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Endo/Repro II Test 1 > 16. Obstetric Hemorrhage and Puerperal Sepsis > Flashcards

16. Obstetric Hemorrhage and Puerperal Sepsis Flashcards

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1
Q

If a patient is hemorrhaging (bleeding profusely) before birth, what should you do?

A
    1. Set up a team (OB, anesthesia, nursing, bleeding protocal) to establish hemodynamic stability
  • 2. Give 2 large bore IV lines
  • 3. Access vitals, amount of bleeding and mental status
  • 4. Medical hx
    1. labs (CBC, coag profile, serial H/H, type and crossmatch)
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2
Q

If a patient is bleeding, how do you replace their blood?

A

Type and crossmatch for 4 units of blood via PRBC (packed RBC) transfusion

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3
Q

How much will 1 unit of PRBC raise Hct and Hgb?

A

Raise Hct by 3% and Hgb by 1g/dL

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4
Q

What should be avoided during the initial examination of antepartum hemorrhage?

A
  • AVOID digital exam (looks at dilation of cervix) until placenta previa is ruled out
  • Instead do sterile speculum exam to look for genital lacerations/cervical lesions.
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5
Q

How many units of blood should you type and crossmatch for during antepartum hemorrhage?

A

4 untis of blood

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6
Q

When assesing the entire situation during the intial evaluation of antepartum hemorrhage, what do you do?

A
  1. US to look at location of placenta and presentation of fetus
  2. Amount of bleeding/maternal status
  3. Gestations age
  4. Conintour FH monitoring
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7
Q

DDx for Vaginal Bleeding BEFORE 20 weeks

A
  1. Abortion
  2. Ectopic PG
  3. Problem with cervix/vagina (cancer, polyp)
  4. Subchorioninc hemorrhage/retroplacental clot
  5. Insufficient cervix
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8
Q

DDx for Vaginal Bleeding AFTER 20 weeks (upper genital tract etiology)

A
  1. Placenta abruption
  2. Placental previa
  3. Uterine rupture
  4. Vasa previa
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9
Q

DDx for Vaginal Bleeding AFTER 20 weeks (lower genital tract etiology)

A
  1. Bloody show labor
  2. cervical polyps
  3. infection/trauma/cancer
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10
Q

What is the most common type of abnormal placentation?

A

Placenta previa => implantation of the placenta over the cervical os, causing 20% of antepartum hemorrhage.

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11
Q

Placenta previa classically presents how?

A

Painless vaginal bleeding

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12
Q

Risk factors for placenta previa, including age?

A
  1. Maternal age >35
  2. Multiparity
  3. Prior previa or C-section
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13
Q

What are the 3 types of placenta previa?

A
    1. Marginal PP => edge of placenta is over margin of cervical os, but does NOT cover it.
    1. Partial PP => partial occlusion of the placenta
    1. Complete PP => placenta completly cover
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14
Q

What is the most serious type of placenta previa and is associated with the most blood loss?

A

Complete PP

least likely to resolve

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15
Q

Placent previa is almost exclusively diagnosed how?

A

US

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16
Q

How likely are placenta previas to resolve on their own?

A

90% will resolve by 32-35 weeks, in a process known as placental migration.

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17
Q

Which one is marginal PP and complete PP?

A

L => marginal

R => complete

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18
Q

What is goal of management of placenal previa in preterm pregnancy; can these patients go home?

A
  • Goal = obtain fetal maturation
  • If bleeding not profuse = bed rest initially
  • If stable and bleeding stops = send home on pelvic rest
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19
Q

When should a patient with placenta previa NL be delivered if the fetuses lungs are matured?

A

36-37 weeks

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20
Q

How is a patient with placenta previa stabilized?

A
  1. Hospitalized
  2. IV access => 2 large bore needles if bleeding profusely
  3. Labs (H/H and Type and cross) anf PT/PTT/ fibrinogen if you suspect coagulopathy
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21
Q

If delivering a patient with placenta previa BEFORE 34 weeks, what should be given?

A
  1. Antenal steroids (betamethasone)
  2. Tocolysis if stable
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22
Q

When encountering a patient with previa, OTHER ABNL placental implantations should be considered. What is the most common?

A

Placenta ACCRETA; firm attachment to the superficial linign of the myometrium

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23
Q

What is placenta increta and percreta?

