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Reproductive Exam 1 > Third Trimester and Pospartum Bleeding > Flashcards

Third Trimester and Pospartum Bleeding Flashcards

1
Q

What is it called when the placenta implants over the cervical os?

A

Placenta previa

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2
Q

What is it called when the placenta implants over the cervical os?

A

Placenta previa

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3
Q

What is a complete or total previa?

A

Placenta completely covers the os (20-40%)

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4
Q

What is a partial previa?

A

Placenta partially covers the internal os (30%)

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5
Q

What is a marginal previa?

A

The edge of the placenta extends to the margin of the internal os (30-50%)

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6
Q

How are people with placenta previa typically delivered and why?

A

Usually C-section because of bleeding

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7
Q

What is the measure called of how many cm above or below the ischial spines a baby is?

A

Station

    • is below
    • is above
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8
Q

What is it called when the placental lies in the lower uterine segment, but doesn’t extend to the cervical os?

A

Low lying placenta

-Not really an issue… just repeat US at 28 weeks to make sure it hasn’t moved towards the os

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9
Q

What is the premature separation of the normally implanted placenta from its attachment to the uterus?

A

Placenta abruptio

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10
Q

What are 3 things that can commonly cause placenta abruptio?

A

Trauma, high BP, or crack cocaine

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11
Q

What is the complete separation of the uterine musculature through all of its layers?

A

Uterine rupture

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12
Q

Where does a uterine rupture commonly happen?

A

At the site of a previous surgery (C-section, fibroids removed ect) becuase it’s a weak point in the uterus… in the situations, just do a C-section

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13
Q

What is considered pospartum hemorrhage?

A

Blood loss in excess of 500mL vaginal delivery or 1000mL for a cesarean

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14
Q

What is it called when the placenta is directly attached to the myometrial wall?

A

Placenta accreta

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15
Q

What is absent in a placenta accreta?

A

No decidua basalis (absent Nitabuch’s layer)

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16
Q

What is it called when the placenta invades the myometrium?

A

Placenta increta

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17
Q

What is it called when the placenta penetrates the myometrium to the serosa or beyond?

A

Placenta percreta

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18
Q

What is is called when the vessels of the umbilical cord insert between the layers of the amnion and chorion away from the placenta?

A

Velamentous cord insertion

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19
Q

What happens in a vasa previa?

A

The unprotected vessels from a velamentous insertion pass over the os… they are predisposed to rupturing

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20
Q

What things increase in pregnancy?

A
  1. Maternal blood volume (up by 40%)
  2. Plasma volume
  3. Erythrocyte volume
  4. 2,3 DPG
  5. Heart rate (10-15bpm)
  6. Stroke volume
  7. Cardiac output (30-40%)
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21
Q

What things decrease in pregnancy?

A
  1. Maternal BP

2. Systemic vascular resistance

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22
Q

Why do you not have to treat anemia in preggo ladies until Hb hits like 10ish?

A

Because is it a physiological dilution of their blood… even through norm Hb is around 12-16, they are chill until like 10 because of this and won’t show shock systems until they have lost a lot of blood

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23
Q

In a normal person, what is the blood flow rate through the uterine artery? What about a preggo lady?

A
  • Normal is 60cc per min
  • Preggo is 6000cc per min
  • AKA, you nick the uterine artery in a prego lady they bleed out (exanguinate) in about 10 min… DON’T DO IT
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24
Q

Pregnancy is associated with what % increase in total blood volume by what week gestation?

A

40%, 13th week

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25
Q

What will the blood volume increase to in an average sized female?

A

6000mL

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26
Q

Antepartum and pospartum bleeding issues complicate what % of pregnancies?

A

4% each

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27
Q

What are the top 3 causes of maternal death in the US?

A
  1. Embolism
  2. HTN disease
  3. Hemorrhage
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28
Q

He gave us a hemorrhage classifications in preggo chart…what was the main thing we were supposed to take away from it?

A

That preggo ladies can loose up to 1000cc blood without showing any symptoms
-Said we didn’t need to know details, but take a glance at …TRUST NO ONE

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29
Q

What are the 2 most common causes of antepartum bleeding?

A
  1. Placenta previa (20%)

2. Placenta abruption (30%)

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30
Q

What are the other 50% of causes of antepartum bleeding that aren’t as common?

A
  1. Uterine rupture
  2. Fetal vessel rupture
  3. Cervical or vaginal lacerations
  4. Cervical or vaginal lesions including cancer
  5. Congenital bleeding disorder
  6. Unknown
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31
Q

You ask about abdominal pain, contractions, placenta previa, c sections or other prior uterine surgeries, smoking, cocaine, or bleeding disorders as part of what?

