OB Hemorrhage

Help!

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

🗑

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

🗑

Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.

To hide a column, click on the column name.

To hide the entire table, click on the "Hide All" button.

You may also shuffle the rows of the table by clicking on the "Shuffle" button.

Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.

Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

Normal Size Small Size show me how

Created by: ltm12