APH, PPH and Maternal Collapse Flashcards
(101 cards)
1
Q
The percentage of Consumptive coagulopathy in abruptio placenta ?
A
occurs in 1/3
2
Q
is life threatening condition in abruptio placenta when blood invades myometrium all the way towards the peritoneal cavity.
A
- Couvelaire uterus (AKA: uteroplacental apoplexy)
3
Q
Incidence of AP
A
1:200
(0-5-1 %)
4
Q
Incidence of fetal death in AP:
A
1:1500
5
Q
The least ethnic group to develop AP
A
Latin American
6
Q
DDX of AP:
A
- PP
-Vasa previa –painless vaginal bleeding with rapid fetal compromise and in utero demise.
-Cervical laceration – More likely in the setting of preterm labor with a cerclage in place.
-Preterm labor – Will have cervical dilation present.
-PPROM – Will have positive pooling of amniotic (bloody or nonbloody) fluid in the vagina on speculum exam, positive ferning test, and decreased amniotic fluid levels on ultrasound.
7
Q
Specific blood test in AP:
A
1) endothelial cell marker “Thrombomodullin”
2) high alfa feto-protein (risk of AP with high a-FP is 10x) < also associated with risk of acreta
3) high Beta-hcg
8
Q
Placenta accreta adherent firmly to the uterine wall due to the absence of…. and ——— layer
A
Decidua basalis & fibrinoid layer i.e. Nitabuch layer (layer of fibrin between the boundary zone of compact endometrium and the cytotrophoblastic shell in the placenta)
9
Q
Features suggestive of placenta Accreta are:
A
- visualisation of irregular vascular sinuses with turbulent flow I.e. large placental lakes
- myometrial thickness less than 1 mm
- absence of subplacental sonolucent zone (which represents the normal decidua basalis)
10
Q
Surgical sutures done in case of PPH:
A
- B lynch suture
- block suture (multiple square)
- hayman suture
- cho square
- Gunshella suture
11
Q
Fluid resuscitation after PPH:
A
- Colloids and crystalloids
- blood
- FFP > to correct clotting factor deficiency, or if 4U of blood given, or if PT> 1.5
- cryoprecipitate
- platelets (if PLT< 50,000 or if 4 U of blood transfused)
12
Q
Uterine inversion management:
Manual removal by …..
A
- Johnsons maneuver
- hydrostatic O Sullivan method
13
Q
What is the Triple P procedure for placenta percreta ?
A
Developed as a conservative instead of peripartum hysterectomy composed of:
1. Perioperative placental localisation & delivery of fetus by Transverse uterine incision above the upper border of placenta
2. Pelvic devascularization
3. Placental non-separation is dealt with myometrial excision and reconstruction of uterine wall.
14
Q
AP increased in severe preeclampsia up to …. folds
A
Three
15
Q
Risk factors of PP
A
1) maternal age >35
2) multifetal pregnancy or multipara
3) smoking
4) male fetus
5) prev PP hx
6) prev uterine surgery
7) IVF pregnancy
8) black race
9) relation with congenital anomaly ? 2x increased
16
Q
Double set procedure:
A
Done when unsure of low lying placenta /placenta previa no clear cut < or = 2cm
17
Q
Abnormal placental implantation:
A
1) accreta (attach)
2) increta (invades)
3) percreta (penetrate)
18
Q
When the tocolytic given in PP:
A
Only if bleeding subsided and you want an interval of time to give dexa in prematurity
19
Q
Maternal complication of APH
A
- bleeding and DIC
- Sheehan syndrome
- AkI > ATN > ACN
- sepsis and anemia
20
Q
Paravaginal haematomas typically present with
A
rectal pain, lower abdominal pain (which is often vague) and symptoms of hypovolaemia.
21
Q
The typical symptoms of vulval and vulvovaginal haematomas are
A
pain and swelling in the perineum. These are usually easy to diagnose if the woman is examined but can be confused with abscesses. Failure to carry out an examination can lead to pain being incorrectly attributed to the expected pain of an episiotomy, a tear or haemorrhoids.
