Post-Partum Hemorrhage

Question 1

postpartum hemorrhage (PPH) definition

Answer 1

500cc for vaginal

1000cc for c-section

Question 2

what is the most common cause of postpartum hemorrhage

Answer 2

uterine atony

Question 3

what is uterine atony

Answer 3

failure to contract uterus

Question 4

what causes uterine atony

Answer 4

on oxytocin too long and receptors are saturated
contracting for too long
tocolytics

Question 5

how will uterus feel if uterine atony

Answer 5

large and boggy

Question 6

treatment of uterine atony

Answer 6

uterine massage
uterotonics (methylergonovine, oxytocin, carboprost, misoprostol vaginally)
mechanical tamponade (Bakri balloon or packing)

Question 7

what uterotonic is contraindicated in asthma

Answer 7

carboprost

Question 8

what uterotonic is contraindicated in HTN

Answer 8

methylergonovine

Question 9

what is methylergonovine

Answer 9

smooth muscle constrictor that mostly acts on the uterus

Question 10

what is carboprost

Answer 10

PGF2-α

Question 11

what is uterine inversion

Answer 11

PPH + no palpable uterus

Question 12

risks of PPH from uterine inversion

Answer 12

oxytocin use

umbilical cord traction

Question 13

treatment of uterine inversion

Answer 13

placing the uterus back where it belongs with bimanual exam
tocolytics may be needed to relax uterus into place
uterotonics may be needed to contract it down

Question 14

risk for vaginal lacerations

Answer 14

precipitous deliveries or macrosomic babies

Question 15

treatment of vaginal lacerations

Answer 15

local anesthesia and suture closed

Question 16

what to look out for with vaginal lacerations

Answer 16

vaginal hematomas

• treatment is packing
• if become retroperitoneal, then surgery likely required

Question 17

what are retained products of conception

Answer 17

parts of the membranes or placenta left behind in the uterus

• uterus will be firm
• can cause continued bleeding weeks after delivery

Question 18

placenta accreta

Answer 18

placenta that has grown too deeply into the wall of the uterus
- in the endometrium, but not into the myometrium

Question 19

placenta increta

Answer 19

burrows into the myometrium

Question 20

placenta percreta

Answer 20

embeds through myometrium and uterine serosa

Question 21

risk factors for placenta accretra/increta/percreta

Answer 21

increased number of pregnancy

Question 22

treatment of retained products

Answer 22

dilation and curettage

if bleeding continues, hysterectomy

Question 23

what is included in DIC panel

Answer 23

platelets
INR
fibrinogen

Question 24

when to be concerned about fibrinogen

Answer 24

normally elevated in pregnancy

- DIC concern if low or ‘inappropriately normal’

Question 25

treatment of DIC

Answer 25

packed red blood cells for low hemoglobin platelets for low platelets FFP for increased INR cryoprecipitate for low fibrinogen

Question 26

what to do with uncontrolled bleeding

Answer 26

operative control after all drugs fail

Question 27

what to do for uncontrolled bleeding from vagina and uterus

Answer 27

cannot tamponade | IV access, fluid, and blood are important

Question 28

how to approach operative control of PPH

Answer 28

uterine packing - help control bleeding source with mechanical pressure - Bakri balloon can be placed

Question 29

procedures to surgically control bleading

Answer 29

``` O'Leary sutures B-lynch compression suture box stitches hypogastric artery ligation uterine artery embolization hysterectomy ```

Question 30

O'Leary sutures

Answer 30

around uterine arteries at level of internal os

Question 31

B-lynch compression suture

Answer 31

on the uterus

Question 32

box stitches

Answer 32

in the uterus to compress the muscle down

Question 33

hypogastric artery ligation

Answer 33

ex-lap

Question 34

uterine artery embolization

Answer 34

done in IR

Question 35

hysterectomy

Answer 35

if everything else fails

Question 36

what may be the first sign of bleeding that you cannot see?

Answer 36

hematoma | decreased urine output

Question 37

how to handle unexplained bleeding

Answer 37

surgical ligation | hysterectomy