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Obstetrics and Gynecology > Hemorrhage > Flashcards

Hemorrhage Flashcards

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1
Q

Postpartum hemorrhage is defined as loss of blood of

A

> 500 ml after third stage of labor

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2
Q

Class 1 Blood loss

A

1000 ml
15%
Dizziness, palpitations

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3
Q

Class 2 blood loss

A 
1500 
20-25%
Tachycardia
Tachypnea
Sweating, weakness and narrowed pulse pressure
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4
Q

Class 3 blood loss

A 
2000 ml
30-35% 
Significant tachycardia and tachypnea
Restlessness
Pallor
Cool extremities
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5
Q

Class 4 blood loss

A

> /= 2500
40%
Shock
Air hunger

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6
Q

Hemodynamic adaptations in pregnant

A 
Inc BV 40-50% by 30th week
Inc RBC mass by 20-30th with good stores
Inc CO by 30-50% in 3rd trimester
Dec vascular resistance
Inc in fibrinogen and procoagulant factors
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7
Q

Anatomical change that promotes hemostasis at 3rd stage labor/post partum

A

Interlacing myometrial fibers

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8
Q

Dry lap sponges 18 x 18

A

25 ml - 50% saturation
50 ml - 75% saturation
75 ml - entire surface
100 ml - saturate and drip

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9
Q

Massive transfusion protocol

A

6 units pRBC: 4 FFP: 1 unit platelet

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10
Q

Position that improves hemodynamic status
Inc SV
Inc CO
dec HR

A

Trendelenburg

Left lateral decubitus

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11
Q

Common causes of hemorrhage in the antepartum period (maternal + fetal concerns)

A 
Ectopic pregnancy 
Abortion
GTN - before 20 weeks 
Abruptio placenta - most common 
Placenta previa
Vasa previa
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12
Q

Most common cause of hemorrhage in antepartum period

A

Abruptio placenta

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13
Q

Causes of hemorrhage in post-partum period

A 
Uterine atony
Genital tract laceration
Hematoma
Uterine inversion
Adherent placenta
Accreta, increta, percreta
Retained placenta, placental fragment
Coagulopathy
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14
Q

Most common significant post-partum cause of hemorrhage

A

Uterine atony

Genital tract laceration

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15
Q

Most frequent cause of obstetrical hemorrhage

A

Failure of uterus to contract sufficiently

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16
Q

Premature separation of normally implanted placenta from uterus prior to delivery after 20 weeks AOG

Placenta abruption initiated by hemorrhage into the decidua basalis

Decidua splits leaving a thin layer adhered to myometrium

Decidual hematoma expands and causes separation and compression of adjacent placenta

A

Abruptio placenta

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17
Q

40-60% of abruptio occur

A

prior to 37 weeks AOG

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18
Q

Abruptio is difficult to diagnose because

A

Concealed

Tetanic contraction of uterus

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19
Q

Hematoma formation from abruptio can

A

go inside sinuses and go into circulation releasing thrombin, thromboplastin material and cause DIC

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20
Q

Abruptio Dx

A

UTZ (retroplacental hematoma)
MRI
Histopath confirmation

Based on clinical picture

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21
Q

Vaginal bleeding with or without tetanic contractions
Sudden pain: trauma, vehicular accident, amniotomy (rapid change in pressure)

Sudden onset ABDOMINAL PAIN
uterine tenderness

Pallor
Baby tachycardic, bradycardic and no FTH

A

Abruptio placenta

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22
Q

PainLESS bleeding

A

Placenta previa

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23
Q

Separation of placenta, blood seeped into myometrium explaining bluish discoloration of the placenta

This uterus will not contract anymore because of blood in between which affects the contractility of muscles

Study These Flashcards
A

Couvelaire uterus

24
Q

Abruptio Mx

Study These Flashcards
A

Amniotomy - to release the pressure and blood will not be pushed to sinuses and thombin and thromboplastin will not be released and will not proceed into DIC

If near delivery, expedite quickly (vaginal)