A

History portion of the initial evaulation for antepartum hemorrhage

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32
Q

What physical things do you check when evaluating for antepartum hemorrhage?

A

Vitals, amount of bleeding, uterine tenderness

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33
Q

True or False: When evaluating for antepartum hemorrhage, you check the cervix?

A

FALSE- DO NOT CHECK CERVIX UNLESS PLACENTA PREVIA HAS BEEN RULED OUT

-You roll with a US or careful spec exam (only open things up a bit to check for the cervix to see if it’s dilated with placenta pouring out through it waiting to explode at you)

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34
Q

What are 3 diagnostic things done for anterpartum hemorrhage evaluation?

A
  1. CBC and coag profile
  2. US
  3. Monitoring
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35
Q

What is the most accurate means of determining the cause of bleeding, but will still miss 50% of abruptions?

A

US- It is good for previa, but harder with abruption

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36
Q

What is seen in 1/200 deliveries and accounts for 20% of all antepartum bleeding?

A

Placenta previa

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37
Q

What are the 3 types of placenta previa?

A
  1. Complete
  2. Partial
  3. Marginal
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38
Q

What are 5 predisposing factors to placenta previa?

A
  1. Previous C-section
  2. Multiparity
  3. Multiple gestation
  4. Advancing maternal age
  5. Previous placenta previa
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39
Q

What are some complicating factors with placenta previa?

A
  1. 1/25 will have an underlying accreta
  2. 20% will have an underlying IUGR
  3. 2x higher rate of congenital abnormalities
  4. 30% malpresentation
  5. Higher incidence of PPROM
  6. Risk of Vasa Previa
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40
Q

What is PPROM?

A

Pre-term, premature rupture of membranes

-When water breaks under 37 weeks

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41
Q

What is PROM?

A

Pre-term rupture of membranes

-Full term, water breaks, no labor, contractions

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42
Q

What does the cervix have to do to deliver a baby?

A

Dilate to 10cm & Efface

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43
Q

Why can a low implantation or low-lying placenta not be bad?

A

Because the uterus grows from the upper 2/3 and up… so as the uterus grows, the placenta might grow “up” and move out of the way as the pregnancy progresses

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44
Q

Why is a vag delivery possible with marginal placenta previa?

A

Because the babies head could possible tamponade off of the vag and allow for the baby to sail on out

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45
Q

What is IUGR?

A

Intra-uterine growth restriction

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46
Q

If something happens once?

A

IT IS LIKELY TO HAPPEN AGAIN

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47
Q

What is the classical presentation of placenta previa?

A

Painless, bright red bleeding

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48
Q

What % of placenta previas are associated with contractions?

A

20%

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49
Q

What are the 2 types of US to diagnose placenta previa and what is the % effective?

A
  1. Transabdominal- 95%

2. Transvaginal- 100% (but this could precipitate bleeding)

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50
Q

What is done is US is inconclusive for placenta previa?

A

Double-set up exam… get yo lady in stirrups to examine, but be ready for a C-section too just in case

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51
Q

What are the first 2 things to do with placenta previa?

A
  1. Stabilize momma: IV, CBC, Type and Cross

2. Assess baby: Monitor, US, determine gestational age/maturity, fetal HR monitoring

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52
Q

If momma is stable and baby is preterm, what do you do with a placenta previa?

A
  1. Amniocentesis for lung maturity
  • If mature: Delivery by C-section
  • If immature: Bed rest, transfusions
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53
Q

In a placenta previa, if the baby is immature and you are trying to hold it in, what are 3 drug considerations to remember?

A
  1. Caution use of tocolytics: Magnesium sulfate id DOC
  2. Beta mimetics could mask tachycardia
  3. RHOGAM BABY
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54
Q

When is Rhogam given?

A

Rh- momma, Rh+ baby
-Give at 28 weeks… after birth, if baby is Rh-, everything is happy and merry… it baby is Rh+ another dose Rhogam within 72 hours of delivery

-ALWAYS DOCUMENT THAT YOU OFFERED RHOGAM

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55
Q

1 vial of Rhogam covers how much mixing of maternal and fetal blood?

A

15cc

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56
Q

What is the blood test to determine the amount of fetal Hb transferred to maternal blood?

A

Kleihaure- Betke

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57
Q

Soooo… since Rhogam vial only covers about 15cc mixing, what do you do if this Kleihaure-Betke test shows that more blood has mixed for whatever reason?

A

GIVE MORE VIAL OF RHOGAM…whoooooop

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58
Q

If momma or baby is unstable with placenta previa, what do you do?

A

C-SECTION

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59
Q

If where is a low lying placenta, momma and baby are stable… what can you do?

