Third Trimester and Pospartum Bleeding Flashcards Preview

Reproductive Exam 1 > Third Trimester and Pospartum Bleeding > Flashcards

Flashcards in Third Trimester and Pospartum Bleeding Deck (235):
1

What is it called when the placenta implants over the cervical os?

Placenta previa

2

What is it called when the placenta implants over the cervical os?

Placenta previa

3

What is a complete or total previa?

Placenta completely covers the os (20-40%)

4

What is a partial previa?

Placenta partially covers the internal os (30%)

5

What is a marginal previa?

The edge of the placenta extends to the margin of the internal os (30-50%)

6

How are people with placenta previa typically delivered and why?

Usually C-section because of bleeding

7

What is the measure called of how many cm above or below the ischial spines a baby is?

Station
- + is below
- - is above

8

What is it called when the placental lies in the lower uterine segment, but doesn't extend to the cervical os?

Low lying placenta

-Not really an issue... just repeat US at 28 weeks to make sure it hasn't moved towards the os

9

What is the premature separation of the normally implanted placenta from its attachment to the uterus?

Placenta abruptio

10

What are 3 things that can commonly cause placenta abruptio?

Trauma, high BP, or crack cocaine

11

What is the complete separation of the uterine musculature through all of its layers?

Uterine rupture

12

Where does a uterine rupture commonly happen?

At the site of a previous surgery (C-section, fibroids removed ect) becuase it's a weak point in the uterus... in the situations, just do a C-section

13

What is considered pospartum hemorrhage?

Blood loss in excess of 500mL vaginal delivery or 1000mL for a cesarean

14

What is it called when the placenta is directly attached to the myometrial wall?

Placenta accreta

15

What is absent in a placenta accreta?

No decidua basalis (absent Nitabuch's layer)

16

What is it called when the placenta invades the myometrium?

Placenta increta

17

What is it called when the placenta penetrates the myometrium to the serosa or beyond?

Placenta percreta

18

What is is called when the vessels of the umbilical cord insert between the layers of the amnion and chorion away from the placenta?

Velamentous cord insertion

19

What happens in a vasa previa?

The unprotected vessels from a velamentous insertion pass over the os... they are predisposed to rupturing

20

What things increase in pregnancy?

1. Maternal blood volume (up by 40%)
2. Plasma volume
3. Erythrocyte volume
4. 2,3 DPG
5. Heart rate (10-15bpm)
6. Stroke volume
7. Cardiac output (30-40%)

21

What things decrease in pregnancy?

1. Maternal BP
2. Systemic vascular resistance

22

Why do you not have to treat anemia in preggo ladies until Hb hits like 10ish?

Because is it a physiological dilution of their blood... even through norm Hb is around 12-16, they are chill until like 10 because of this and won't show shock systems until they have lost a lot of blood

23

In a normal person, what is the blood flow rate through the uterine artery? What about a preggo lady?

-Normal is 60cc per min
-Preggo is 6000cc per min
-AKA, you nick the uterine artery in a prego lady they bleed out (exanguinate) in about 10 min... DON'T DO IT

24

Pregnancy is associated with what % increase in total blood volume by what week gestation?

40%, 13th week

25

What will the blood volume increase to in an average sized female?

6000mL

26

Antepartum and pospartum bleeding issues complicate what % of pregnancies?

4% each

27

What are the top 3 causes of maternal death in the US?

1. Embolism
2. HTN disease
3. Hemorrhage

28

He gave us a hemorrhage classifications in preggo chart...what was the main thing we were supposed to take away from it?

That preggo ladies can loose up to 1000cc blood without showing any symptoms
-Said we didn't need to know details, but take a glance at ...TRUST NO ONE

29

What are the 2 most common causes of antepartum bleeding?

1. Placenta previa (20%)
2. Placenta abruption (30%)

30

What are the other 50% of causes of antepartum bleeding that aren't as common?

1. Uterine rupture
2. Fetal vessel rupture
3. Cervical or vaginal lacerations
4. Cervical or vaginal lesions including cancer
5. Congenital bleeding disorder
6. Unknown

31

You ask about abdominal pain, contractions, placenta previa, c sections or other prior uterine surgeries, smoking, cocaine, or bleeding disorders as part of what?