A
  • Placenta increta => invades myometrium
  • Placenta percreta => through the myometrium INTO the uterine serosa
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24
Q

RF and Treatment of Placenta Acreta

A
  • RF = Previous c-section (esp high with multiple)
  • Tx = cesearean hysterectomy
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25
MCC of 3rd trimester bleeding?
P**lacental abruption** =\> premature separateion of NL implanted placenta
26
Classic case of placenta abruption
* Patient presents in 3rd trimester with **PAINFUL bleeding,** a **tender uterus** that is **hyperactive** and **fetal distress/death.**
27
What is the **most common risk factor** for placental abruption?
**Maternal HTN**
28
How should pts with placental abruption be delivered?
* Mom and bb stable =\> vaginal * Fetal distress or uncontrolled bleeded =\> c-section
29
If **pregnant mothe**r presents after **MVA** or **physical abuse** how long should they be monitored for placental abruption?
**4-6 hours**
30
What is the most common cause of **DIC** in pregnancy?
**Placental abruption**
31
Management of placenta abruption?
**same as placenta previa;** stabilize the patient, prepare for catestophic hemoorhage (serial blood draws, NPO, type and cross 4 units) and prepare for preterm delivery (give bexamethasone if before 34 weeks).
32
What is **couvelaire uterus**?
When placental abrupts, blood extravates into the uterus causing red/purple serosa
33
What is **uterine rupture** and symptoms?
Uterine rupture = complete seperates of uterine muscles through all layers 1. Sudden onset of INTENSE abdominal pain +/- vaginal bleeding 2. Abnormal FHR/ cessation of fetal heart tones 3. Regression of the presenting part
34
What is the most common risk factor for uterine rupture?
1. Prior uterine incision (c-section/mymectomy)
35
How is **uterine rupture** managed?
1. Immediate laparotomy and delivery of fetus 2. Repair if possible 3. If large rupture =\> cesarean hysterectomy 4. ALL future pregnancies have to be delivered via **c-section**
36
**Fetal bleeding** that occurs during the 3rd trimester is most often due to what?
**Velamentous insertion** of umbilical cord =\> cord inserts at a distance away from the placenta and the vessels have to traverse between chorion/amnoin without the protective Whartons jelly. If unprotected vessel passes over cervical os =\> vasa previa.
37
What is the leading cause of maternal death worldwide?
**Post-partum hemorrhage** (most occur within 24 hours).
38
**Postpartum hemorrhage** is defined as how much blood loss following a vaginal birth vs. C-section?
- **\>500cc** following vaginal birth - **\>1000cc** following C-section
39
Differentiate **primary** vs. **secondary postpartum hemorrhage?**
- **Primary** is that which occurs within first 24 hours; often uterine atony - **Secondary** occurs from \>24 hours - 12 weeks
40
MCC of secondary post-partum hemorrhage
* 1. Subinvolution of placenta sote * 2. Retained products of conception * 3. Infection * 4. Inherited coagulation defects
41
Post-partum hemorrhage due to uterine atony occurs when?
**Uterus does not contract** after placenta is delivered, creating a **"boggy" uterus** upon palpation.
42
Uterine atony MC occurs when?
RIGHT before or after delivery of placenta
43
RF for uterine atonys
1. LARGE uterus (multiples, polyhydramnois) 2. ABNL labor 3. Conditions that infere with contraction of uterus
44
**Effective hemostasis** after separation of the placenta is dependent on what?
**Myometrium** to compress the severed vessels
45
* What are some strategies to managin uterine atony? * What is the last resort and how can we preserve pregnancy
1. **- BIMANUAL MASSAGE of the uterus + start meds at the same time:** 1. Oxytocin, Methylgenovine, 15- methy prostandin F2a, Dinoproston/Misoprostol. 2. Uterine packing: 4in gauze or large volume balloon 3. Interventional radiology 4. Surgery = last resort 1. if pt wants to preserve fertility = cut uterine arteries 2. If unstable =\> total abdominal hysterectomy
46
What confirms the diagnosis of uterine atony?
***Bimanual massage*** =\> uterus will feel bogy =\> decrease bleeding, expel clots, allow time for other measures to be done
47
**Methylergonovine** can be given for tx of *postpartum hemorrhage*, but should be avoided in whom?
**HTN patients**
48