A

Attempt a vag delivery

  1. Fetal head should tamponade the bleeding
  2. Buuuuut… do a double set up with prep for a C-section
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60
Q

What happens in 1/120 births, with a fetal death rate of 1/500, and 80% occur prior to the onset of labor?

A

Placental abrupion

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61
Q

What is the age of viability?

A

24 weeks

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62
Q

What is a normal baby HR?

A

110-160

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63
Q

What is used to tell how far along baby is?

A

Uterine height

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64
Q

If the baby is below the umbilicus, how far along is it?

A

Under 20 weeks- NO C-SECTION

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65
Q

How do you save baby?

A

SAVE MOMMA (#1 COD for fetal is maternal shock)

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66
Q

What are risk factors for placenta abruption?

A
  1. Maternal hypertension
  2. Cocaine abuse, especially “crack”
  3. Trauma
  4. Smoking
  5. Polyhdraminios and multiple gestation- rapid decompression of an over-distended uterus
  6. Previous Abruption 5% recurrence, if two or more 25% recurrence rate
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67
Q

What is the gestational age where the baby should be okay?

A

Over 32 weeks…under this.. significant morbiditiy

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68
Q

Why can polyhydraminos cause placenta abruption?

A

With lots of amniotic fluid, when the water breaks there is a rapid decompression of the uterus and the placenta can just detach off

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69
Q

What is the most common cause of DIC in pregnancy?

A

Placenta abruption

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70
Q

What are complicating factors with placenta abruption?

A
  1. Perinatal mortality rate due to abruption, is 35%.
  2. Accounts for 15% of third trimester stillbirths.
  3. 15% of livebirths have neurologic damage.
  4. Most common cause of DIC in pregnancy.
  5. Hypovolemic shock, renal failure.
  6. Sheehan’s syndrome
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71
Q

What is the MOA of placenta abruption?

A
  1. Hemorrhage into the decidua basalis with formation of a hematoma.
  2. The seperation of the decidua from the basal plate perpetuates itself causing further separation as well as compression and destruction of tissue.
  3. If the blood dissects upward into the fundus, it will cause a concealed hemorrhage.
  4. If the blood dissects downward it will be revealed.

-Sorry…too lazy to make fancy questions out of this… and he didn’t spend time talking about it anyways

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72
Q

What is it called when there is a blueish purple discoloration to the uterus caused by blood dissecting into the myometrium?

A

Couvelaire Uterus

-Blueberry appearing–> Blood into myometrium after abruption

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73
Q

If a lady has a couvelaire urterus, what does she need?

A

Hysterectomy

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74
Q

What is the hallmark of placenta abruption?

A

Painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone

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75
Q

What makes the diagnosis of placenta abrption?

A

Clinical… US isn’t very affective

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76
Q

What % of ladies with placenta abruption have vag bleeding and what does it look like?

A

80% and it’s dark red (because it dissected, it is deoxygenated by the time it gets out)

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77
Q

What are other symptoms/issues seen with placenta abruption?

A
  1. Pain: 66%
  2. Fetal Distress: 60%
  3. Uterine Hyperactivity: 34%
  4. Fetal Demise: 15%
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78
Q

What will the abdomen be like with a placental abruption?

A

HARD BELLY

-It will feel like a contraction that isn’t going away

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79
Q

What are 6 aspects of management for placental absruption?

A
  1. Stabilize Mother
  2. IV’s
  3. Serial Coagulation Profiles
  4. Keep blood products on hand (DIC)
  5. Fetal Monitoring
  6. Vaginal Delivery preferred route. C-section for obstetrical reasons only
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80
Q

What is the complete separation of the uterine musculature through all of it’s layers?

A

Uterine rupture

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81
Q

Where is the fetus in uterine rupture?

A

Extruded into the abdomen

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82
Q

What is the incidence of uterine rupture?

A

0.5%

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83
Q

When can uterine rupture occur?

A

During or before labor, or at the time of delivery

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84
Q

What % of uterine ruptures are associated with previous uterine scar?

A

40%

  1. C/S most common- with prior LTCS -0.5% risk, with a previous vertical incision 5% risk.
  2. Myomectomy
  3. Metroplasty
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85
Q

What % of uterine ruptures occur in previously unscarred uterus?

A

60%

-GRand multip, ect… I think this was 5+ pregnancies?

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86
Q

What are 2 complicating factors with uterine rupture?

A
  1. Maternal mortality 1%

2. Fetal mortality 32%

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87
Q

What are 6 things used to diagnose uterine rupture?