History portion of the initial evaulation for antepartum hemorrhage

32

What physical things do you check when evaluating for antepartum hemorrhage?

Vitals, amount of bleeding, uterine tenderness

33

True or False: When evaluating for antepartum hemorrhage, you check the cervix?

FALSE- DO NOT CHECK CERVIX UNLESS PLACENTA PREVIA HAS BEEN RULED OUT

-You roll with a US or careful spec exam (only open things up a bit to check for the cervix to see if it's dilated with placenta pouring out through it waiting to explode at you)

34

What are 3 diagnostic things done for anterpartum hemorrhage evaluation?

1. CBC and coag profile
2. US
3. Monitoring

35

What is the most accurate means of determining the cause of bleeding, but will still miss 50% of abruptions?

US- It is good for previa, but harder with abruption

36

What is seen in 1/200 deliveries and accounts for 20% of all antepartum bleeding?

Placenta previa

37

What are the 3 types of placenta previa?

1. Complete
2. Partial
3. Marginal

38

What are 5 predisposing factors to placenta previa?

1. Previous C-section
2. Multiparity
3. Multiple gestation
4. Advancing maternal age
5. Previous placenta previa

39

What are some complicating factors with placenta previa?

1. 1/25 will have an underlying accreta
2. 20% will have an underlying IUGR
3. 2x higher rate of congenital abnormalities
4. 30% malpresentation
5. Higher incidence of PPROM
6. Risk of Vasa Previa

40

What is PPROM?

Pre-term, premature rupture of membranes
-When water breaks under 37 weeks

41

What is PROM?

Pre-term rupture of membranes
-Full term, water breaks, no labor, contractions

42

What does the cervix have to do to deliver a baby?

Dilate to 10cm & Efface

43

Why can a low implantation or low-lying placenta not be bad?

Because the uterus grows from the upper 2/3 and up... so as the uterus grows, the placenta might grow "up" and move out of the way as the pregnancy progresses

44

Why is a vag delivery possible with marginal placenta previa?

Because the babies head could possible tamponade off of the vag and allow for the baby to sail on out

45

What is IUGR?

Intra-uterine growth restriction

46

If something happens once?

IT IS LIKELY TO HAPPEN AGAIN

47

What is the classical presentation of placenta previa?

Painless, bright red bleeding

48

What % of placenta previas are associated with contractions?

20%

49

What are the 2 types of US to diagnose placenta previa and what is the % effective?

1. Transabdominal- 95%
2. Transvaginal- 100% (but this could precipitate bleeding)

50

What is done is US is inconclusive for placenta previa?

Double-set up exam... get yo lady in stirrups to examine, but be ready for a C-section too just in case

51

What are the first 2 things to do with placenta previa?

1. Stabilize momma: IV, CBC, Type and Cross
2. Assess baby: Monitor, US, determine gestational age/maturity, fetal HR monitoring

52

If momma is stable and baby is preterm, what do you do with a placenta previa?

1. Amniocentesis for lung maturity

-If mature: Delivery by C-section
- If immature: Bed rest, transfusions

53

In a placenta previa, if the baby is immature and you are trying to hold it in, what are 3 drug considerations to remember?

1. Caution use of tocolytics: Magnesium sulfate id DOC
2. Beta mimetics could mask tachycardia
3. RHOGAM BABY

54

When is Rhogam given?

Rh- momma, Rh+ baby
-Give at 28 weeks... after birth, if baby is Rh-, everything is happy and merry... it baby is Rh+ another dose Rhogam within 72 hours of delivery

-ALWAYS DOCUMENT THAT YOU OFFERED RHOGAM

55

1 vial of Rhogam covers how much mixing of maternal and fetal blood?

15cc

56

What is the blood test to determine the amount of fetal Hb transferred to maternal blood?

Kleihaure- Betke

57

Soooo... since Rhogam vial only covers about 15cc mixing, what do you do if this Kleihaure-Betke test shows that more blood has mixed for whatever reason?

GIVE MORE VIAL OF RHOGAM...whoooooop

58

If momma or baby is unstable with placenta previa, what do you do?