22
Q
supravaginal haematoma can present with
A
abdominal pain but often first presents with signs of hypovolaemia, including cardiovascular collapse. On abdominal examination the uterus is deviated upward and laterally, to the opposite side from the broad ligament haematoma
23
Q
1st sign of uterine rupture is:
A
Fetal bradycardia (variable decelerations)
24
Q
Signs of impending scar rupture:
A
• Fetal tachycardia
• scar tenderness
25
incidence of Placenta Previa following CS:
1 CS > (1.3%) 2%
2 CS > 4%
3 CS > 6%
4 CS > 8%
6CS or more > (3.4%)
*Ahmed Ghazi
والنسب بين القوسين من:
(MFMU study)
26
Risk of placenta accreta spectrum in:
Placenta previa only > %
PP + 1 CS > %
PP + 2 CS > %
PP + 3 CS > %
PP + 4 CS > %
Placenta previa only > 5% (other source: 3%)
PP + 1 CS > 25% (other source: 11%)
PP + 2 CS > 35 % ( other source: 40%)
PP + 3 CS > 45 % ( other source: 61%)
PP + 4 CS > 55% ( other source: 67%)
PP + 5 CS > ( 67%)
Other source is ACOG
First one ? Dr. Ghazi
27
Percentage of Abnormal placenta implantation:
Acreta 80%
Increta 15 %
Percreta 5%
28
Vasa previa happen in which type of umbilical cord insertion
Velamentous cord insertion
29
Percentage of placenta accrete in:
Following:
1 CS 0.3%
2 CS 0.6 %
Previous 3 CS 0.9 %
30
The most common sign of uterine rupture is a
non reassuring CTG with variable deceleration evolving into late decelerations, bradycardia and undetectable fetal heart rate pattern.
31
Factors associated with placenta praevia in the primigravidas
history of assisted conception
history of endometriosis
A vast majority of the primigravidas had either posterior type II or type III placenta praevia.
32
MROP antimicrobial prophylaxis:
Ampicillin or Cefazolin
33
surgical Interventions for uterine inversion:
*Huntington procedure a combined effort is made to reposition the uterus by simultaneously pushing upward from below and pulling upward from above. Application of atraumatic clamps to each round ligament and upward traction may be helpful or placing a deep traction suture in the inverted fundus or grasping it with tissue forceps may be of aid.
* Haultain incision: If a constriction ring still prohibits repositioning, a sagittal surgical cut is made
posteriorly through the muscular ring to release it.
34
is the most common cause of
transfusion-related mortality
Transfusion-related acute lung injury (TRALI) The syndrome is characterized by severe dyspnea,
hypoxia, and noncardiogenic pulmonary edema that develop within 6 hours of
transfusion
35
Complications of embolization:
relatively uncommon but can be severe: iatrogenic iliac artery rupture, uterine ischemic necrosis,
and uterine infection.
36
Retained Placenta- risk factors? (4)
prior Cesarean delivery,
uterine leiomyomas
prior uterine curettage
succenturiate lobe of placenta
37
Grey Turner sign indicate
Discoloration of the flank may indicate retroperitoneal or intraperitoneal hge
38
Recommended Anti-microbial Prophylaxis after manual Removal of Placenta
Ampicillin or cefazolin
39
Risk factors of uterine inversion
1- FundaI implantation of Placenta.
2-Uterine atony
3-Cord traction applied beforePlacental Separation
4- abnormally adherent Placenta
40
incidence of uterine inversion
1 in 2000 to 1 in 20000 vaginal Deliveries
41
Colporrehexis
entire or Partial Avulsion of cervix from vaginal wall or defined as rupture of vaginal vault or upper one third of vaginal wall
42
severe Abruption Considered When one or more of the following:
1- Maternal sequelae that includes: DIC,shock, Transfusion, hysterectomy,Renal failure, Death.
2- Fetal Complications like Non-reasesuring Fetal status, FGR, Death.
3-Neonatal outcome that include: Preterm Delivery, Growth restriction, Death.
