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OBGYN 2023 > Post-partum haemorrhage - amboss > Flashcards

Post-partum haemorrhage - amboss Flashcards

1
Q

define

A

obstetric emergency
blood loss >1000mL
or
blood loss presenting with signs and symptoms of hypovolaemia wihtin 24 hours of delivery

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2
Q

primary PPH

A

within 24 hours of delivery

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3
Q

secondary PPH

A

between 24 hours post delivery

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4
Q

morbidity/mortality

A

no. 1 cause of maternal mortality and morbidity worldwide

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5
Q

main causes of PPH

A

uterine atony
maternal brith trauma
abnormal placental seperation
velamentous cord insertion
coagulation disorders

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6
Q

4 T’s causes of PPH

A

Tone: uterine atony
Trauma: laceration, uterine inversion
Tissue: retained placenta
Thrombin: bleeding diathesis

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7
Q

clinical features

A

rapid heavy vaginal bleeding
hypovolaemia: decreased blood pressure, increased heart rate, dizziness

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8
Q

physical examination findings

A

lacerations, hematoma, any other visible cause of bleeding, boggy uterus

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9
Q

lab investigation

A

haematocrit, hemoglobin to estimate blood loss

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10
Q

findings on speculum examination

A

uterine inversion
retained placental tissue or membranes
puerperal hematoma

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11
Q

ultrasound findings

A

used to determine the correlation between the placenta and the cervical os
uterine atony
abnormal placental attatchment
colour doppler ultrasound will confirm abnormal placental attatchment (eg. showing turbulent blood flow)

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12
Q

general measures of management

A

control blood loss
monitoring of vital signs and urine output
oxygenation
two large-bore IV access (>16 gauge) and ice pack
fluid therapy (with IV crystalloid solutions)
blood transfusions (whole blood or red cell concentrates) and/or platelet transfusions if necessary

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13
Q

surgical measures of management

A

in cases of uncontrolled bleeding - ligation of uterine or internal iliac arteries, or uterine artery embolication: decreases bleeding by reducing myometrial perfusion, but fertility remains intact because of collateral blood supply by the ovarian arteries
uterine suturing
hysterectoimy - generally a last resort

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14
Q

prevention of PPH

A

identification of anaemia and coagulopathies
sonogrpahy to identify placenta accreta in women with a Hx of caesareans
active management of third staage of labour
avoidance of unecessary episiotomy

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15
Q

complications of PPH

A

anaaemia
hypovolaemic shock
thromboembolism
Sheehan syndrome
infection
maternl death
DIC
fetal death
abdominal compartment syndrome

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16
Q

causes of primary PPH

A

uterine atony
uterine inversion
retained placenta or bnormal placentation
birth trauma
velamentous cord insertion

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17
Q

causes of secondary PPH

A

retained products of conception
subinvolution of the placental site
coagulaation disorders
postpartum endometritis

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18
Q

define uterine atony

A

failure of the uterus to effectively contract after complete or incomplete delivery of the placenta, which can lead to severe post partum bleeding from the myometriala vessles
most common caauses of PPH (~80%)

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19
Q

pathophysiology of uterine atony

A

normally the myometrium contracts and compresses the spirla aarteries which stops bleeding after delivery
failure of the myometrium to effectively contrct can lead to rapid and severe heamorrhage

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20
Q

risk factors for uterine atony

A

overdistension of the uterus: large for gestational age newborn, multiple pregnancy, polyhydramnios
exhausted myometrium: multiparity, post term pregnancy, prolonged delivery, prolonged oxytocin use
anatomical abnormalities: abnormal placental implantation, uterine leiomyomas
infection: chorioamnionitis
other: medications lowering contractions, preterm delivery, high maternal BMI

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21
Q

clinical features of uterine. atony

A

profuse vaginal bleeding
soft enlarged (increased fundal height), boggy ascending uterus

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22
Q

diagnosis of uterine atony

A

bimanual pelvic exam
speculum examination of the vagina and cervix to evaluaate possible sources of extrauterine bleeding (eg. vaginal injury caused during birth)

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23
Q

haemorrhage control in uterine atony

A

uterotonic agents: IV oxytocin, IM carboprost tromethamine, IM methylergonovine, prostoglandins such as misopristol
tranexamic acid: should be aministered as soon as possible to stop fibronolysis and reduce liklihood of mortality
early clmaping and cutting of umbilical cord

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24
Q

when to use tranexamic acid in uterine atony

A

concimmitant with uterotonic agents
should be aministered as soon as possible to stop fibronolysis and reduce liklihood of mortality