C-SECTION

59

If where is a low lying placenta, momma and baby are stable... what can you do?

Attempt a vag delivery
1. Fetal head should tamponade the bleeding
2. Buuuuut... do a double set up with prep for a C-section

60

What happens in 1/120 births, with a fetal death rate of 1/500, and 80% occur prior to the onset of labor?

Placental abrupion

61

What is the age of viability?

24 weeks

62

What is a normal baby HR?

110-160

63

What is used to tell how far along baby is?

Uterine height

64

If the baby is below the umbilicus, how far along is it?

Under 20 weeks- NO C-SECTION

65

How do you save baby?

SAVE MOMMA (#1 COD for fetal is maternal shock)

66

What are risk factors for placenta abruption?

1. Maternal hypertension
2. Cocaine abuse, especially “crack”
3. Trauma
4. Smoking
5. Polyhdraminios and multiple gestation- rapid decompression of an over-distended uterus
6. Previous Abruption 5% recurrence, if two or more 25% recurrence rate

67

What is the gestational age where the baby should be okay?

Over 32 weeks...under this.. significant morbiditiy

68

Why can polyhydraminos cause placenta abruption?

With lots of amniotic fluid, when the water breaks there is a rapid decompression of the uterus and the placenta can just detach off

69

What is the most common cause of DIC in pregnancy?

Placenta abruption

70

What are complicating factors with placenta abruption?

1. Perinatal mortality rate due to abruption, is 35%.
2. Accounts for 15% of third trimester stillbirths.
3. 15% of livebirths have neurologic damage.
4. Most common cause of DIC in pregnancy.
5. Hypovolemic shock, renal failure.
6.Sheehan’s syndrome

71

What is the MOA of placenta abruption?

1. Hemorrhage into the decidua basalis with formation of a hematoma.
2. The seperation of the decidua from the basal plate perpetuates itself causing further separation as well as compression and destruction of tissue.
3. If the blood dissects upward into the fundus, it will cause a concealed hemorrhage.
4. If the blood dissects downward it will be revealed.

-Sorry...too lazy to make fancy questions out of this... and he didn't spend time talking about it anyways

72

What is it called when there is a blueish purple discoloration to the uterus caused by blood dissecting into the myometrium?

Couvelaire Uterus

-Blueberry appearing--> Blood into myometrium after abruption

73

If a lady has a couvelaire urterus, what does she need?

Hysterectomy

74

What is the hallmark of placenta abruption?

Painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone

75

What makes the diagnosis of placenta abrption?

Clinical... US isn't very affective

76

What % of ladies with placenta abruption have vag bleeding and what does it look like?

80% and it's dark red (because it dissected, it is deoxygenated by the time it gets out)

77

What are other symptoms/issues seen with placenta abruption?

1. Pain: 66%
2. Fetal Distress: 60%
3. Uterine Hyperactivity: 34%
4. Fetal Demise: 15%

78

What will the abdomen be like with a placental abruption?

HARD BELLY
-It will feel like a contraction that isn't going away

79

What are 6 aspects of management for placental absruption?

1. Stabilize Mother
2. IV’s
3. Serial Coagulation Profiles
4. Keep blood products on hand (DIC)
5. Fetal Monitoring
6. Vaginal Delivery preferred route. C-section for obstetrical reasons only

80

What is the complete separation of the uterine musculature through all of it's layers?

Uterine rupture

81

Where is the fetus in uterine rupture?

Extruded into the abdomen

82

What is the incidence of uterine rupture?

0.5%

83

When can uterine rupture occur?

During or before labor, or at the time of delivery

84

What % of uterine ruptures are associated with previous uterine scar?

40%

1. C/S most common- with prior LTCS -0.5% risk, with a previous vertical incision 5% risk.
2. Myomectomy
3. Metroplasty

85

What % of uterine ruptures occur in previously unscarred uterus?

60%

-GRand multip, ect... I think this was 5+ pregnancies?

86

What are 2 complicating factors with uterine rupture?

1. Maternal mortality 1%
2. Fetal mortality 32%

87

What are 6 things used to diagnose uterine rupture?