A
  1. Must have high index of suspicion.
  2. Sudden onset of intense abdominal pain and vaginal bleeding
  3. Hyperventilation, agitation and tachycardia
  4. After rupture, momentary relief of pain but it returns.
  5. Fetal Distress
  6. Palpable fetal parts in abdomen.
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88
Q

What is done for uterine rupture?

A
  1. Immediate laparotomy
  2. Usually a total abdominal hysterectomy is performed (TOC)
  3. Possibly a debridement of rupture site and primary closure if fertility is still desired by patient
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89
Q

Where are the contractile fibers located in the uterus?

A

Upper 2/3

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90
Q

What is removed in a TAH?

A

Uterus and cervix (subtotal leaves cervix and takes uterus)

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91
Q

If you had a C-section and the cut up high, can you ever do a vag delivery?

A

Probs not… if you had a low transverse incision, possible (because of where contractile fibers are located

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92
Q

Just gonna toss in some stats about vasa previa…

A
  1. Incidence - 1/5000.
  2. Rupture 0.1 to 0.8%.
  3. 50% fetal mortality.
  4. If membranes rupture, 75% mortality.
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93
Q

What is the % indicence of postpartum hemorrhage?

A

4%

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94
Q

What is the physiology of postpartum hemorrhage?

A

The uterus fails to contract around the myometrial spiral arterioles and decidual veins at the attachment site after placental separation

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95
Q

What is the number 1 cause of postpartum hemorrage?

A

Uterine atony

96
Q

What is the number 2 cause of postpartum hemorrhage?

A

Genital tract trauma… laceration on vag wall, cervix, ect… this is a highly vascular area, especially when pregnant

97
Q

What are some other causes of postpartum hemorrhage?

A
  1. Retained placental fragments
  2. Uterine Inversion
  3. Low Placental Implantation
  4. Coagulation disorders: Abruption, retained dead fetus, inherited coagulopathy, amniotic fluid embolism
98
Q

What causes the majority of postpartum hemorrthage?

A

Uterine Atony (75-80%)

99
Q

What are predisposing factors to uterine atony?

A
  1. Overdistension of the uterus: Multiple gestation, polyhydramnios, fetal macrosomia
  2. Prolonged Labor
  3. Grand Multip (>5)
  4. Pitocin stimulation/ Magnesium Sulfate Tx.
  5. Chorioamnionitis
100
Q

What is a drug like oxytocin that induces contractions and can be used pre and post partum?

A

Pitocin

101
Q

Why is pitocin used postpartum?

A

Get the placenta out… AFTERBIRTH…MMMMMM

102
Q

Can oxytocin receptors become saturated?

A

YES

103
Q

What are 2 uses of magnesium sulfate?

A
  1. Gestational HTN: Prevents the conversion of pre-eclampsia to eclampsia
  2. Tocolytic: Relaxes the uterus and stops contractions
104
Q

What 3 things constitute pre-eclampsia?

A
  1. Proteinuria
  2. Edema
  3. HTN
105
Q

What constitutes plain old eclampsia?

A
  1. Proteinuria
  2. Edema
  3. HTN
  4. Seizures
106
Q

How do you diagnose postpartum hemorrhage?

A

Inspection/palpation

-This diagnoses all causes except coagulation

107
Q

What is the main strategy for management of uterine atony?

A

PITOCIN

108
Q

What are some other options to manage uterine atony?

A
  1. Massage
  2. Methergine (ergonovine maleate)- If not HTN
  3. Prostaglandin F2-Alpha
  4. Cytotec
  5. Embolization of Uterine Arteries- Need an IV radiologist to do this… not realistic
  6. Ligation of Uterine or Hypogastric arts.
  7. B-Lynch Stitch- Suture outside/around uterus to squeeze down onto it
  8. Supracervical hysterectomy- Remove the uterus
109
Q

How do you diagnose genital tract trauma?

A

EXPLORE

110
Q

How do you diagnose genital tract trauma?

A

EXPLORE

111
Q

What is a complete or total previa?

A

Placenta completely covers the os (20-40%)

112
Q

What is a partial previa?

A

Placenta partially covers the internal os (30%)

113
Q

What is a marginal previa?

A

The edge of the placenta extends to the margin of the internal os (30-50%)

114
Q

How are people with placenta previa typically delivered and why?

A

Usually C-section because of bleeding

115
Q

What is the measure called of how many cm above or below the ischial spines a baby is?

A

Station

    • is below
    • is above
116
Q

What is it called when the placental lies in the lower uterine segment, but doesn’t extend to the cervical os?

A

Low lying placenta

-Not really an issue… just repeat US at 28 weeks to make sure it hasn’t moved towards the os

117
Q

What is the premature separation of the normally implanted placenta from its attachment to the uterus?