If not in labor, proceed to CS or else DIC

25
Degrees of abruptio
Mild Moderate - baby fead Severe - DIC
26
Presence of placental tissue over or near internal cervical os
Placenta previa
27
Restriction of activity in previa is only required if the condition persists more than
28 weeks or if bleeding or contraction develops before this time
28
Placenta previa resolves if detected in 2nd trimester due to formation of
lower uterine segment | placental migration
29
PAINLESS vaginal bleeding appearing near end of 2nd trimester 10% if lowlying no bleeding
Placenta previa Total - completely covering Os Marginal - portion of placenta near os Low-lying - edge of placenta quite close but does not overlap
30
Placenta previa risk factors
``` Inc parity Advanced age Maternal cigarette smoking - carbon monoxide hypoxemia causing placental hypertrophy Placenta previa In vitro fertilization Cocaine Infertility Multiple gestation Malpresentation IUGR Preterm labor Congenital anomalies Previous history of previa Prior uterine surgeries ```
31
Cigarette smoking causes placental hypertrophy because
Carbon monoxide hypoxia promotes hypertrophy Placenta edge may reach the lower part of the uterus ans cover the entire cervical canal Atrophy or inflammation of decidua may cause defective vascularization
32
CI in Placenta previa
IE TVS is not because it doesn’t touch cervix
33
Placenta previa Dx
Transabdominal UTZ - identifies implantation site, confirms the diagnosis of placenta previa TVS - accurate in assessing distance, measures how much of the placenta overlaps MRI
34
Placenta previa Tx
``` CS Preterm: Steroids (lung maturity) MgSO4 (neuroprotection) Tocolytic Bed rest No coitus Repeat UTZ 32-35 weeks Deliver 36-37 w ```
35
Presence of fetal vessels (velamentous cord insertiong over cervical os Prone to compression leading to anoxia and laceration leading to fetal hemorrhage Fetal death instantaneous hence warrants immediate CS
Vasa previa
36
Vasa Previa risk factors
``` Bilobed or succenturiate-lobed placenta Vilamentous insertion of umbilical cord Placenta succenturiata IVF pregnancy Multiple gestation Second tri placenta previa or low-lying placenta ```
37
Branching off of umbilical cord before reaching the placenta therefore exposed within the membrane The cord and vessels go upright up to surface of the placenta before branching off
Velamentous insertion of umbilical cord
38
Velamentous insertion Dx
Color Doppler Ultrasound Blue - flow away from sonologist Red - flow towards sonologist Yellow - turbulent flow
39
Placenta consists of large lobe and smaller one connected together by a membrane Umbilical cord is inserted into the large lobe branches of its vessels cross the membrane to the small succenturiate (accessory lobe) Accessory lobe may be retained in the uterus after delivery leading to postpartum hemorrhage There could be fetal hemorrhage
Placenta succenturiata
40
Placenta previa Dx
UTZ with Doppler flow History of vaginal bleeding after rupture of the membrane due to laceration of thr fetal vessels IE: pulsations of fetal vessels in the membrane that overlie the cervical OS
41
Vasa Previa Tx
If prior term and not bleeding: NST to check for cord compression CS at 34-35 weeks If during labor: Immediate CS
42
Most important and most preventable cause of postpartum hemorrhage
Disseminated intravascular coagulation
43
Hemostatic mechanisms to prevent hemorrhage
``` Platelet aggregation and platelet plug formation Local vasoconstriction Clot polymerization Fibrous tissue fortification of clot Uterine contraction ```
44
Most common cause of postpartum hemorrhage (80%)
Uterine atony
45
If atony is prior to placental delivery
manually extract placental
46
If atony is after placental delivery
medical management + bimanual compression of uterus
47
If pure atony but stable patient,
tamponade (uterine packing) with gauze or balloon selective embolization surgical intervention
48
Uterine atony sx
Ligation of uterine and internal iliac artery Hysterectomy
49
Medical Management (Uterotonic)
Oxytocin Carbetocin -long acting oxytocin agonist Ergot derivatives (Methylergometrine maleate, Methergine, Ergonavine) - rapid if oxytocin not working PGE1 (Misoprostol) - transrectal PGEF2a (Carboprost) - not given in asthmatics PGE2 (Dinoprostone)
50
Uterine atony ligation is done in
``` Internal iliac/hypogastric artery Uterine artery (branch) at isthmus for lateral laceration ```
51
Abnormal attachment of placenta to the uterine lining due to absence of decidua basalis and an incomplete development of fibrinoid layer
Placenta accreta
52
Placenta on myometrium
Accreta
53
Penetrates deep into myometrium
Increta
54
Beyond the myometrium and possibly in neighboring structures
Percreta
55
Risk factor for Placenta Accreta
``` Placenta previa and prior CS Increased parity and age Myoma uteri (submucous) Previous uterine surgery Previous curettage leading to endometrial defects ```
56
Placenta accreta Tx
CS Hysterectomy at 34-35 weeks
57
If uterine preservation is requested with focal accrete, give
methotrexate

Obstetrics and Gynecology (18 decks)

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