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Principles II, Exam 1 > Hemorrhage > Flashcards

Hemorrhage Flashcards

1
Q

Which breech position is most common

A

Frank breech 50-70% most common

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2
Q

Increased perinatal mortality due to

A

Cord compression
Intracranial bleed
Asphyxia

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3
Q

What is induction of labor associate with

A

Higher risk of post partum hemorrhage

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4
Q

Frequently underestimated failure to

A

Failure to:
Initiate treatment quickly
Recognize risk factors
Estimate extent of blood loss

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5
Q

What are the goals

A 
Maternal resuscitation 
Fetal delivery
Removal of placenta
Contraction of uterus
Adequate UO 
30% loss of volume b4 dec in BP
Assess capillary refil along UO
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6
Q

What med is used to relax uterus

A

NTG 400-800 mcq SL or

50-125 mcq IV for internal podalic version

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7
Q 
Sponges and blood 18in x 18in standard lap sponge
50%
75%
100% no dripping
100% dripping
A

50% = 25 ml
75% = 50 ml
100% = 75 no blood dripping
100 ml with blood dripping

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8
Q 
Factor VII (rFVIIa) 
When to use it
What's the dose
A 
Use in hemophilia 
Off label use for OB bleed
Major bleed source identified/controlled
Given after 10-12 uPRBC, 6-10 uFFP
Platelets >50,000; fibrinogen >50; temp >32; pH>7.2
Dose: 90 mcq/kg q3 hrs, max of 9 doses
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9
Q

Tranexamic acid

A

Decreased blood flow
Decreased bleeding duration
Decreased need for excessive Pitocin during c/s

Given slow IV

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10
Q

Placental implamantation in lower uterine segment b4 fetal presentation

A

Placenta previa = c/s
Complete 40%
Partial 30% or low lying
Marginal 30%

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11
Q

Placenta previa s/s

A
  • Painless vaginal bleeding
  • Bleeding augmented: unable to constrict and contract vessels
  • Potentially emergent c/s
  • Lg bore IVs
  • T/S, T/C if actively bleeding
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12
Q

Anesthesia plan for placenta previa

Hemodynamically unstable

A

Copious blood loss—SHOCK
C/S - GA w/OET, 100% O2
Etomidate .2-.3 mg/kg or Ketamine .5-1mg/kg
RSI, lg IV, CVP, Foley
Replace blood w/blood and crystalloids
Warmer
Neonate may be asphyxiated, acidotic, hypovolemic

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13
Q

Anesthesia for stable placenta previa

A

SAB or epidural

Mag sulfate infusion can worsen hypotension ask if ok to turn off

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14
Q

What is placenta accreta

A

Placenta fails to separate from uterine wall

Invasive implamantation into uterine wall, bladder, bowel, etc

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15
Q

Chorionic villi attach to the myometrium without normal intervening decidua basalis

A

Placenta accreta

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16
Q

Treatment for placenta accreta

A
  • C/S b4 35 weeks to decrease hemorrhage
  • Balloon occlusion catheters placed in anterior division of internal iliac arteries (contraleteral). Inflated after umbilical cord is cut or occluded w/gelfoam
  • c/s performed under epidural anesthesia or GA
  • hysterectomy increta 3.6 L blood loss and 12L for percreta
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17
Q

Which placenta is more common to happen after previous c/s and previa

A

Placenta Accreta

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18
Q

What does conservative treatment leaving it in, for accreta puts pt at risk for

A

Infection
Bleeding
Fistula formation
Failure of placental absorption

19
Q

Placenta abruption
When
Associated with

A

-Separation of normally implanted placenta after 20 weeks and b4 birth
-ass w: HTN, increased parity, uterine abnormalities, previous abruption , maternal cocaine use, trauma
1% of pregnancies

20
Q

High risk with placenta abruption

A

IUGR, decidual necrosis, placental infarcts

12% perinatal mortality

21
Q

What arteries are ruptured in placenta abruption

A

Spiral artery- hemorrhage and retro placental clot formation- extends- involves more vessels- presses on uterus- pushes amniotic fluid to maternal circulation