**15-methyl PGF2a (Hemabate)** can be given for tx of postpartum hemorrhage but should be avoided in which pt's?
**Asthmatic pts**
49
**Dinoprostone (PGE2)** can be given for postpartum hemorrhage, but should be avoided in which pt's?
**HypOtensive**
50
What kind of stitches and sutures can we do for **atonic uterus?**
* **O'Leary stritches** =\> ligate uterine arteries * **B-lynch suture**
51
What is the 2nd most common cause of postpartum hemorrhage following vaginal delivery?
Trauma during delivery
52
50% of patients with post-partum hemorrhage will have what?
**Retained placental fragments,** which can cause bleeding because the uterus cannot contract around the tissue.
53
What is the treatment for **retained placenta**?
- **Manual removal** if bleeding is profuse - **+/- uterine curettage** with or without U/S guidance, being careful not to perforate
54
**Uterine inversion,** another cause of post-partum hemorrhage, occurs when?
**Top of the fundus of uterus** descends into the vagina and sometimes through the cervix.
55
If uterus inversion occurs BEFORE the placenta is delivered, what should be done?
**Correct inversion** BEFORE you deliver the placenta.
56
**Uterine inversion** can cause what complications?
1. **Copious bleeding** 2. **Hypovolemic shock**
57
Treatment of Uterine Inversion
* **1. Manually replace =\> then start oxytocin to cause uterus to contract** * 2. If larpartomy, get an anesthesiologist.
58
What coagulation disorders can cause post-partum hemorrhage? treatments?
* 1. **Amniotic fluid embolism** =\> amnioti fluid is infused into mom * Tx: respiratory support, correct hypovolemic shock and replace coag factors * **2. VW disease** =\> factor 8 def =\> prolong bleeding time * Tx: Factor 8 concentrate or cryoprecipitate. * **3. Idiopathic thrombocytopenia =\>** abnl platelets w short life * Tx: platelet infusion
59
What are the contents of **fresh frozen plasma** and how much does 1 unit increase the fibrinogen?
* Fibrinogen, antithrombin 3, factor 5 and 8 * 10 mg/dL
60
What are the contents of **Crypercipitate** and how much does 1 unit increase the fibrinogen?
* Fibrinogen, vWF, factors 8 and 13 * 10 mg/dL
61
What are the contents of **platelets** and how much does 1 unit increase the platet count by?
* Platelets, RBC, WBC, plasma * 5-10K mm3
62
What is **puerperal sepsis**?
**Overgrowth of pathogenic organisms** that occur after delivery because the **pH** of the vagina becomes **more alkaline.**
63
Puerperal sepsis can cause what symptom?
**Fetal morbidity** =\> temperature \>100.4 for more than 2 consecutive days during the first 10 days after delivery (exclusing first 24 hours), most often due to endometritis
64
Organism with what oxygen dependence cause majority of puerperal infections; which organisms most commonly?
**ANAEROBIC** ---\> Peptostreptococcus, Peptococcus, and Streptococcus
65
What are the key clinical findings for ***puerpral sepsis***?
**Postpartum fever** and **↑ uterine tenderness** on postpartum **day 2-3**
66
What the treatment for **puerperal sepsis**; what if caused by **Bacteroides fragilis**?
- **Ampicillin** + **Gentamicin** - Bacterioides fragilis is resistant to this combo, but sensitive to **Clindamycin**
67
**Septic pelvic thrombophlebitis** fufills the criteria for which pathogenesis of thrombosis?
**Virchow's triad** 1. Endothelial damage 2. Venous stasis 3. Hypercoagulable state of pregnancy
68
How does the presentation of **ovarian vein thrombophlebitis** differ from deep **septic pelvic vein thrombophlebitis**?
* Ovarian vein will have *fever* + *abdominal pain within 1 week of delivery* ---\> *_appear critically ill_* * Pelvic vein will usually have *unlocalized fever in first few days that is NON-responsive to Abx* and pt's *_do NOT appear critically ill_*
69
Can thrombosis be seen on radiograph for ovarian vein thrombophelbitis or deep septiv pelvic vein thrombophlebitis?
* OVTP: 20% * DSPVTP: no
70
* How do we prevent more thrombosis in septic pelvic thrombophlebitis? * If no thombosis, continue for how long? * If ovarian vein thrombosis is seen on XR, anticoagulants should be continued for how long?
* Anticoaguation (unfractionated heparin/ LMW heparin) * Fever goes away x 48 hours. * 6 weeks

Endo/Repro II Test 1 (23 decks)

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