1. Must have high index of suspicion.
2. Sudden onset of intense abdominal pain and vaginal bleeding
3. Hyperventilation, agitation and tachycardia
4. After rupture, momentary relief of pain but it returns.
5. Fetal Distress
6. Palpable fetal parts in abdomen.

88

What is done for uterine rupture?

1. Immediate laparotomy
2. Usually a total abdominal hysterectomy is performed (TOC)
3. Possibly a debridement of rupture site and primary closure if fertility is still desired by patient

89

Where are the contractile fibers located in the uterus?

Upper 2/3

90

What is removed in a TAH?

Uterus and cervix (subtotal leaves cervix and takes uterus)

91

If you had a C-section and the cut up high, can you ever do a vag delivery?

Probs not... if you had a low transverse incision, possible (because of where contractile fibers are located

92

Just gonna toss in some stats about vasa previa...

1. Incidence - 1/5000.
2. Rupture 0.1 to 0.8%.
3. 50% fetal mortality.
4. If membranes rupture, 75% mortality.

93

What is the % indicence of postpartum hemorrhage?

4%

94

What is the physiology of postpartum hemorrhage?

The uterus fails to contract around the myometrial spiral arterioles and decidual veins at the attachment site after placental separation

95

What is the number 1 cause of postpartum hemorrage?

Uterine atony

96

What is the number 2 cause of postpartum hemorrhage?

Genital tract trauma... laceration on vag wall, cervix, ect... this is a highly vascular area, especially when pregnant

97

What are some other causes of postpartum hemorrhage?

1. Retained placental fragments
2. Uterine Inversion
3. Low Placental Implantation
4. Coagulation disorders: Abruption, retained dead fetus, inherited coagulopathy, amniotic fluid embolism

98

What causes the majority of postpartum hemorrthage?

Uterine Atony (75-80%)

99

What are predisposing factors to uterine atony?

1. Overdistension of the uterus: Multiple gestation, polyhydramnios, fetal macrosomia
2. Prolonged Labor
3. Grand Multip (>5)
4. Pitocin stimulation/ Magnesium Sulfate Tx.
5. Chorioamnionitis

100

What is a drug like oxytocin that induces contractions and can be used pre and post partum?

Pitocin

101

Why is pitocin used postpartum?

Get the placenta out... AFTERBIRTH...MMMMMM

102

Can oxytocin receptors become saturated?

YES

103

What are 2 uses of magnesium sulfate?

1. Gestational HTN: Prevents the conversion of pre-eclampsia to eclampsia
2. Tocolytic: Relaxes the uterus and stops contractions

104

What 3 things constitute pre-eclampsia?

1. Proteinuria
2. Edema
3. HTN

105

What constitutes plain old eclampsia?

1. Proteinuria
2. Edema
3. HTN
4. Seizures

106

How do you diagnose postpartum hemorrhage?

Inspection/palpation

-This diagnoses all causes except coagulation

107

What is the main strategy for management of uterine atony?

PITOCIN

108

What are some other options to manage uterine atony?

1. Massage
2. Methergine (ergonovine maleate)- If not HTN
3. Prostaglandin F2-Alpha
4. Cytotec
5. Embolization of Uterine Arteries- Need an IV radiologist to do this... not realistic
6. Ligation of Uterine or Hypogastric arts.
7. B-Lynch Stitch- Suture outside/around uterus to squeeze down onto it
8. Supracervical hysterectomy- Remove the uterus

109

How do you diagnose genital tract trauma?

EXPLORE

110

How do you diagnose genital tract trauma?

EXPLORE

111

What is a complete or total previa?

Placenta completely covers the os (20-40%)

112

What is a partial previa?

Placenta partially covers the internal os (30%)

113

What is a marginal previa?

The edge of the placenta extends to the margin of the internal os (30-50%)

114

How are people with placenta previa typically delivered and why?

Usually C-section because of bleeding

115

What is the measure called of how many cm above or below the ischial spines a baby is?

Station
- + is below
- - is above

116

What is it called when the placental lies in the lower uterine segment, but doesn't extend to the cervical os?

Low lying placenta

-Not really an issue... just repeat US at 28 weeks to make sure it hasn't moved towards the os

117

What is the premature separation of the normally implanted placenta from its attachment to the uterus?

