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OB Hemorrhage
| Question | Answer |
|---|---|
| Most massive hemorrhages occur | after delivery, most commonly caused by uterine atony |
| Greatest cause of pregnancy related deaths worldwide | Hemorrhage (28%)/ one quarter |
| Conceptualizing Hemorrhage in OB | Obstetrical, Medical, Surgical |
| Class 1 blood loss | 900ml, 15% lost, Signs and Sx: usually none |
| Class 2 blood loss | 1200-1500mL, 20-25%, Signs and Sx: ↑pulse, respiratory rateorthostatic changes↓capillary refill, ↓pulse pressure |
| Class 3 1800-2100mL, 30-35% | marked tachycardia, tachypneacold, clammy skin |
| Class 4 >/=2400mL, >/=40% | weak or absent pulse, BPoliguria, cardiac arrest |
| Causes of hemorrhage during pregnancy | trauma, ectopic pregnancy, placenta previa, abruptio placenta |
| Placenta Previa | Abnormal implantation. Historically presented as painless vaginal bleeding in the absence of contraction. Now diagnosed by US. Pelvic Exam can result in disruption of the placenta with catastrophic results |
| First thing to do with pregnancy bleeding | US |
| Abruptio Placentae | Premature Separation. Partial wtih concealed hemorrhage, Partial with apparent Hemorrhage, Complete separation concealed hemorrhage |
| Indicator of palcenta separation | fetal distress |
| Risk factors for Abruptio Placenta | HTN, trauma, smoking, cocaine use, PPROM, chorioamnionitis, rapid decompression of the uterus, thrombophilia |
| Couvelaire uterus | is a life threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity. |
| Causes of postpartum Hemorrhage | Uterine rupture, uterine inversion, birth trauma, retained placenta, uterine atony, disseminated intravascular coagulation, von Willebrand's dz or another bldg disorder |
| Failure of the uterus to contract | Uterine atony. Top cause of postpartum hemorrhage |
| Uterine rupture | 1/2000 deliveries. Usually associated with previous uterine surgery. May occur spontaneously |
| Don't pull on the umbilical cord to retrieve the placenta b/c | you don't want to cause uterine inversion if in case the placenta has not yet separated from the uterine wall. |
| Uterine Inversion | Shock is out of proportion to blood loss. Not neccessarily associated with cord traction. Associated with uterine atony, fundal placenta, first baby |
| Birth Trauma more common with: | Forcepts delivery, vacuum extraction delivery, first baby, large baby, precipitous labor and delivery, episiotomy |
| Retained Placenta | retained placental fragments, placenta accreta (embedded in the wall of the uterus). Usually give 30 minutes for placenta to come out on its own (uterine massage used) |
| Placenta Accreta | 78%, to the myometrium |
| Placenta Increta | 17%, into the myometrium |
| Placenta percreta | 5%, through the myometrium to the uterine serosa. May invade into adjacent structures like the bladder or rectum |
| Normal Placenta formation | placenta decidua |
| Uterine Atony risk factors | Chorioamnionitis, over-distended uterus, long labor, oxytocin in labor, magnesium sulfate, general anesthesia, multiparity, previous postpartum hemorrhage |
| Magnesium sulfate | used for abolishing contractions in preterm labor, preventing seizures in preeclampsia. May interfere with uterine contractility |
| Uterine Atony Tx | Oxtocics: oxytocin, prostaglandin f2alpha, misoprostol, methylergonovine, bimanual compression |
| Surgical Tx of uterine hemorrhage and atopy | curettage, laparotomy, B-lynch suture, uterine artery ligation, progressive uterine devascularization, hypogastric artery ligation, hysterectomy, embolization |
| B-lynch suture | A technique that forces the uterus to contract by weaving a suture through it. |
| Assessment of Pt who presents with bleeding | hx and quantification of blood loss, vital signs and physical assessment, fetal assessment: fetal heart tones, fetal monitor, US. Lab assessment |
| Immediate interventions in a bleeding pts | IV access with one or two 16-18 gauage catheters, supplemental oxygen, foley catheter |
| Lab assessment | type and crossmatch, CBC (hct, hgb, plt), coagulation studies, Kleihauer-Betke |
| Classic presentation of Placenta previa | painless vaginal bleeding in the 3rd trimester. Vaginal exam is contraindicated |
| Placental Abruption | premature spearation of the normally implanted placenta from the uterine wall, resulting in hemorrhage. 50% occur before labor after week 30. |
| Large placental separations may result in | premature delivery, uterine tetany, disseminated intravascular coagulation (DIC), and hypovolemic shock |
| Classic presentation of placental separation | 3rd trimester vaginal bleeding associated with severe abdominal pain and/or frequent, strong contractions, firm/tender uterus |
| Classic sign of placental abruption that can only be seen at the time of c-section delivery | Couvelaire uterus |
| Major risk factors for placental separation | HTN (chronic or gestational) and previous hx of abruption |
| Management of a uterine rupture | Immediate laparotomy and delivery of the fetus |
| Non-obstetric causes of bleeding | cervical (severe cervicitis, polyps, CA), Vaginal/Vulvar (lacerations, varices, CA), Hemorrhoids, congenital bleeding disorder, abdominal or pelvic trauma, hematuria |
Created by:
ltm12