43
in some chronic Placental Abruption Subsequent oligohydramnious happen Which called
Chronic Abruption oligohydramnious Sequence(CAOS )
44
Risk factors of Abruptio placenta:
For each relative risk and xgreater
- prior Abruption (RR: 10-188)
- preeclampsia 2.1- 4
- increased age and parity 1.3-2.3
- HTN (RR:1.8-3.0) 3x higher
- hydramnious (RR:2-8) 8thx
- PPROM 5% in PPROM and 17% with previable rupture (RR: 2.4-4.9)
- cigarettes smoking (RR: 1.4-1.9) 2x
- congenitally malformed uterus 8%
- choriomanionitis 3
- multi-fetal gestation 2-8
- low birthweight 14
- single umbilical artery 3.4
- subchorionic hematoma 5.7
- uterine leiomyoma 2.6
45
Women with previous two severe Abruption had a risk for a third Abruption around
50 fold
46
For mother with Previous term placental Abruption what is the timing plan of delivery at next pregnancy ?
Induction of labor at 37 wks (Ruiter and coworkers)
At 38 wks (Parkland hospital)
47
incidence of Placenta Previa
0.3% or 1Case Per 300-400
48
Ratio of accreta: increte : Percrete
80:15:5
49
incidence of Placenta accreta
1 in 700
50
Timing of Elective Placenta Previa Who are not Bleeding at
(Timing that Balance the fetal immaturity risks against maternal APH )
and Timing if suspected Adherent Placenta
36-37 wks (NIH Workshop)
34-37 wks (SMFM)
38 Wks (Parkland)
if suspected Adherent Placenta:
34-35 wks (NIH workshop)
36 wks ( Parkland)
51
US reevaluation of Placenta Previa at which weeks
At Parkland, women with a placenta previa identified at 18 to 22 weeks' gestation with a prior cesarean delivery are evaluated again at 28 weeks and those without at 32 weeks. Restriction of activity is not necessary unless a previa persists beyond 28 weeks or if clinical findings such as bleeding or contractions develop before this time. At 32 weeks' gestation, if the placental edge is still <2 cm from the os, then transvaginal sonography is repeated at 36 weeks.
52
Risk of recurrence In subsequent pregnancies following placenta accreta in Woman whom hysterectomy is avoided ? What the other risks that she prone to in next pregnancy ?
have an estimated 20-percent incidence of recurrence (Cunningham, 2016; Roeca, 2017). In addition, some evidence shows that these women have greater risks for previa, uterine rupture, and hysterectomy (Eshkoli, 2013).
53
in placenta accreta syndrome. What is the Pre-operative Prophylactic catheterization that you may Consider ?
1. Ureteral Catheterization
2. Baloon tipped Intraarterial Catheterization
54
incidence of DIC in Pregnancy
ranges btw 0.03 to 0.35
55
Triad of Amniotic fluid embolization ;
Hemodynamic & Respiratory compromise along with DIC
56
Shock due to aspiration of GI contents during GA esp in CS
Mandelson syndrome is chemical pneumonitis or aspiration pneumonitis
57
Predisposing risk factors of Amniotic fluid Embolism
- Preceiptated Labor
- meconium Stained fluid
- tears into uterine & other large Pelvic veins
- old Maternal age
- Postterm pregnancy
- Labor induction and augmentation
- Eclampsia
- Cesarean, forceps/vaccum delivery
- Placental Abruption& Previa
- hydramnious
58
Purpura Fulminans
This severe—often lethal—form of consumptive coagulopathy is caused by microthrombi in small blood vessels leading to skin necrosis and sometimes vasculitis. Debridement of large areas of skin over the extremities and buttocks frequently requires treatment in a burn unit. Purpura fulminans usually complicates sepsis in women with heterozygous protein C deficiencies and low protein C serum levels (Levi, 2010b). Note that homozygous protein C or S deficiency results in fatal neonatal purpura fulminans.