Placenta abruptio

118

What are 3 things that can commonly cause placenta abruptio?

Trauma, high BP, or crack cocaine

119

What is the complete separation of the uterine musculature through all of its layers?

Uterine rupture

120

Where does a uterine rupture commonly happen?

At the site of a previous surgery (C-section, fibroids removed ect) becuase it's a weak point in the uterus... in the situations, just do a C-section

121

What is considered pospartum hemorrhage?

Blood loss in excess of 500mL vaginal delivery or 1000mL for a cesarean

122

What is it called when the placenta is directly attached to the myometrial wall?

Placenta accreta

123

What is absent in a placenta accreta?

No decidua basalis (absent Nitabuch's layer)

124

What is it called when the placenta invades the myometrium?

Placenta increta

125

What is it called when the placenta penetrates the myometrium to the serosa or beyond?

Placenta percreta

126

What is is called when the vessels of the umbilical cord insert between the layers of the amnion and chorion away from the placenta?

Velamentous cord insertion

127

What happens in a vasa previa?

The unprotected vessels from a velamentous insertion pass over the os... they are predisposed to rupturing

128

What things increase in pregnancy?

1. Maternal blood volume (up by 40%)
2. Plasma volume
3. Erythrocyte volume
4. 2,3 DPG
5. Heart rate (10-15bpm)
6. Stroke volume
7. Cardiac output (30-40%)

129

What things decrease in pregnancy?

1. Maternal BP
2. Systemic vascular resistance

130

Why do you not have to treat anemia in preggo ladies until Hb hits like 10ish?

Because is it a physiological dilution of their blood... even through norm Hb is around 12-16, they are chill until like 10 because of this and won't show shock systems until they have lost a lot of blood

131

In a normal person, what is the blood flow rate through the uterine artery? What about a preggo lady?

-Normal is 60cc per min
-Preggo is 6000cc per min
-AKA, you nick the uterine artery in a prego lady they bleed out (exanguinate) in about 10 min... DON'T DO IT

132

Pregnancy is associated with what % increase in total blood volume by what week gestation?

40%, 13th week

133

What will the blood volume increase to in an average sized female?

6000mL

134

Antepartum and pospartum bleeding issues complicate what % of pregnancies?

4% each

135

What are the top 3 causes of maternal death in the US?

1. Embolism
2. HTN disease
3. Hemorrhage

136

He gave us a hemorrhage classifications in preggo chart...what was the main thing we were supposed to take away from it?

That preggo ladies can loose up to 1000cc blood without showing any symptoms
-Said we didn't need to know details, but take a glance at ...TRUST NO ONE

137

What are the 2 most common causes of antepartum bleeding?

1. Placenta previa (20%)
2. Placenta abruption (30%)

138

What are the other 50% of causes of antepartum bleeding that aren't as common?

1. Uterine rupture
2. Fetal vessel rupture
3. Cervical or vaginal lacerations
4. Cervical or vaginal lesions including cancer
5. Congenital bleeding disorder
6. Unknown

139

You ask about abdominal pain, contractions, placenta previa, c sections or other prior uterine surgeries, smoking, cocaine, or bleeding disorders as part of what?

History portion of the initial evaulation for antepartum hemorrhage

140

What physical things do you check when evaluating for antepartum hemorrhage?

Vitals, amount of bleeding, uterine tenderness

141

True or False: When evaluating for antepartum hemorrhage, you check the cervix?

FALSE- DO NOT CHECK CERVIX UNLESS PLACENTA PREVIA HAS BEEN RULED OUT

-You roll with a US or careful spec exam (only open things up a bit to check for the cervix to see if it's dilated with placenta pouring out through it waiting to explode at you)

142

What are 3 diagnostic things done for anterpartum hemorrhage evaluation?

1. CBC and coag profile
2. US
3. Monitoring

143

What is the most accurate means of determining the cause of bleeding, but will still miss 50% of abruptions?

US- It is good for previa, but harder with abruption

144

What is seen in 1/200 deliveries and accounts for 20% of all antepartum bleeding?

Placenta previa

145

What are the 3 types of placenta previa?

1. Complete
2. Partial
3. Marginal

146

What are 5 predisposing factors to placenta previa?

