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Preterm labor/hemm

QuestionAnswer
Preterm birth 20-37 weeks after first day of last menstrual
Second leading cause of neonatal mortality preterm
mortality rate after 23 weeks 84%
Survival with preterm improves with each week that labor is delayed
Look at fetal development slide slide 9
Most common causes of preterm death Most common is resp distress but others include patent ductus arteriosus, intravent hemm, and necrotizing enterocolitis
There is a decline in morbitidy between 32-36wks
Look at table 1 for risk factors of preterm slide 12
Describe etiologic sequelae for preterm A person can have allergy or mulptiple preg, uterine abnormalities or polyoligohydraminos or uterine distension that leads to: amiochorion decidua->inflam->prostglandin synth->preterm
What is the most consistent risk factor for preterm Hx of preterm delivery bc that suggests a genetic contribution
What hormone cut down on preterm births by 1/3 Progesterone
S/S preterm labor Findings of persistent uterine contractions ( 4 in 20 minutes) Intermittent abdominal cramping Menstrual-like cramping Pelvic pressure Backache Increase in vaginal discharge Vaginal spotting or bleeding
What confirms preterm labor Cervical dilation of 2cm or effacement of 80% confirms preterm labor
5 criteria to begin tocolytic therapy Gestational age between 20 and 34 weeks Fetal weight less than 2500 grams Absence of fetal distress No clinical signs of infection Weighing maternal vs Fetal risk of tocolytic therapy
Tocolytic Anticontraction
Contraindications to stopping labor - 6 reasons for contraindication of long term inhibition Fetal death Fetal anomalies incompatible with life Fetal distress that warrants immediate delivery Chorioamnionitis Severe hemorrhage Severe chronic and/or pregnancy induced HTN
Relative contraindiction to stopping labor Cervical dilation > 4cm, ruptured membranes, SGA fetus and maternal cardiac disease
Treatment/delay tactics for preterm labor Bedrest Hydration Tocolytic therapy
2 kinds of tocolytic therapies PRROM and chorioamnitis
General MOA tocolytics and types available Promote uterine relaxation by interfering with myometrial contraction- reduce free Ca or Beta adrenergi. Most reduce free Ca.
How do beta adrenergics work as tocolytics Beta-adrenergic agents promote intracellular storage of calcium by interfering with adenylyl cyclase, which in turn perpetuates an increase in cAMP
How do Ca and Mg work as tocolytics Magnesium and Calcium antagonists act by inhibiting the influx of calcium through the cell membrane
Mag sulfate dose and MOA Anatgonizes intracell Ca. 4-6g loading with 2-4g every hour after
Terbutaline (Bricanyl)dose and MOA Beta 2 agonist sympamimetic that decreases intracell Ca. 0.25-0.5mg SC Q3-4 hrs
Ritodrine (Yutopar) dose and MOA Beta 2 agonist sympamimetic that decreases intracell Ca. 0.05-0.35mg per minute IV
Nifedipine/procardia dose and MOA CA channel blocker. 5-10mg SL Q15-20 min to a max of 4x. Then 10-20mg Q4-6 hours
Indomethacin dose and MOA Prostoglandin and cyclooxygenase inhibitor. 50-100mg rectal then 25-50mg orally Q6hr
6 Potential complications with mag sulfate pulmonary edema, profound hypotension, profound musc paralysis, maternal tetany, cardiac arrest, respiratory depression
8 potential complications with beta adrenergics hypokalemia, hyperglycemia, hypotension, pulmonary edema, arrythmia, cardiac insufficiency, myocardia ischemia, maternal death
3 potential complications with indomethacin renal failure, hepatitis, GI bleed with chronic use
potential issue with nifedipine transient hypotension
Antenatal corticosteroids - why are they used, at what time period, MOA, what kind of timeframe is best for benefits Use: Reduce risk and severity of RDS Time: 24 – 34 weeks gestation MOA: Corticosteroids promote fetal lung maturation by inducing production of surfactant Optimal benefits: within 7 days of delivery
Why are preterm babies more vulnerable to depressant effect of anesthesia? (5 reasons) Dec protein for drug binding– drug affinity by the protein that is present Higher levels of bilirubin, which may compete for protein binding Greater drug access to the CNS due to incomplete blood-brain barrier dec ability to metabolize and excrete drug
What do preterms have a higher incidence of at delivery Higher incidence of acidosis during labor and delivery
Is anesthesia harmful or beneficial to preterms Its better, there have been less deaths perinatally when given anesthesia
Review 37.1 in text 37.1
5 reasons for antepartum hemm Abortion Ectopic gestation Placenta previa Abruptio placenta Vasa previa
3 reasons for intrapartum hemm Uterine rupture Splenic or hepatic rupture Some sources include abruptio placenta as being intrapartum hemorrhage *may also be related to antepartum mechanisms
6 reasons for postpartum hemm Placental implantation abnormalities Uterine inversion Uterine atony Retained placenta Lacerations Ischiorectal hematoma
14 risk factors for hemm Elderly gravida Macrosomia Previous uterine surgery Abnormal fetal presentation Difficult delivery Tocolytics Antepartum problems Grand multipariety Placental abnormalities Maternal trauma Uterine infection prev hemm forcep/vacum obesity dm p