59
Amniotic fluid embolism management
CPR, If resuscitation is successful, hemodynamic instability is common in survivors. Both fever and hyperoxia will worsen ischemia—reperfusion injury to the brain, and thus both are avoided. A suitable goal for temperature is 36°C and for mean arterial pressure is 65 mm Hg (Society for Maternal-Fetal Medicine, 2016). Additional supportive care measures such as intubation are usually necessary. During the phase of right ventricular failure, inotropic agents such as dobutamine may improve right heart output, and later systemic hypotension should be treated with vasopressors such as norepinephrine. Excess fluid administration is discouraged due to risks of worsening dilation of an already engorged right ventricle, which may cause right-sided myocardial infarction and displacement of the interventricular septum. Beginning either immediately after cardiopulmonary collapse or during the ensuing phases of injury, a coagulopathy develops in most cases from activation of factor VII and X. This may be exacerbated by ongoing hemorrhage. A common source of obstetrical bleeding is uterine atony. Therefore, immediate evaluation of coagulation parameters is prudent with concurrent clinical management of bleeding.
60
abruptio placentae recurrence risk
In 1 previous pregnancy:
In 2 consecutive pregnancies:
the risk of a recurrent abruption and fetal demise:
In 1 previous pregnqncy 4-12%.
If the patient has abruptio placentae in 2 consecutive pregnancies, the risk of recurrence rises to 25%.
If the abruption is severe and results in the death of the fetus, the risk of a recurrent abruption and fetal demise is 7%.
61
The recurrence risk of placental attachment disorder following uterine conservation treatments is
20%.
62
Maternal death is defined by the WHO as
the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes
63
invasive placental implantation caused by a defect in which decidua?
It is caused by a defect in decidua basalis resulting in an abnormally invasive placental implantation
64
sometimes it was difficult to distinguish between placental tissue and blood clots in US what is the best way to differentiate ?
ultrasonography combined gray scale-color Doppler and sonohysterography is the best predictor in women with a suspicion of RPOC.
65
Vulvar hematomas may be located in one of two anatomic areas
anterior triangle: When the hematoma occurs anterior to the superficial transverse perineal muscles, the perineal membrane (previously called the urogenital diaphragm) and Colles’ fascia prevent the extension of bleeding.
- posterior triangle: When posterior to the superficial transverse perineal muscles, it is the anal fascia that prevents extension.
66
Smokers have — fold to have abruptio while every pack smoked per day increase the risk —%.
Smokers have 2.5 fold to have abruptio while every pack smoked per day increase the risk 40%.
67
Disadvantages of UAE include risks for
risks for subsequent pregnancy complications, collateral ovarian infarction, and formation of uterine synechiae.
68
In myomectomy The choice of Pfannenstiel incision is typically appropriate for uteri --- weeks' size or smaller. Larger uteri usually require a midline vertical abdominal incision.
In myomectomy The choice of Pfannenstiel incision is typically appropriate for uteri 14 weeks' size or smaller. Larger uteri usually require a midline vertical abdominal incision.
69
Vasopressin. 8-Arginine vasopressin (Pitressin) dose used for myomectomy
Each vial of Pitressin is standardized to contain 20 pressor unit/mL, and dose used for myomectomy are 20 U diluted in 30 to 100 mL of saline (Frishman. 2009). Vasopressin is typically injected along the planned serosal incision(s). The plasma half life of this agent is 10 to 20 minutes. For this reason. injeclion of vasopressin is ideally discontinued 20 minutes prior to uterine repair to allow evaluation of bleeding from myometrial incisions (Hutchins, 1996).
70
In the woman with obstetrical hemorrhage, the platelet count should be maintained >---/µL by the infusion of platelet concentrates. A fibrinogen level <-- mg/dL or a sufficiently prolonged ----- in a woman with surgical bleeding is an indication for replacement.
In the woman with obstetrical hemorrhage, the platelet count should be maintained >50,000/µL by the infusion of platelet concentrates. A fibrinogen level <150 mg/dL or a sufficiently prolonged PT or PTT in a woman with surgical bleeding is an indication for replacement.
71
------ is the most frequent coagulation defect found with blood loss and multiple transfusions.
Thrombocytopenia is the most frequent coagulation defect found with blood loss and multiple transfusions.
72
Platelet transfusions are considered with ongoing obstetrical hemorrhage if the platelet count falls below ----/µL (Kenny, 2015).
Platelet transfusions are considered with ongoing obstetrical hemorrhage if the platelet count falls below 50,000/µL (Kenny, 2015).
73
six-unit bag raises the platelet count by approximately ----/µL.
six-unit bag raises the platelet count by approximately 20,000/µL.