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25
Q

excluding coagulation disorders in uterine atony

A

eg. DIC, hyperfibronolysis
blood coagulation should be tested and treaatment based on results of coagulation panel
administer tranexamic acid in hyperfibrinolysis

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26
Q

surgical procedures for uterine atony

A

uterine balloon tamponade or packing: if severe bleeding persists, regardless of adequate general measures
compression sutures eg. B-Lynch suture
surgical ligation of uterine or internal iliac arteries
last resort: hysterectomy

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27
Q

define uterine inversion

A

an obstetric emergency in which the uterine fundus collapses into the endometrial cavity, resulting in a complete or partial inversion of the uterus
uncommon compliocaation of vaginal delivery
high morbidity and mortality

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28
Q

degrees of uterine inversion

A

partial uterine inversion: uterine fundus collapses into the endometrial cavity, without surpassing the cervix
complete uterine inversion: uterine fundus collapses into the endometrial cavity and descends through the cervix, but remains within the vaginal introitus
uterine prolapse: uterine fundus descends through the vaginal introitus

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29
Q

risk factors for uterine inversion

A

uncontrolled cord traction and/or excessive fundal pressure
fetal macrosomia
previous uterine inversion
use of uterine muscle relaxants during the antepartum period
difficult removal of placenta
nulliparity
uterine abnormalities
prolonged delivery
retained placental tissue

30
Q

clinical features of acute uterine inversion

A

brisk postpartum haemorrhage
lower abdo pain
round mass protruding from cervix or vagina
absent fundus
urinary retention

31
Q

chronic uterine inversion clinical features

A

Hx of PPH
irregular bleeding
asymptomatic, round vaginal mass
vaginal discharge
chronic pelvic pain

32
Q

diagnosis of uterine inversion

A

clinical diagnosis
can be confirmed via USS

33
Q

general measures for uterine inversion treatment

A

immidiate manual uterine repositioning should be performed
stop all uterotonic agents to relax the uterus
only remove the placenta after successful repositioning of the uterus
chronic uterine inversion will require surgery

34
Q

define retained placenta

A

retention of the placental tissue inside the uterine cavity following the first 30 minutes post-partum
approx. 3% of vaginal deliveries

35
Q

classification of retained placenta

A

adherant placenta: a placenta that is not attatched due to insufficienct uterine contractions
trapped placenta: a detatched placenta that cannot be delivered spontaneously or with light cord tractions becasue fo cervical closure

36
Q

risk factors for retained placenta

A

prior history of retained placenta
placenta praevia
plecenta accreta spectrum
prior caesarean
uterine fibroids
prolonged use of uterotonic medications
preterm labour
assisted reproduction procedures

37
Q

clinical features of retained placenta

A

severe bleeding before placental delivery
physical examination: visualisation of placental fragments or fetal membranes within the uterus

38
Q

treatment of retained placenta

A

manual removal
consider administering nitroglycerin and perform under adequate anaesthesia
administr prophylactic antibiotics
surgical management where manual extraction fails

39
Q

define abnormal placentation

A

defective decidual layer of the placenta leading to abnormal attatchment and seperation during post partum period

40
Q

placenta accreta

A

chronionic villi attatch to the myometrium (but do not invade or penetrate the myometrium) rather than the decidua basalis

41
Q

placenta increta

A

chorionic villi invade or penetrate into the myometrium

42
Q

placenta percreta

A

chorionic villi penetrate the myometrium, penetrate the serosa, and in some cases, adjacenta organs/structures

43
Q

classification of abnormal placentation

A

placenta accreta, placenta increta or placenta percreta depending on the implantation of the trophoblast into the uterine wall

44
Q

risk factors for abnormal placentation

A

any prior damage to the endometrium
- history of uterine surgery
- prior births by c-section
- placenta praevia
- multiparity
- advanced maternal age
- assisted reproduction procedures
- asherman syndrome

45
Q

clinical features of abnormal placentation

A

abnormal uterine bleeding
post partum haemorrrhage at the time of attemopted manual seperation of the placenta

46
Q

diganosis of abnormal placentation

A

USS: thinning of uterine myometrial wall, placental lacunae, loss of clear space behind the placenta, disruption of junction between the bladder wall and uterine serosa

47
Q

treatment of abnormal placentation

A

prevent pre-delivery
active management of third stage of labour
surgical procedures: dilation and curettage or vacuum removal of RPOC
caesarean hysterectomy
uterine preserving measures are contraindicated in placenta accreta spectrum due to high maternal mortality