A

Placenta abruptio

118
Q

What are 3 things that can commonly cause placenta abruptio?

A

Trauma, high BP, or crack cocaine

119
Q

What is the complete separation of the uterine musculature through all of its layers?

A

Uterine rupture

120
Q

Where does a uterine rupture commonly happen?

A

At the site of a previous surgery (C-section, fibroids removed ect) becuase it’s a weak point in the uterus… in the situations, just do a C-section

121
Q

What is considered pospartum hemorrhage?

A

Blood loss in excess of 500mL vaginal delivery or 1000mL for a cesarean

122
Q

What is it called when the placenta is directly attached to the myometrial wall?

A

Placenta accreta

123
Q

What is absent in a placenta accreta?

A

No decidua basalis (absent Nitabuch’s layer)

124
Q

What is it called when the placenta invades the myometrium?

A

Placenta increta

125
Q

What is it called when the placenta penetrates the myometrium to the serosa or beyond?

A

Placenta percreta

126
Q

What is is called when the vessels of the umbilical cord insert between the layers of the amnion and chorion away from the placenta?

A

Velamentous cord insertion

127
Q

What happens in a vasa previa?

A

The unprotected vessels from a velamentous insertion pass over the os… they are predisposed to rupturing

128
Q

What things increase in pregnancy?

A
  1. Maternal blood volume (up by 40%)
  2. Plasma volume
  3. Erythrocyte volume
  4. 2,3 DPG
  5. Heart rate (10-15bpm)
  6. Stroke volume
  7. Cardiac output (30-40%)
129
Q

What things decrease in pregnancy?

A
  1. Maternal BP

2. Systemic vascular resistance

130
Q

Why do you not have to treat anemia in preggo ladies until Hb hits like 10ish?

A

Because is it a physiological dilution of their blood… even through norm Hb is around 12-16, they are chill until like 10 because of this and won’t show shock systems until they have lost a lot of blood

131
Q

In a normal person, what is the blood flow rate through the uterine artery? What about a preggo lady?

A
  • Normal is 60cc per min
  • Preggo is 6000cc per min
  • AKA, you nick the uterine artery in a prego lady they bleed out (exanguinate) in about 10 min… DON’T DO IT
132
Q

Pregnancy is associated with what % increase in total blood volume by what week gestation?

A

40%, 13th week

133
Q

What will the blood volume increase to in an average sized female?

A

6000mL

134
Q

Antepartum and pospartum bleeding issues complicate what % of pregnancies?

A

4% each

135
Q

What are the top 3 causes of maternal death in the US?

A
  1. Embolism
  2. HTN disease
  3. Hemorrhage
136
Q

He gave us a hemorrhage classifications in preggo chart…what was the main thing we were supposed to take away from it?

A

That preggo ladies can loose up to 1000cc blood without showing any symptoms
-Said we didn’t need to know details, but take a glance at …TRUST NO ONE

137
Q

What are the 2 most common causes of antepartum bleeding?

A
  1. Placenta previa (20%)

2. Placenta abruption (30%)

138
Q

What are the other 50% of causes of antepartum bleeding that aren’t as common?

A
  1. Uterine rupture
  2. Fetal vessel rupture
  3. Cervical or vaginal lacerations
  4. Cervical or vaginal lesions including cancer
  5. Congenital bleeding disorder
  6. Unknown
139
Q

You ask about abdominal pain, contractions, placenta previa, c sections or other prior uterine surgeries, smoking, cocaine, or bleeding disorders as part of what?

A

History portion of the initial evaulation for antepartum hemorrhage

140
Q

What physical things do you check when evaluating for antepartum hemorrhage?

A

Vitals, amount of bleeding, uterine tenderness

141
Q

True or False: When evaluating for antepartum hemorrhage, you check the cervix?

A

FALSE- DO NOT CHECK CERVIX UNLESS PLACENTA PREVIA HAS BEEN RULED OUT

-You roll with a US or careful spec exam (only open things up a bit to check for the cervix to see if it’s dilated with placenta pouring out through it waiting to explode at you)

142
Q

What are 3 diagnostic things done for anterpartum hemorrhage evaluation?

A
  1. CBC and coag profile
  2. US
  3. Monitoring
143
Q

What is the most accurate means of determining the cause of bleeding, but will still miss 50% of abruptions?

A

US- It is good for previa, but harder with abruption

144
Q

What is seen in 1/200 deliveries and accounts for 20% of all antepartum bleeding?

A

Placenta previa

145
Q

What are the 3 types of placenta previa?

A
  1. Complete
  2. Partial
  3. Marginal
146
Q

What are 5 predisposing factors to placenta previa?