22
Q

Which placenta
Painful bleeding and increased uterine activity

Painless bleeding; may be profuse

A

Placenta abruption: painful

Placenta previa: painless

23
Q

What this the definite treatment of placenta abruptio

A

To empty the uterus; vaginal delivery is preferred if there is fetal demise

50% prenatal mortality
4L of blood can be concealed in the uterus

24
Q

Abruptio placenta mild to mod

A

90%, diagnose by excluding placenta previa
Usually no hypotension, coagulopathy, fetal distress
Epidural or SAB OK
Vag, not common

25
Q

Abruptio placenta severe

A

NO REGIONAL - 50% clotting issues DIC, platelets factor 5, 8, FSPs
Thromboplastin released from placenta - activates extrinsic clotting pathway
Activation of circulating plasminogen- destroys fibrinogen which causes fibrinolytic and DIC
Rx: FFP, platelets, cryoprecipitate

26
Q

Anesthetic management for abruptio placenta

A
  • C/S life saving for fetus and mother
  • blood 6:4:1 PRBC:FFP:platelets
  • avoid excessive crystalloids
  • infant extensive resuscitation
  • uterotonics drugs
27
Q

What causes uterine rupture

A

Separation of uterine scar: myomectomy, prev c/s, rapid labor, weak/stretched uterine muscles, iatrogenic

28
Q

When can VBAC be attempted
Signs of rupture
Rx

A

Only if scar is low and transverse
Signs of rupture: bleeding, pain not always, absence of FHT, hypotension and shock

Tx same as for hypovolemic abruption, laparotomy

29
Q

Uterine inversion Rx

A

Relax the uterus GA, NTG

30
Q

Post partum hemorrhage: retained placenta

Rx

A

Manual exploration of the uterus need anesthesia
Epidural top off
Oxygen, ketamine, versed- MUST HAVE SPONT RESPIRATION
Pitocin, Methergine per doc

31
Q

Which post partum hemorrhage can happen immediately or several hours after delivery

A

Uterine atony

32
Q

Leading cause of maternal death

A

Uterine atony

Can loose 2 L in

33
Q

Management of uterine atony non surgical

A

Bifundal massage
Pitocin, Methergine, F2a prostaglandin
Oxygen
Resuscitate with blood products and crystalloids
May need advance lines art line or central line

34
Q

Surgical Management of post partum hemorrhage

A
  • B/L surgical ligation of arteries - 85% effective
  • Intrauterine balloon tamponade - 80% effective
  • Lynch procedure: suture technique to control bleeding
  • postpartum hysterectomy: definitive Rx is for uterine atony, PAcreta
  • angiographic arterial embolization: done preop for acreta
35
Q

Anesthetic management for postpartum hemorrhage

A

GA even if epidural working, high risk of coagulopathy
Multiple blood products
Secure airway
Be aggressive
Death: delay in surg, inadequate blood replacement and loss

36
Q

What is another name for amniotic fluid embolism

A

Anaphylactoid syndrome of pregnancy

37
Q

Amniotic fluid embolism

Phase 1

A

Early phase:
Transient, intense pulmonary vasospasm, R heart dysfunction
Low CO, hypoxemia, hypotension
50% die
CO2 level goes down, not ETT displacement, AFE - stuff gets in lungs

38
Q

Amniotic fluid embolism

Phase 2

A

LV failure
Pul edema
DIC

39
Q

Treatment for AFE

A

O2
Maintenance of Cardiac function, volume replacement, inotropes
Control of hemorrhage: PRBC, FFP, and treatment for, cryo

40
Q

Who is at highest risk for amniotic fluid embolism

A

Multiples, placenta abruption, eclampsia, uterine rupture, inductions

40
Q

S/s do amniotic fluid embolism

A

Dyspnea, cyanosis, CV collapse, coma coagulation disorders

41
Q

What is the most dangerous and untreatable condition in obstetrics

A

Amniotic fluid embolism
15% of survivors are neurologically intact
40% of neonates

42
Q

How does AFE happens

A

Presence of abnormal, open sinusoids at the uterotonics placental side
Or
Lacerations of endocervical veins - most common
Contraction forces amniotic fluid into these sites

Principles II, Exam 1 (8 decks)

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