1. Previous C-section
2. Multiparity
3. Multiple gestation
4. Advancing maternal age
5. Previous placenta previa

147

What are some complicating factors with placenta previa?

1. 1/25 will have an underlying accreta
2. 20% will have an underlying IUGR
3. 2x higher rate of congenital abnormalities
4. 30% malpresentation
5. Higher incidence of PPROM
6. Risk of Vasa Previa

148

What is PPROM?

Pre-term, premature rupture of membranes
-When water breaks under 37 weeks

149

What is PROM?

Pre-term rupture of membranes
-Full term, water breaks, no labor, contractions

150

What does the cervix have to do to deliver a baby?

Dilate to 10cm & Efface

151

Why can a low implantation or low-lying placenta not be bad?

Because the uterus grows from the upper 2/3 and up... so as the uterus grows, the placenta might grow "up" and move out of the way as the pregnancy progresses

152

Why is a vag delivery possible with marginal placenta previa?

Because the babies head could possible tamponade off of the vag and allow for the baby to sail on out

153

What is IUGR?

Intra-uterine growth restriction

154

If something happens once?

IT IS LIKELY TO HAPPEN AGAIN

155

What is the classical presentation of placenta previa?

Painless, bright red bleeding

156

What % of placenta previas are associated with contractions?

20%

157

What are the 2 types of US to diagnose placenta previa and what is the % effective?

1. Transabdominal- 95%
2. Transvaginal- 100% (but this could precipitate bleeding)

158

What is done is US is inconclusive for placenta previa?

Double-set up exam... get yo lady in stirrups to examine, but be ready for a C-section too just in case

159

What are the first 2 things to do with placenta previa?

1. Stabilize momma: IV, CBC, Type and Cross
2. Assess baby: Monitor, US, determine gestational age/maturity, fetal HR monitoring

160

If momma is stable and baby is preterm, what do you do with a placenta previa?

1. Amniocentesis for lung maturity

-If mature: Delivery by C-section
- If immature: Bed rest, transfusions

161

In a placenta previa, if the baby is immature and you are trying to hold it in, what are 3 drug considerations to remember?

1. Caution use of tocolytics: Magnesium sulfate id DOC
2. Beta mimetics could mask tachycardia
3. RHOGAM BABY

162

When is Rhogam given?

Rh- momma, Rh+ baby
-Give at 28 weeks... after birth, if baby is Rh-, everything is happy and merry... it baby is Rh+ another dose Rhogam within 72 hours of delivery

-ALWAYS DOCUMENT THAT YOU OFFERED RHOGAM

163

1 vial of Rhogam covers how much mixing of maternal and fetal blood?

15cc

164

What is the blood test to determine the amount of fetal Hb transferred to maternal blood?

Kleihaure- Betke

165

Soooo... since Rhogam vial only covers about 15cc mixing, what do you do if this Kleihaure-Betke test shows that more blood has mixed for whatever reason?

GIVE MORE VIAL OF RHOGAM...whoooooop

166

If momma or baby is unstable with placenta previa, what do you do?

C-SECTION

167

If where is a low lying placenta, momma and baby are stable... what can you do?

Attempt a vag delivery
1. Fetal head should tamponade the bleeding
2. Buuuuut... do a double set up with prep for a C-section

168

What happens in 1/120 births, with a fetal death rate of 1/500, and 80% occur prior to the onset of labor?

Placental abrupion

169

What is the age of viability?

24 weeks

170

What is a normal baby HR?

110-160

171

What is used to tell how far along baby is?

Uterine height

172

If the baby is below the umbilicus, how far along is it?

Under 20 weeks- NO C-SECTION

173

How do you save baby?

SAVE MOMMA (#1 COD for fetal is maternal shock)

174

What are risk factors for placenta abruption?

1. Maternal hypertension
2. Cocaine abuse, especially “crack”
3. Trauma
4. Smoking
5. Polyhdraminios and multiple gestation- rapid decompression of an over-distended uterus
6. Previous Abruption 5% recurrence, if two or more 25% recurrence rate

175

What is the gestational age where the baby should be okay?

Over 32 weeks...under this.. significant morbiditiy

176

Why can polyhydraminos cause placenta abruption?