48
Q

prognosis of abnormal placentation

A

morbidity in approx. 27%
placenta percreta is associated with the highest level of complications

49
Q

define birth trauma

A

can result in bleeding lacerations, puerperal haematomas and/or uterine rupture

50
Q

puerperal hematoma

A

accumulation of blood in the vulva, vagina, or retroperitoneum, most commonly caused by iatrogenic injury during childbirth
- vulvar hematoma
- vaginal hematoma
- retroperitoneal hematoma

51
Q

epidemiology of birth trauma

A

second most common cause of PPH (~20%)

52
Q

aetiology of birth trauma

A

iatrogenic injury: cervical laceration, lower vaginal trauma, uterine rupture, puerpural hematoma
other: fetal macrosomia, malpresentation of the fetus, uncontrolled delivery, prolonged second stage of labour, primiparity, coagulopathy, hypertensive disease of pregnancy

53
Q

features of hematoma or bleeding laceration of the female genital tract

A

severe pain in the labia, pelvis and/or perineum < 24 hours after delivery
severe bleeding, hypovolaemic shock
vaginal hematoma: protruding, tender, palpable vaginal mass

54
Q

features of retroperitoneal hematoma

A

pelvic pain
signs and symptoms of hypovolaemia eg. tachy carida, hypotension, disphoresis, pale skin, dizziness

55
Q

treatment of birth trauma following vaginal delivery

A

immidiate repair of visible bleeding lacerations
arterial embolisation for the haemodynamicaally stable pateint
incision and drainage of the hematoma or immidiate laparotomy for the haemodynamically unstable patient

56
Q

treatment of birth trauma following caesarean section

A

uterine artery ligation
uterine pressure suture technique (B-Lynch) if other measures fail

57
Q

if there is life threatening complications in birth trauma

A

hysterectomy

58
Q

define velamentous cord insertion

A

abnromal cord insertion into chorioamniotic membranes, resulting in exposed vessels only surrounded by thin fetal membranes, the absense of protective Wharton Jelly

59
Q

epidemiology of velamentous cord insertion

A

1% of single pregnancies
15% of twin pregnancies
associated with an increased risk of haemorrhage during third stage labour

60
Q

risk factors for velamentous cord insertion

A

placenta praevia
low-lying placenta
multiple pregnancies
assisted reproduction procedures
succenturiate placenta

61
Q

clinical features of velamentous cord insertion

A

possibel painless vaginal bleedings, typically in the third trimester: blood loss only occurs in the fetus
features of fetal hypoxia, especially following rupture of membranes

62
Q

diagnosis of velametnous cord insertion in the prenatal period

A

transabdominal US: helps to determine the correlation between the placenta and the cervical os
transvaginal color doppler US: indicated to rule out vasa praevia

63
Q

management of velamentous cord insertion if diagnosed prenatally

A

regular fetal asessment
deliver <40 weeks

64
Q

menagement of velametnous cord insertion if diagnosed intrapartum

A

vaginal delivery if there are no signs of fetla distress
emergency c-section: signs fetal distress, PPH, vasa praevia

65
Q

complications of velamentous cord insertion

A

vasa praevia
fetal death
premature infant
fetal growth restriction
fetal malformation

66
Q

definition of subinvolution of placental implantation site

A

a condition in which the uterus remains abnormally large following delivery because of the persistance of dilated uteroplacental vessels

67
Q

epidemiology of subinvolution of placental implantation site

A

occurs most commonly in the second week post partum
second most common cause of secondary post partum haemorrhage

68
Q

risk factors for subinvolution of placental implantation site

A

multiparity
caesarean delivery
uterine atony
endometritis
coagulopathy
retained products of conception

69
Q

clinical features of subinvolution of placental implantation sute

A

abnormal, severe uterine bleeding, most commonly during second week post partum
fever, chills
lower abdominal pain
signs of hypovolaemia

70
Q

diagnsotics of subinvolution of placental implantation site

A

USS: hypoechioc tortuous vessels in the myometrium
pulsed wave doppler
histopathological examination: large, dilated myometrial arteries with thickeneed walls and intravascular thrombosis.

71
Q

treatment of subinvolution of placental implantation site

A

uterotonic agens eg. IV oxytocin
surgical - D&C
severe bledding - uterine artery embolisaation, hysterectomy for patients with severe bleeding

OBGYN 2023 (28 decks)

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