A
  1. Previous C-section
  2. Multiparity
  3. Multiple gestation
  4. Advancing maternal age
  5. Previous placenta previa
147
Q

What are some complicating factors with placenta previa?

A
  1. 1/25 will have an underlying accreta
  2. 20% will have an underlying IUGR
  3. 2x higher rate of congenital abnormalities
  4. 30% malpresentation
  5. Higher incidence of PPROM
  6. Risk of Vasa Previa
148
Q

What is PPROM?

A

Pre-term, premature rupture of membranes

-When water breaks under 37 weeks

149
Q

What is PROM?

A

Pre-term rupture of membranes

-Full term, water breaks, no labor, contractions

150
Q

What does the cervix have to do to deliver a baby?

A

Dilate to 10cm & Efface

151
Q

Why can a low implantation or low-lying placenta not be bad?

A

Because the uterus grows from the upper 2/3 and up… so as the uterus grows, the placenta might grow “up” and move out of the way as the pregnancy progresses

152
Q

Why is a vag delivery possible with marginal placenta previa?

A

Because the babies head could possible tamponade off of the vag and allow for the baby to sail on out

153
Q

What is IUGR?

A

Intra-uterine growth restriction

154
Q

If something happens once?

A

IT IS LIKELY TO HAPPEN AGAIN

155
Q

What is the classical presentation of placenta previa?

A

Painless, bright red bleeding

156
Q

What % of placenta previas are associated with contractions?

A

20%

157
Q

What are the 2 types of US to diagnose placenta previa and what is the % effective?

A
  1. Transabdominal- 95%

2. Transvaginal- 100% (but this could precipitate bleeding)

158
Q

What is done is US is inconclusive for placenta previa?

A

Double-set up exam… get yo lady in stirrups to examine, but be ready for a C-section too just in case

159
Q

What are the first 2 things to do with placenta previa?

A
  1. Stabilize momma: IV, CBC, Type and Cross

2. Assess baby: Monitor, US, determine gestational age/maturity, fetal HR monitoring

160
Q

If momma is stable and baby is preterm, what do you do with a placenta previa?

A
  1. Amniocentesis for lung maturity
  • If mature: Delivery by C-section
  • If immature: Bed rest, transfusions
161
Q

In a placenta previa, if the baby is immature and you are trying to hold it in, what are 3 drug considerations to remember?

A
  1. Caution use of tocolytics: Magnesium sulfate id DOC
  2. Beta mimetics could mask tachycardia
  3. RHOGAM BABY
162
Q

When is Rhogam given?

A

Rh- momma, Rh+ baby
-Give at 28 weeks… after birth, if baby is Rh-, everything is happy and merry… it baby is Rh+ another dose Rhogam within 72 hours of delivery

-ALWAYS DOCUMENT THAT YOU OFFERED RHOGAM

163
Q

1 vial of Rhogam covers how much mixing of maternal and fetal blood?

A

15cc

164
Q

What is the blood test to determine the amount of fetal Hb transferred to maternal blood?

A

Kleihaure- Betke

165
Q

Soooo… since Rhogam vial only covers about 15cc mixing, what do you do if this Kleihaure-Betke test shows that more blood has mixed for whatever reason?

A

GIVE MORE VIAL OF RHOGAM…whoooooop

166
Q

If momma or baby is unstable with placenta previa, what do you do?

A

C-SECTION

167
Q

If where is a low lying placenta, momma and baby are stable… what can you do?

A

Attempt a vag delivery

  1. Fetal head should tamponade the bleeding
  2. Buuuuut… do a double set up with prep for a C-section
168
Q

What happens in 1/120 births, with a fetal death rate of 1/500, and 80% occur prior to the onset of labor?

A

Placental abrupion

169
Q

What is the age of viability?

A

24 weeks

170
Q

What is a normal baby HR?

A

110-160

171
Q

What is used to tell how far along baby is?

A

Uterine height

172
Q

If the baby is below the umbilicus, how far along is it?

A

Under 20 weeks- NO C-SECTION

173
Q

How do you save baby?

A

SAVE MOMMA (#1 COD for fetal is maternal shock)

174
Q

What are risk factors for placenta abruption?

A
  1. Maternal hypertension
  2. Cocaine abuse, especially “crack”
  3. Trauma
  4. Smoking
  5. Polyhdraminios and multiple gestation- rapid decompression of an over-distended uterus
  6. Previous Abruption 5% recurrence, if two or more 25% recurrence rate
175
Q

What is the gestational age where the baby should be okay?

A

Over 32 weeks…under this.. significant morbiditiy

176
Q

Why can polyhydraminos cause placenta abruption?

