traction effect on the surrounding peritoneum, may also occur, resulting in a paradoxical bradycardia.

Question 3

UW. uterine inversion. risk factors? 3

Answer 3

fetal macrosomia, rapid labor and delivery, and placenta accreta

Question 4

UW. uterine inversion. mechanism

Answer 4

Uterine inversion likely occurs due to excessive fundal pressure and traction on the umbilical cord prior to placental separation, which can lead to cord avulsion. The excessive traction causes the fundus to collapse into the endometrial cavity and prolapse through the cervix, resulting in a firm, rounded mass protruding through the vagina. As a result, the fundus is no longer palpable transabdominally.

Question 5

UW. uterine inversion. vs uterine rupture?

Answer 5

Uterine rupture = not associated with a vaginal mass.

Question 6

UW. uterine inversion. Mx?

Answer 6

immediate manual replacement of the uterus by placing a hand in the vagina and pushing the prolapsed uterus back through the cervix to return it to its anatomic position.

Question 7

UW. uterine inversion. Why need to do immediately manual replacement?

Answer 7

Delay in reduction of the prolapse can make manual uterine replacement more difficult because the uterus can become edematous and the cervix may contract around the inverted uterus

Question 8

UW. uterine inversion. how to Mx is placenta is still attached?

Answer 8

If the placenta is still attached to the uterine wall, as in this patient, it should not be removed until after the uterus is replaced because of the risk of massive hemorrhage

Question 9

UW. uterine inversion. Manual replacement of the uterus requires moderate uterine relaxation; therefore STOP what????

Answer 9

uterotonics (eg, oxytocin) are discontinued because they increase uterine tone (ie, contractility) and may make manual uterine replacement impossible to perform.

Question 10

UW. uterine inversion. Manual replacement of the uterus requires moderate uterine relaxation; therefore GIVE what????

Answer 10

Uterine relaxants (eg, terbutaline, nitroglycerin) are typically reserved for patients in whom initial attempts at reduction are unsuccessful because such relaxants increase the risk of persistent uterine atony (ie, bogginess) and associated postpartum hemorrhage (Choice A).

Question 11

UW. uterine inversion. Manual replacement If unsucessful???

Answer 11

If attempts at manual uterine replacement fail, the next step in management is laparotomy to prevent exsanguination

Question 12

Educational objective:
Uterine inversion requires discontinuation of uterotonics (eg, oxytocin) and immediate manual replacement of the uterus to prevent exsanguination. Uterine relaxants and laparotomy may be required if initial attempts at manual reduction are unsuccessful.

Answer 12

.

Question 13

UW. vaginal hematoma table. risk factors? 4

Answer 13

operative vaginal delivery
infan >=4kg
nulliparity
prolonged 2nd stage of labor

Question 14

UW. vaginal hematoma table. CP? 3

Answer 14

vaginal mass
rectal or vaginal pressure
+/- hypovolemic shock

Question 15

UW. vaginal hematoma table. Tx if NONexpanding?

Answer 15

observation

Question 16

UW. vaginal hematoma table. Tx if expanding?

Answer 16

embolization, surgery

Question 17

UW. vaginal hematoma. During delivery, stretching of the vaginal canal can injure the uterine artery, particularly in nulliparous patients undergoing operative vaginal delivery (eg, forceps-assisted) or delivering an infant ≥4000 g (8.8 lb).

Answer 17

.

Question 18

UW. vaginal hematoma.
Blood collects in paravaginal space (a large potential space) -> massive occult bleeding, evidenced only by hypovolemic shock (eg, hypotension, tachycardia, diaphoresis) initially. However, as blood continues to collect -> protruding vaginal mass, often associated with rectal or vaginal pressure and minimal vaginal bleeding.

Answer 18

.

Question 19

UW. vaginal hematoma. MX based on what?

Answer 19

HD stability

Question 20

UW. vaginal hematoma. HD unstable?

Answer 20

expanding hematomas require treatment (eg, arterial embolization, surgery).

Question 21

UW. vaginal hematoma. HD stable?

Answer 21

Nonexpanding vaginal hematomas are observed

Question 22

UW. vaginal hematoma. other variants. A retained placenta is associated with …?

Answer 22

A retained placenta is associated with uterine atony –> heavy bleeding

Question 23

UW. vaginal hematoma. other variants. Uterine inversion vs hematoma?

Answer 23

firm and palpable at the umbilicus in hematoma. in inversion not palpable