74
rFVIIa will not be effective if the plasma fibrinogen level is <-- mg/dL or the platelet count is <30,000/µL.
rFVIIa will not be effective if the plasma fibrinogen level is <50 mg/dL or the platelet count is <----/µL.
75
tranexamic acid (TXA) mechanism of action
tranexamic acid (TXA) reversibly binds to plasminogen, and thereby blocks plasmin binding to fibrin. Fibrin strands are not broken, and a clot persists to slow down bleeding.
76
gravidas with hemorrhage following vaginal birth or during cesarean delivery, mortality rates from obstetrical hemorrhage were --- percent in those given a 1-g intravenous TXA dose plus traditional care for bleeding. This rate was statistically lower than the ----percent death rate in women given traditional care alone (WOMAN Trial, 2017)
gravidas with hemorrhage following vaginal birth or during cesarean delivery, mortality rates from obstetrical hemorrhage were 1.2 percent in those given a 1-g intravenous TXA dose plus traditional care for bleeding. This rate was statistically lower than the 1.7-percent death rate in women given traditional care alone (WOMAN Trial, 2017)
77
Most investigators define ARDS as
radiographically documented pulmonary infiltrates, a ratio of arterial oxygen tension to the fraction of inspired oxygen (PaO2:FiO2) <200, and no evidence of heart failure (Baron, 2018).
78
Three stages describe ARDS development
First, the exudative phase follows widespread injury to the alveolar epithelium and to the microvascular endothelium, including the pulmonary vasculature. This endotheliopathy results in increased pulmonary capillary permeability, surfactant loss or inactivation, diminished lung volume, and vascular shunting that creates arterial hypoxemia. Next, the proliferative phase usually begins approximately 7 days later and lasts up to 21 days. Most patients recover during this phase. Last, the fibrotic phase results from healing. Despite these insults, the long-term prognosis for pulmonary function is surprisingly good
79
newborns delivered within 5 minutes of arrest, -- percent are neurologically intact; within 6 to 15 minutes, -- percent are intact; within 16 to 25 minutes, -- percent are intact; and within 26 to 35 minutes, only -- percent are intact
newborns delivered within 5 minutes of arrest, 98 percent are neurologically intact; within 6 to 15 minutes, 83 percent are intact; within 16 to 25 minutes, 33 percent are intact; and within 26 to 35 minutes, only 25 percent are intact
80
If the abruption is severe and results in the death of the fetus, the risk of a recurrent abruption and fetal demise is
7%
81
The risk of recurrence of abruptio placentae is reportedly
4-12%.
82
If the patient has abruptio placentae in 2 consecutive pregnancies, the risk of recurrence rises to
25%.
83
IV fluid resuscitation in shock calculation
Crystalloids 30 ml /kg within the first 3 hrs
84
For women with placenta previa, the risk of placenta accreta is with
1xCS
2xCS
3xCS
4XCS
5xCS
3%, 11%, 40%, 61%, and 67%, for the first, second, third, fourth, and fifth or more cesarean, respectively. (ACOG)
85
The risk of placenta previa was —-% with an unscarred uterus
The risk of placenta previa was 0.26% with an unscarred uterus
86
Uterine rupture rate with oxytocin was —- % (4/376) after one previous caesarean section and —- % (1/54) after more than one previous caesarean; with misoprostol it was — % (1/123) and — % (1/19) respectively.
Uterine rupture rate with oxytocin was 1.1 % (4/376) after one previous caesarean section and 1.9 % (1/54) after more than one previous caesarean; with misoprostol it was 0.8 % (1/123) and 5.3 % (1/19) respectively.
87
systematic review by Guise and coworkers (2010) concludes that the uterine rupture risk was significantly elevated in women undergoing TOLAC—absolute risk of — percent and relative risk of -—compared with women choosing ERCD.
systematic review by Guise and coworkers (2010) concludes that the uterine rupture risk was significantly elevated in women undergoing TOLAC—absolute risk of 0.47 percent and relative risk of 20.7—compared with women choosing ERCD.
