Obstetric Hemorrhage, Sepsis - Moulton

Question 1

How much blood (PRBCs) must I give to raise the Hgb by 1 and the Hct by 3?

Answer 1

1 unit (250-300 cc)

Question 2

A pregnant patient is bleeding BEFORE birth. What must first be determined BEFORE using your fingers to examine?

Answer 2

Placenta previa (could rupture membranes with fingers)

Question 3

Placental abruption, previa, uterine rupture – bleed when?

Answer 3

AFTER 20 weeks

Question 4

Pain or no?
- Previa vs. Abruption
More common?
- Previa vs. Abruption

Answer 4

Previa - no
Abruption - yes

Abruption

Question 5

Risk factors for placenta previa

Answer 5

• Over 35 years
• Multiparity
• Multiple gestations
• Prior previa
• Previous C-section

Question 6

3 kinds of placenta previa

Answer 6

• Marginal (does NOT cover Os)
• Partial
• Complete

Question 7

Most placenta previa’s diagnosed at 30 weeks will do what?

Answer 7

“Migrate” by 32-35 weeks

Question 8

When/how are unresolved placenta previa’s delivered?

Answer 8

C-section – 36-37 weeks (BEFORE LABOR) WHEN fetal lungs are mature

Question 9

Placenta percreta (through myometrium) – manage how?

Answer 9

C-section hysterectomy

Question 10

Most common risk factor for placenta abruption

Answer 10

Maternal HTN

Question 11

If external trauma to the pregnant abdomen occurs, when will abruption most likely occur?

Answer 11

Within 6 hours

Question 12

***Sudden intense, painful bleeding after 20 weeks - most likely?

Will often see what on baby exam? Cervical exam if during labor?

Answer 12

Placenta abruption

Abnormal FHR

Regression of “station”

Question 13

Abruption is the most common cause of ____ in pregnancy

Answer 13

DIC

Question 14

• ***Chance of uterine rupture after…
  
  • Low transverse uterine incision
  • Classical/vertical incision (C-section, myomectomy)

Answer 14

1%

4-7%

Question 15

Vasa previa

How to diagnose?

Answer 15

Unprotected fetal vessel passing over the cervical os

Acute vaginal bleeding, tachycardia followed by bradycardia

Question 16

Postpartum hemorrhage/bleeding w/in first 24 hours…? (1)

24 hours to 12 weeks? (3)

Answer 16

Uterine atony (80%)

Sloughing of eschar, retained products, subinvolution of uterus

Question 17

***Postpartum palpation reveals a “boggy uterus”, bleeding from vagina

Risk factors?

Answer 17

Uterine atony

• Overly large uterus (multiples, polyhydramnios)
• Abnormal labor
• Leiomyoma
• Mag. sulfate

Question 18

***A patient has a complicated labor and is on oxytocin for a prolonged period of time. Risk? Why?

Answer 18

Postpartum uterine atony

Oversaturated receptors –> weak contraction later

Question 19

Non-pharm management of uterine atony

Answer 19

Bimanual massage of uterus

Question 20

2 drugs for uterine atony w/ contraindications

Other drugs?

Answer 20

Methylergonovine (Methergine) – HTN

15-methyl-PGF2a (Hemabate) – ASTHMA

Oxytocin, Dinoprostone, Misoprostol

Question 21

Postpartum, develops respiratory distress, cyanosis, CV collapse, hemorrhage, coma

Treatment?

Prognosis?

Answer 21

Amniotic fluid embolism

Respiratory support, correct shock, replace clotting factors

BAD (80% death)

Question 22

Puerperal sepsis - defined as what?

This is generally called what?

Answer 22

Fever over 100.4 AFTER the first 24 hours for 2+ days within the first 10 days

Endometritis

Question 23

Puerperal sepsis - most common organisms

If aerobic?

Answer 23

Anaerobic cocci (Peptostrepto, Pepto, Strepto)

E. coli, Enterococci

Question 24

Postpartum - fever, uterine tenderness on days 2-3 (+ chills, malaise, anorexia)…

Most likely Dx?

Treatment? Most common regimen?

If resistant to the above regimen, most likely bug? Treatment?

Answer 24

Puerperal sepsis (endometritis)

Antibiotics - Ampicillin + Gentamicin

B. fragilis – Clindamycin

Question 25

***Postpartum - consistent fever that does not respond to antibiotics, patient does not feel super ill, no evidence of thrombosis anywhere…

Dx?

Treatment?

Answer 25

Deep septic pelvic vein thrombophlebitis

Heparin until fever is gone for 2 days

Question 26

Postpartum - fever and abdominal pain within 1 week of delivery, pain localized to one side…

Dx?

Treatment?

Answer 26

Ovarian vein thrombophlebitis

Anti-coagulate for 6 weeks, repeat imaging