Abruptio placentae accounts for... 31% OF ALL THIRD TRIMESTER BLEEDING
Abruptio placentae defined SEPARATION OF THE PLACENTA FROM THE DECIDUA BASALIS BEFORE DELIVERY OF THE FETUS
Abruptio placentae incidence OCCURS IN ABOUT 1.3 % OF ALL PREGNANCIES (& INCREASING) WITH THE MAJORITY OCCURING AT LESS THAN 36 WEEKS GESTATION IT RECURS IN 9% OF THOSE WITH PREVIOUS ABRUPTION
Clinical diagnosis of abruptio placentae Dx with U/S PAINFUL VAGINAL BLEEDING PORT WINE - NON-CLOTTED BLOOD BLOOD LOSS OFTEN CONCEALED All of these lead to fetal death
7 s/s abruptio placentae Painful vaginal bleeding Uterine tenderness/Back pain/Abdominal pain Fetal distress High frequency contractions Uterine hypertonus (tetanic contraction) Preterm labor Dead fetus
9 risk factors for abruptio placentae MATERNAL COCAINE USAGE CIGARETTE SMOKING & ALCOHOL CHRONIC HYPERTENSION PREECLAMPSIA SHORT UMBILICAL CORD MULTIPLE BIRTHS UTERINE ABNORMALITIES/PREVIOUS HISTORY OF PLACENTAL ABRUPTION TRAUMA HYPERTENSION
Grading of abruptio placentae ASYMPTOMATIC(Grade 0) Vag bleeding with or w/o uterine tetany, no sign of maternal shock or fetal distress(Grade1) Ext vag bleeding, no shock, but fetal distress is present(Grade 2) +maternal shock, fetal demise, and coagulopathy may be present(Grade 3
Management of abruptio placentae EVALUATION HYPOVOLEMIA COAGULOPATHY MONITORING - CVP/A-LINE ? BLOOD LOSS AGENTS FOR GENERAL ANESTHESIA
5 fetal risks with IUGR Major fetal risk: hypoxia Fetal distress and intrauterine fetal death occur more frequently with abruption than placenta previa 15% to 25% of perinatal deaths occur secondary to abruption RDS is the most common neonatal complication.
How many births are complicated with abruption due to IUGR As many as 50% of deliveries complicated by abruption
Look at slide with clinical staging of blood loss Slide 84
7 complications with IUGR UTERINE ATONY POST PARTUM BLEEDING COAGULOPATHY WITH DIC ACUTE RENAL FAILURE PITUITARY NECROSIS C/S HYSTERECTOMY ANEMIA
Most common cause of DIC abruption
coagulopathy occurs in ---% of all placental abruptions 10%
Explain DIC with abruption Separation of placenta causes a release of thromboplastin into the circulation, which in turn triggers the extrinsic coagulation cycle and there is an increase in fibrin degradation products and decrease in platelets
Lab of choice for placental abruption FDP
COUVELAIRE UTERUS : define, risk of coagulopathy,associated with, things to expect IT IS A WIDE SPREAD EXTRAVASATION OF BLOOD INTO THE MYOMETRIUM AS MUCH AS 4L OF BLOOD HAS BEEN CONCEALED THE MORE CONCEALED BLOOD THE HIGHER RISK OF COAGULOPATHY ALWAYS ASSOCIATED WITH ABRUPTIO PLACENTA HYSTERECTOMY AND MASSIVE BLOOD LOSS TO BE EXPECT
Placenta previa: incidence and definition ACCOUNTS FOR ABOUT 22 % OF THIRD TRIMESTER BLEEDING OCCURENCE IS ABOUT 3.6 per 1000 PREGNANCIES IMPLANTATION OF THE PLACENTA IN THE LOWER UTERINE SEGMENT IN ADVANCE OF FETUS
6 risk factors for placenta previa PREVIOUS C/SECTION MULTIPARIETY ADVANCED MATERNAL AGE LARGE PLACENTA PREVIOUS UTERINE SURGERY CIGARETTE SMOKING
Diagnosis of placenta previa PRESENTING PART PALPATION IN UPPER UTERINE SEGMENT ULTRA SOUND ANALYSIS,ABDOMINAL,TRANSVAGINAL MRI “RARE CIRCUMSTANCES DOUBLE SET UP IN OPERATING ROOM” “PAINLESS VAGINAL BLEEDING”
Placenta previa: uncommon effects and rate of fetal death Blood loss is not concealed Shock is not common Rare DIC unless massive blood loss (Dilutional thrombocytopenia) Fetal mortality is 4-8% (complications of prematurity) Fetal distress is UNCOMMON
3 anesthetic considerations for placenta previa “Double set-up” for dx, vaginal delivery or possible cesarean delivery Cesarean delivery for an elective hemodynamically stable parturient Cesarean delivery for actively bleeding parturient for emergency cesarean delivery (hemodynamically unstable)
3 reasons placenta previas are still at risk for intra and post operative blood loss Obstetrician may cut into placenta during uterine incision After delivery, the lower uterine segment implantation site does not contract as well as the normal fundal implantation site Patients with placenta previa are risk for placenta accreta
Vasa previa defined and when it should be suspected The velamentous insertion of the cord where fetal vessels transverse the fetal membranes ahead of the fetal presenting part. Suspect: whenever bleeding occurs with ROM, particularly if the rupture is accompanied by FHR decelerations or bradycardia
Is vasa previa bad for mom It poses no risk
2 things vasa previa is associated with Also associated with multiple gestation (triplets) It is associated with one of the highest fetal mortality rates (50% to 75%) of any complications of pregnancy
Fetal blood loss with vasa previa 250ml
Occurance of vasa previa Rare occurrence (1 in 2000 to 3000) deliveries
5 risks of getting vadsa previa Multiple pregnancies Women with low riding placentas Placenta previa Bi-lobed placenta Pregnancy from in-vitro fertilization
Created by: Twitz82 on 2011-07-16



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