88
systematic review by Guise and coworkers (2010) concludes that the uterine rupture risk was significantly elevated in women undergoing TOLAC—absolute risk of — percent and relative risk of -—compared with women choosing ERCD.
systematic review by Guise and coworkers (2010) concludes that the uterine rupture risk was significantly elevated in women undergoing TOLAC—absolute risk of 0.47 percent and relative risk of 20.7—compared with women choosing ERCD.
89
those with a prior lower-segment rupture have up to a --percent recurrence risk, whereas prior upper-segment rupture confers a -- to --percent risk
those with a prior lower-segment rupture have up to a 6-percent recurrence risk, whereas prior upper-segment rupture confers a 9- to 32-percent risk
90
In prior uterine rupture delivery recommended at
36-37 was (ACOG)
91
Several advanced bipolar devices also offer improved vessel sealing. With various instruments, vessels measuring up to 5 mm (—-, —— —) and up ro 7 mm (—) can be coagulated with minimal thermal spread
Several advanced bipolar devices also offer improved vessel sealing. With various instruments, vessels measuring up to 5 mm (LigaSure, Gyrus Plasma Kinetic) and up ro 7 mm (ENSEAL) can be coagulated with minimal thermal spread
92
expectant management of preeclampsia in significantly preterm pregnancies was complicated by placental abruption in — percent
expectant management of preeclampsia in significantly preterm pregnancies was complicated by placental abruption in 4 percent
93
expectant management of preeclampsia in significantly preterm pregnancies was complicated by placental abruption in — percent
expectant management of preeclampsia in significantly preterm pregnancies was complicated by placental abruption in 4 percent
94
Women with abruption and fetal death have a recurrence rate of — percent, and half of these abruptions caused another fetal death
Women with abruption and fetal death have a recurrence rate of 12 percent, and half of these abruptions caused another fetal death
95
The American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine (2021) recommend delivery for otherwise
uncomplicated placenta previa between — 0/7 and — 6/7 weeks.
The American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine (2021) recommend delivery for otherwise
uncomplicated placenta previa between 36 0/7 and 37 6/7 weeks.
96
The American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine (2021) recommend delivery for otherwise
uncomplicated placenta previa between — 0/7 and — 6/7 weeks.
The American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine (2021) recommend delivery for otherwise
uncomplicated placenta previa between 36 0/7 and 37 6/7 weeks.
97
Five characteristic sonographic findings suggest PAS:
(1) placental lacunae; (2) thinning of the retroplacental myometrium; (3) disruption of the bladder-uterine serosal interface; (4) bridging vessels from the placenta to the bladder-serosal interface; and (5) placental bulge that pushes outward and distorts the contour of the uterus
98
Delivery Timing
The American College of Obstetricians and Gynecologists (2018; 2021) recommends
individualization and suggests delivery between 340/7 and 356/7 weeks’ gestation. They cite a decision-analysis study that justifies elective delivery without fetal lung maturity testing after 34 completed weeks (Robinson, 2010). The Society for Maternal–Fetal Medicine (2018) recommends delivery between 34 and 37 weeks. Two earlier surveys found that most practitioners do not deliver these women until 36 weeks or later
99
How to determined blood loss if inaccurately estimated?
After pregnancy hypervolemia is lost at delivery, blood loss can be estimated by calculating 500 mL loss for each 3 volume percent drop in hematocrit. Its nadir depends on the speed of resuscitation with intravenous crystalloids and blood products. With ongoing blood loss, the real-time hematocrit is at its maximum whenever measured in the delivery, operating, or recovery room
100
Cervical Laceration’s when to repair
Superficial lacerations of the cervix can be seen on close inspection in more than half of all vaginal deliveries. Most of these measure <0.5 cm and seldom require repair.
101
If “low placenta” was diagnosed at 20 week ultrasound. How often is this found and what is the likelihood of persistent placenta previa at term? How can one predict the likelihood of previa at term?
Less than 20% (12%) are left overlapping the cervix at term
Placental migration occurs as the lower uterine segment develops
Unlikely to persist if not overlapping or less than 10mm covering the os
More likely to persist if the placenta is covering 15-25mm or more
Overlap of 20mm or more at any time in T3 is predictive of need for C-section