A

With lots of amniotic fluid, when the water breaks there is a rapid decompression of the uterus and the placenta can just detach off

177
Q

What is the most common cause of DIC in pregnancy?

A

Placenta abruption

178
Q

What are complicating factors with placenta abruption?

A
  1. Perinatal mortality rate due to abruption, is 35%.
  2. Accounts for 15% of third trimester stillbirths.
  3. 15% of livebirths have neurologic damage.
  4. Most common cause of DIC in pregnancy.
  5. Hypovolemic shock, renal failure.
  6. Sheehan’s syndrome
179
Q

What is the MOA of placenta abruption?

A
  1. Hemorrhage into the decidua basalis with formation of a hematoma.
  2. The seperation of the decidua from the basal plate perpetuates itself causing further separation as well as compression and destruction of tissue.
  3. If the blood dissects upward into the fundus, it will cause a concealed hemorrhage.
  4. If the blood dissects downward it will be revealed.

-Sorry…too lazy to make fancy questions out of this… and he didn’t spend time talking about it anyways

180
Q

What is it called when there is a blueish purple discoloration to the uterus caused by blood dissecting into the myometrium?

A

Couvelaire Uterus

-Blueberry appearing–> Blood into myometrium after abruption

181
Q

If a lady has a couvelaire urterus, what does she need?

A

Hysterectomy

182
Q

What is the hallmark of placenta abruption?

A

Painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone

183
Q

What makes the diagnosis of placenta abrption?

A

Clinical… US isn’t very affective

184
Q

What % of ladies with placenta abruption have vag bleeding and what does it look like?

A

80% and it’s dark red (because it dissected, it is deoxygenated by the time it gets out)

185
Q

What are other symptoms/issues seen with placenta abruption?

A
  1. Pain: 66%
  2. Fetal Distress: 60%
  3. Uterine Hyperactivity: 34%
  4. Fetal Demise: 15%
186
Q

What will the abdomen be like with a placental abruption?

A

HARD BELLY

-It will feel like a contraction that isn’t going away

187
Q

What are 6 aspects of management for placental absruption?

A
  1. Stabilize Mother
  2. IV’s
  3. Serial Coagulation Profiles
  4. Keep blood products on hand (DIC)
  5. Fetal Monitoring
  6. Vaginal Delivery preferred route. C-section for obstetrical reasons only
188
Q

What is the complete separation of the uterine musculature through all of it’s layers?

A

Uterine rupture

189
Q

Where is the fetus in uterine rupture?

A

Extruded into the abdomen

190
Q

What is the incidence of uterine rupture?

A

0.5%

191
Q

When can uterine rupture occur?

A

During or before labor, or at the time of delivery

192
Q

What % of uterine ruptures are associated with previous uterine scar?

A

40%

  1. C/S most common- with prior LTCS -0.5% risk, with a previous vertical incision 5% risk.
  2. Myomectomy
  3. Metroplasty
193
Q

What % of uterine ruptures occur in previously unscarred uterus?

A

60%

-GRand multip, ect… I think this was 5+ pregnancies?

194
Q

What are 2 complicating factors with uterine rupture?

A
  1. Maternal mortality 1%

2. Fetal mortality 32%

195
Q

What are 6 things used to diagnose uterine rupture?

A
  1. Must have high index of suspicion.
  2. Sudden onset of intense abdominal pain and vaginal bleeding
  3. Hyperventilation, agitation and tachycardia
  4. After rupture, momentary relief of pain but it returns.
  5. Fetal Distress
  6. Palpable fetal parts in abdomen.
196
Q

What is done for uterine rupture?

A
  1. Immediate laparotomy
  2. Usually a total abdominal hysterectomy is performed (TOC)
  3. Possibly a debridement of rupture site and primary closure if fertility is still desired by patient
197
Q

Where are the contractile fibers located in the uterus?

A

Upper 2/3

198
Q

What is removed in a TAH?

A

Uterus and cervix (subtotal leaves cervix and takes uterus)

199
Q

If you had a C-section and the cut up high, can you ever do a vag delivery?

A

Probs not… if you had a low transverse incision, possible (because of where contractile fibers are located

200
Q

Just gonna toss in some stats about vasa previa…

A
  1. Incidence - 1/5000.
  2. Rupture 0.1 to 0.8%.
  3. 50% fetal mortality.
  4. If membranes rupture, 75% mortality.
201
Q

What is the % indicence of postpartum hemorrhage?

A

4%

202
Q

What is the physiology of postpartum hemorrhage?

A

The uterus fails to contract around the myometrial spiral arterioles and decidual veins at the attachment site after placental separation

203
Q

What is the number 1 cause of postpartum hemorrage?