With lots of amniotic fluid, when the water breaks there is a rapid decompression of the uterus and the placenta can just detach off

177

What is the most common cause of DIC in pregnancy?

Placenta abruption

178

What are complicating factors with placenta abruption?

1. Perinatal mortality rate due to abruption, is 35%.
2. Accounts for 15% of third trimester stillbirths.
3. 15% of livebirths have neurologic damage.
4. Most common cause of DIC in pregnancy.
5. Hypovolemic shock, renal failure.
6.Sheehan’s syndrome

179

What is the MOA of placenta abruption?

1. Hemorrhage into the decidua basalis with formation of a hematoma.
2. The seperation of the decidua from the basal plate perpetuates itself causing further separation as well as compression and destruction of tissue.
3. If the blood dissects upward into the fundus, it will cause a concealed hemorrhage.
4. If the blood dissects downward it will be revealed.

-Sorry...too lazy to make fancy questions out of this... and he didn't spend time talking about it anyways

180

What is it called when there is a blueish purple discoloration to the uterus caused by blood dissecting into the myometrium?

Couvelaire Uterus

-Blueberry appearing--> Blood into myometrium after abruption

181

If a lady has a couvelaire urterus, what does she need?

Hysterectomy

182

What is the hallmark of placenta abruption?

Painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone

183

What makes the diagnosis of placenta abrption?

Clinical... US isn't very affective

184

What % of ladies with placenta abruption have vag bleeding and what does it look like?

80% and it's dark red (because it dissected, it is deoxygenated by the time it gets out)

185

What are other symptoms/issues seen with placenta abruption?

1. Pain: 66%
2. Fetal Distress: 60%
3. Uterine Hyperactivity: 34%
4. Fetal Demise: 15%

186

What will the abdomen be like with a placental abruption?

HARD BELLY
-It will feel like a contraction that isn't going away

187

What are 6 aspects of management for placental absruption?

1. Stabilize Mother
2. IV’s
3. Serial Coagulation Profiles
4. Keep blood products on hand (DIC)
5. Fetal Monitoring
6. Vaginal Delivery preferred route. C-section for obstetrical reasons only

188

What is the complete separation of the uterine musculature through all of it's layers?

Uterine rupture

189

Where is the fetus in uterine rupture?

Extruded into the abdomen

190

What is the incidence of uterine rupture?

0.5%

191

When can uterine rupture occur?

During or before labor, or at the time of delivery

192

What % of uterine ruptures are associated with previous uterine scar?

40%

1. C/S most common- with prior LTCS -0.5% risk, with a previous vertical incision 5% risk.
2. Myomectomy
3. Metroplasty

193

What % of uterine ruptures occur in previously unscarred uterus?

60%

-GRand multip, ect... I think this was 5+ pregnancies?

194

What are 2 complicating factors with uterine rupture?

1. Maternal mortality 1%
2. Fetal mortality 32%

195

What are 6 things used to diagnose uterine rupture?

1. Must have high index of suspicion.
2. Sudden onset of intense abdominal pain and vaginal bleeding
3. Hyperventilation, agitation and tachycardia
4. After rupture, momentary relief of pain but it returns.
5. Fetal Distress
6. Palpable fetal parts in abdomen.

196

What is done for uterine rupture?

1. Immediate laparotomy
2. Usually a total abdominal hysterectomy is performed (TOC)
3. Possibly a debridement of rupture site and primary closure if fertility is still desired by patient

197

Where are the contractile fibers located in the uterus?

Upper 2/3

198

What is removed in a TAH?

Uterus and cervix (subtotal leaves cervix and takes uterus)

199

If you had a C-section and the cut up high, can you ever do a vag delivery?

Probs not... if you had a low transverse incision, possible (because of where contractile fibers are located

200

Just gonna toss in some stats about vasa previa...

1. Incidence - 1/5000.
2. Rupture 0.1 to 0.8%.
3. 50% fetal mortality.
4. If membranes rupture, 75% mortality.

201

What is the % indicence of postpartum hemorrhage?

4%

202

What is the physiology of postpartum hemorrhage?

