Third Trimester Bleeding and Postpartum Hemorrhage

Question 1

What are simple things that can cause third trimester bleeding?

Answer 1

1) pelvic exam
2) intercourse
3) preterm labor
4) ectropion

Question 2

What is placental abruption?

Answer 2

an abnormal premature separation of the placenta from the uterus

Question 3

How does placental abruption classically present?***

Answer 3

Classically presents s painful contractions***

Question 4

What are the risk factors for placental abruption?

Answer 4

1) hypertension
2) trauma
3) tobacco use
4) cocaine
5) multifetal gestation

Question 5

What is the management of placental abruption?

Answer 5

1) > 34 weeks = deliver

2) < 34 weeks = may delay delivery is mother and fetus are stable

Question 6

What is a feared complication of placental abruption?

Answer 6

DIC

Question 7

What is placenta previa?

Answer 7

Placenta located over the internal os

complete, partial or marginal

Question 8

How does placenta previa classically present?**

Answer 8

Classically presents as painless bleeding ***

Question 9

How do you diagnos placenta previa?

Answer 9

ultrasound

Question 10

What is the management for placenta previa?

Answer 10

1) pelvic rest (often hospitalization)

2) deliver as soon as fetal lungs are mature

Question 11

What is vasa previa?

Answer 11

placental vessels cross over the internal os before the fetus

Question 12

What can happen if vasa previa isn’t diagnosed quickly?

Answer 12

fetal exsanguination

Question 13

What is placenta Accreta?

Answer 13

Abnormal Attachment of placenta to myometrium

Question 14

What is the pathogenesis of placenta Accreta?

Answer 14

thin or absent decidua (endometrial lining)

Question 15

What are the risk factors for placenta accreta?

Answer 15

1) previous C-sections
2) placenta previa
3) previous D&C

Question 16

How do you manage placenta accrets?

Answer 16

C-section with hysterectomy with special considerations

Question 17

What is placenta Increta?

Answer 17

the placenta Invades the myometrium

Question 18

How do you manage placenta increta?

Answer 18

C-section

Question 19

What is placenta Percreta?

Answer 19

placenta Penetrates the uterus

Question 20

When does the uterus return to normal size after delivery and how?

Answer 20

1) starts resizing immediately after delivery and finished by 4 weeks post partum
2) do to contraction of myometrium stimulated by oxytocin and prostaglandins

Question 21

What is the definitions of postpartum hemorrhage?

Answer 21

1) > 500ml blood loss for vaginal surgery
2) > 1,000ml blood loss for C-section
3) better def = excessive bleeding that makes the patient symptomatic or results in signs of hypovolemia

Question 22

What percent of blood loss do you start to see signs and what are they?

Answer 22

1) 15-25% (1,000-15,000 ml)

2) weakness, tachycardia, sweating

Question 23

** What are the four T’s of post partum hemorrhage**

Answer 23

1) Tone (uterine atony)
2) Tissue (retained placenta)
3) Trauma (lacerations and hematomas)
4) Thrombocytopenia (coagulation defects)

Question 24

What causes most cases of PPH?

Answer 24

80% due to uterine atony

Question 25

What is uterine atony?

Answer 25

poor "boggy" muscle tone allows for continued blood flow through the spiral arteries to the placental implantation site

Question 26

How is uterine atony managed?

Answer 26

1) bimanual massage - stimulates oxytocin 2) Pitocin (oxytocin analog) 3) Methergine (not for HT pts, if doesn't work fast move on!) 4) Prostoglandins 5) Misoprostal 6) Caroprost tromethamine (PGF2alpha - a long acting prostaglandin - not for asthmatics) 7) Bakri Balloon = last straw before surgery!

Question 27

What is the etiology of a retained placenta?

Answer 27

incomplete separation

Question 28

What are the risk factors and treatment of a retained placenta?

Answer 28

1) fibroid, previous C-section or D&C | 2) Tx = manual removal or D&C

Question 29

What is a succenturiate placental lobe and why do we remove it?

Answer 29

1) an accessory lobe | 2) if not removed can lead to PPH

Question 30

When do most hematomas occur?

Answer 30

1) after forceps, vacuum or episiotomy | 2) can occur without these

Question 31

What is the management of hematomas?

Answer 31

1) non-expanding a) compression and observe 2) expanding b) surgical evacuation and repair

Question 32

What maternal risk factors put her at risk for uterine atony?

Answer 32

1) prolonged labor 2) augmented labor 3) rapid labor 4) overdistended uterus 5) chorioamnionitis

Question 33

What maternal risk factors put her at risk for coagulation defect?

Answer 33

1) history of PPH 2) preeclampsia/HELLP 3) asian or hispanic

Question 34

What maternal risk factors put her at risk for trauma?

Answer 34

1) episiotomy 2) operative delivery 3) VBAC

Question 35

How do you manage PPH?

Answer 35

1) evaluate bleeding and assess your patients overall status a) signs and Sx of blood loss b) inspect placenta c) bimanual exam to assess atony d) look for lacerations 2) review risk factors 3) assemble team 4) you may have to restart at step 1!!!

Question 36

What puts a mom at risk for uterine rupture?

Answer 36

VBAC - vaginal birth after C-section

Question 37

What is amniotic fluid embolism and what are the signs?

Answer 37

1) entry of amniotic fluid in maternal circulation | 2) respiratory distress, cyanosis, CV collapse, hemorrhage, coma