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OBGYN 2023 > Post-partum haemorrhage - amboss > Flashcards

Post-partum haemorrhage - amboss Flashcards

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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) in the ACFs 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
excluding coagulation disorders in uterine atony
eg. DIC, hyperfibronolysis blood coagulation should be tested and treaatment based on results of coagulation panel administer tranexamic acid in hyperfibrinolysis
26
surgical procedures for uterine atony
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
27
define uterine inversion
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
28
degrees of uterine inversion
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
29
risk factors for uterine inversion
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
clinical features of acute uterine inversion
brisk postpartum haemorrhage lower abdo pain round mass protruding from cervix or vagina absent fundus urinary retention
31
chronic uterine inversion clinical features
Hx of PPH irregular bleeding asymptomatic, round vaginal mass vaginal discharge chronic pelvic pain
32
diagnosis of uterine inversion
clinical diagnosis can be confirmed via USS
33
general measures for uterine inversion treatment
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
define retained placenta
retention of the placental tissue inside the uterine cavity following the first 30 minutes post-partum approx. 3% of vaginal deliveries
35
classification of retained placenta
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
risk factors for retained placenta
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
clinical features of retained placenta
severe bleeding before placental delivery physical examination: visualisation of placental fragments or fetal membranes within the uterus
38
treatment of retained placenta
manual removal consider administering nitroglycerin and perform under adequate anaesthesia administr prophylactic antibiotics surgical management where manual extraction fails
39
define abnormal placentation
defective decidual layer of the placenta leading to abnormal attatchment and seperation during post partum period
40
placenta accreta
chronionic villi attatch to the myometrium (but do not invade or penetrate the myometrium) rather than the decidua basalis
41
placenta increta
chorionic villi invade or penetrate into the myometrium
42
placenta percreta
chorionic villi penetrate the myometrium, penetrate the serosa, and in some cases, adjacenta organs/structures
43
classification of abnormal placentation
placenta accreta, placenta increta or placenta percreta depending on the implantation of the trophoblast into the uterine wall
44
risk factors for abnormal placentation
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
clinical features of abnormal placentation
abnormal uterine bleeding post partum haemorrrhage at the time of attemopted manual seperation of the placenta
46
diganosis of abnormal placentation
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
treatment of abnormal placentation
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
prognosis of abnormal placentation
morbidity in approx. 27% placenta percreta is associated with the highest level of complications
49
define birth trauma
can result in bleeding lacerations, puerperal haematomas and/or uterine rupture
50
puerperal hematoma
accumulation of blood in the vulva, vagina, or retroperitoneum, most commonly caused by iatrogenic injury during childbirth - vulvar hematoma - vaginal hematoma - retroperitoneal hematoma
51
epidemiology of birth trauma
second most common cause of PPH (~20%)
52
aetiology of birth trauma
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
features of hematoma or bleeding laceration of the female genital tract
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
features of retroperitoneal hematoma
pelvic pain signs and symptoms of hypovolaemia eg. tachy carida, hypotension, disphoresis, pale skin, dizziness
55
treatment of birth trauma following vaginal delivery
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
treatment of birth trauma following caesarean section
uterine artery ligation uterine pressure suture technique (B-Lynch) if other measures fail
57
if there is life threatening complications in birth trauma
hysterectomy
58
define velamentous cord insertion
abnromal cord insertion into chorioamniotic membranes, resulting in exposed vessels only surrounded by thin fetal membranes, the absense of protective Wharton Jelly
59
epidemiology of velamentous cord insertion
1% of single pregnancies 15% of twin pregnancies associated with an increased risk of haemorrhage during third stage labour
60
risk factors for velamentous cord insertion
placenta praevia low-lying placenta multiple pregnancies assisted reproduction procedures succenturiate placenta
61
clinical features of velamentous cord insertion
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
diagnosis of velametnous cord insertion in the prenatal period
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
management of velamentous cord insertion if diagnosed prenatally
regular fetal asessment deliver <40 weeks
64
menagement of velametnous cord insertion if diagnosed intrapartum
vaginal delivery if there are no signs of fetla distress emergency c-section: signs fetal distress, PPH, vasa praevia
65
complications of velamentous cord insertion
vasa praevia fetal death premature infant fetal growth restriction fetal malformation
66
definition of subinvolution of placental implantation site
a condition in which the uterus remains abnormally large following delivery because of the persistance of dilated uteroplacental vessels
67
epidemiology of subinvolution of placental implantation site
occurs most commonly in the second week post partum second most common cause of secondary post partum haemorrhage
68
risk factors for subinvolution of placental implantation site
multiparity caesarean delivery uterine atony endometritis coagulopathy retained products of conception
69
clinical features of subinvolution of placental implantation sute
abnormal, severe uterine bleeding, most commonly during second week post partum fever, chills lower abdominal pain signs of hypovolaemia
70
diagnsotics of subinvolution of placental implantation site
USS: hypoechioc tortuous vessels in the myometrium pulsed wave doppler histopathological examination: large, dilated myometrial arteries with thickeneed walls and intravascular thrombosis.
71
treatment of subinvolution of placental implantation site
uterotonic agens eg. IV oxytocin surgical - D&C severe bledding - uterine artery embolisaation, hysterectomy for patients with severe bleeding

OBGYN 2023 (43 decks)

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