The uterus fails to contract around the myometrial spiral arterioles and decidual veins at the attachment site after placental separation

203

What is the number 1 cause of postpartum hemorrage?

Uterine atony

204

What is the number 2 cause of postpartum hemorrhage?

Genital tract trauma... laceration on vag wall, cervix, ect... this is a highly vascular area, especially when pregnant

205

What are some other causes of postpartum hemorrhage?

1. Retained placental fragments
2. Uterine Inversion
3. Low Placental Implantation
4. Coagulation disorders: Abruption, retained dead fetus, inherited coagulopathy, amniotic fluid embolism

206

What causes the majority of postpartum hemorrthage?

Uterine Atony (75-80%)

207

What are predisposing factors to uterine atony?

1. Overdistension of the uterus: Multiple gestation, polyhydramnios, fetal macrosomia
2. Prolonged Labor
3. Grand Multip (>5)
4. Pitocin stimulation/ Magnesium Sulfate Tx.
5. Chorioamnionitis

208

What is a drug like oxytocin that induces contractions and can be used pre and post partum?

Pitocin

209

Why is pitocin used postpartum?

Get the placenta out... AFTERBIRTH...MMMMMM

210

Can oxytocin receptors become saturated?

YES

211

What are 2 uses of magnesium sulfate?

1. Gestational HTN: Prevents the conversion of pre-eclampsia to eclampsia
2. Tocolytic: Relaxes the uterus and stops contractions

212

What 3 things constitute pre-eclampsia?

1. Proteinuria
2. Edema
3. HTN

213

What constitutes plain old eclampsia?

1. Proteinuria
2. Edema
3. HTN
4. Seizures

214

How do you diagnose postpartum hemorrhage?

Inspection/palpation

-This diagnoses all causes except coagulation

215

What is the main strategy for management of uterine atony?

PITOCIN

216

What are some other options to manage uterine atony?

1. Massage
2. Methergine (ergonovine maleate)- If not HTN
3. Prostaglandin F2-Alpha
4. Cytotec
5. Embolization of Uterine Arteries- Need an IV radiologist to do this... not realistic
6. Ligation of Uterine or Hypogastric arts.
7. B-Lynch Stitch- Suture outside/around uterus to squeeze down onto it
8. Supracervical hysterectomy- Remove the uterus

217

What is the second most common cause of postpartum hemorrhage?

Genital tract trauma....lacerations of the vagina/cervix

-This is common following operative deliveries

218

How do you diagnose genital tract trauma?

EXPLORE

219

How do you manage genital tract trauma?

1. Surgical repair
2. Suture above apex
3. Conservative management if possible

220

What positions on the clock are the blood supply to the cervix that you need to watch out for if suturing?

3 and 9

221

What is retained placenta?

Fragments pieces that didn't come out

222

3 kinds of retained placenta?

Accreta, increta, percretas

223

How do you diagnose a retained placenta?

Exploration

224

What is treatment for retained placenta?

Manual removal or a D&C

225

If there is accreta with retained placenta, what might be requried?

Hysterectomy

226

What is a uterine inversion?

Turning inside out of uterus
-Happens in 1/20,000 pregnancies

227

What normally causes a uterine inversion?

Iatrogenic- Pull to hard on the cord

228

What can happen with uterine inversion?

Patient can go into profound vasovagal shock

229

How do you diagnose a uterine inversion?

It is in yo face

230

What do you do to fix a uterine inversion?

1. IV volume expansion
2. Halothane anesthesia or terbutaline to relac uterus
3. Replace with fist, give pitocin
4. Possible surgical suspension

231

Are coagulation disorders common?

NO

232

What are 4 mentioned coagulation disorders?

1. Von Willebrand’s disease (Factor 8)
2. Amniotic Fluid Embolism 80% mortality DIC
3. Placenta Abruption- DIC
4. Thrombotic thrombocytopenia

233

How do you diagnose a coagulation disorder?

It's one of exclusion

234

How do you manage coagulation disorders?

1. Support respiratory, cardio, ect.
2. Reverse coagulopathy with blood products, cyroprecipitate, FFP, ect.

235

Can you give whole blood/platelets to someone with DIC?

NO.... it will just be chewed up... give FFP yo