A

Uterine atony

204
Q

What is the number 2 cause of postpartum hemorrhage?

A

Genital tract trauma… laceration on vag wall, cervix, ect… this is a highly vascular area, especially when pregnant

205
Q

What are some other causes of postpartum hemorrhage?

A
  1. Retained placental fragments
  2. Uterine Inversion
  3. Low Placental Implantation
  4. Coagulation disorders: Abruption, retained dead fetus, inherited coagulopathy, amniotic fluid embolism
206
Q

What causes the majority of postpartum hemorrthage?

A

Uterine Atony (75-80%)

207
Q

What are predisposing factors to uterine atony?

A
  1. Overdistension of the uterus: Multiple gestation, polyhydramnios, fetal macrosomia
  2. Prolonged Labor
  3. Grand Multip (>5)
  4. Pitocin stimulation/ Magnesium Sulfate Tx.
  5. Chorioamnionitis
208
Q

What is a drug like oxytocin that induces contractions and can be used pre and post partum?

A

Pitocin

209
Q

Why is pitocin used postpartum?

A

Get the placenta out… AFTERBIRTH…MMMMMM

210
Q

Can oxytocin receptors become saturated?

A

YES

211
Q

What are 2 uses of magnesium sulfate?

A
  1. Gestational HTN: Prevents the conversion of pre-eclampsia to eclampsia
  2. Tocolytic: Relaxes the uterus and stops contractions
212
Q

What 3 things constitute pre-eclampsia?

A
  1. Proteinuria
  2. Edema
  3. HTN
213
Q

What constitutes plain old eclampsia?

A
  1. Proteinuria
  2. Edema
  3. HTN
  4. Seizures
214
Q

How do you diagnose postpartum hemorrhage?

A

Inspection/palpation

-This diagnoses all causes except coagulation

215
Q

What is the main strategy for management of uterine atony?

A

PITOCIN

216
Q

What are some other options to manage uterine atony?

A
  1. Massage
  2. Methergine (ergonovine maleate)- If not HTN
  3. Prostaglandin F2-Alpha
  4. Cytotec
  5. Embolization of Uterine Arteries- Need an IV radiologist to do this… not realistic
  6. Ligation of Uterine or Hypogastric arts.
  7. B-Lynch Stitch- Suture outside/around uterus to squeeze down onto it
  8. Supracervical hysterectomy- Remove the uterus
217
Q

What is the second most common cause of postpartum hemorrhage?

A

Genital tract trauma….lacerations of the vagina/cervix

-This is common following operative deliveries

218
Q

How do you diagnose genital tract trauma?

A

EXPLORE

219
Q

How do you manage genital tract trauma?

A
  1. Surgical repair
  2. Suture above apex
  3. Conservative management if possible
220
Q

What positions on the clock are the blood supply to the cervix that you need to watch out for if suturing?

A

3 and 9

221
Q

What is retained placenta?

A

Fragments pieces that didn’t come out

222
Q

3 kinds of retained placenta?

A

Accreta, increta, percretas

223
Q

How do you diagnose a retained placenta?

A

Exploration

224
Q

What is treatment for retained placenta?

A

Manual removal or a D&C

225
Q

If there is accreta with retained placenta, what might be requried?

A

Hysterectomy

226
Q

What is a uterine inversion?

A

Turning inside out of uterus

-Happens in 1/20,000 pregnancies

227
Q

What normally causes a uterine inversion?

A

Iatrogenic- Pull to hard on the cord

228
Q

What can happen with uterine inversion?

A

Patient can go into profound vasovagal shock

229
Q

How do you diagnose a uterine inversion?

A

It is in yo face

230
Q

What do you do to fix a uterine inversion?

A
  1. IV volume expansion
  2. Halothane anesthesia or terbutaline to relac uterus
  3. Replace with fist, give pitocin
  4. Possible surgical suspension
231
Q

Are coagulation disorders common?

A

NO

232
Q

What are 4 mentioned coagulation disorders?

A
  1. Von Willebrand’s disease (Factor 8)
  2. Amniotic Fluid Embolism 80% mortality DIC
  3. Placenta Abruption- DIC
  4. Thrombotic thrombocytopenia
233
Q

How do you diagnose a coagulation disorder?

A

It’s one of exclusion

234
Q

How do you manage coagulation disorders?

A
  1. Support respiratory, cardio, ect.

2. Reverse coagulopathy with blood products, cyroprecipitate, FFP, ect.

235
Q

Can you give whole blood/platelets to someone with DIC?

A

NO…. it will just be chewed up… give FFP yo

Reproductive Exam 1 (9 decks)

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