OB/GYN
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| What are the most common causes of maternal death? | -Hemorrhage
-Embolism
-Hypertensive disease
-infections
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| antepartum hemorrhage? | significant bleeding that occurs during the third trimester, or after 20/24 weeks gestation
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| initial evaluation of bleeding patient includes? | -establish hemodynamic stability
-2large bore IV/Central venous line
-vitals/mental status
-CBC/coag profile/4units crossmatch
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| when should a pelvic exam be perfomed in a patient with antepartum hemorrhage? | after U/S has ruled out presence of placenta previa
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| placenta previa? | an abnoramally implanted placenta
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| two most common causes of antepartum hemorrhage? | -Placenta previa
-placenta abruption
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| classic presentation of placenta previa? | painless vaginal bleeding after mid-second trimester
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| classic presentation of placenta abruption | painful contractions accompanying significant vaginal bleeding after mid-second trimester
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| complete placenta previa | placenta completely covers the internal os of the uterine cervix
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| partial placenta previa | placenta partially covers the internal os
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| marginal placenta previa | placenta with edge extending to margin of internal os
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| low-lying placenta | edge of the placenta is within 2cm of the internal cervical os
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| incidence of placenta previa before 20 weeks gestation | 4-6%
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| 90% placenta previa resolve by third trimester due to? | upward placental migration
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| factors predisposing to placenta previa | 1 multiparity
2 multiple gestation
3 increasing maternal age
4 prior placenta previa
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| Management of placenta previa depends on? | GESTATIONAL AGE
AMOUNT OF BLEEDING
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| goal in management of placenta previa | obtain fetal lung maturity without compromising the health of the mother
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| if the patient reaches 36 weeks? | assess lung maturity by amniocentesis
deliver by C/S
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| why should a patient with previa deliver vaginally? | lower uterine segment is poorly contractile>>increased postpartum bleeding
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| what can exacerbate bleeding in previa/ | PLACENTA ACCRETA
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| placental accreta/increta/percerta | abnormal attachment to:
1- uterine wall (no nitabuch's layer
2- placenta penetrates into myomet
3- placenta penetrates through myome
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| Abruptio placenta | premature separation of a normally implanted placenta
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| risk factors for placental abruption | -maternal hypertension
-prior abruption
-trauma
-polyhydraminos w/rapid compression
-PPROM
-short umbilicus
-cocaine/cigarette
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| pathophyhsiology of placental separation | hmg into decidua basalis >>hematoma>> compression/destruction of placental tissue
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| concealed hemg | blood dissect upward toward the fundus
more dangerous than revealed
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| revealed hmg | blood extends downward toward the cervix
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| couvelaire uterus | bleeding into myometrium of the uterus, discolored uterine surface.
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| complication seen more often with placental abruption than previa | -coagulopathy. 2ndry to hypofibrinogenemia
-fetal to maternal hmg
-DIC
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| how is placental abruption dx? | clinically, U/s detects only 2%
may coexist with placenta previa, so do U/S even if suspecting abruption
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| management of abruption? | maternal hemodynamics and fetal monitoring, serial hematocrit, coag profile, delivery.
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| should tocolytics be used in abruption? | NO. uterine tone is needed to control bleeding
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| complications of abruption | fetal: hypoxia>death
maternal: DIC/Hypovol> acute renal faliure/sheehan syndrome
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| uterine rupture? | complete separation of the uterine musculature through all of its layers
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| incidence of uterine rupture? | .5 %
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| causes of uterine rupture? | -spontaneous
-traumatic
-prior uterine scar
before labor/during labor/@ delivery
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| Dx of uterine rupture | sudden onset intense abdominal pain w/some vaginal bleeding
abnormal fetal heart rate pattern/fetus more easily palpated
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| management of rupture? | immediate laparotomy
debridment and closure or hysterectomy.
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| dx of fetal bleeding? | Apt test. vaginal blood put into tube add water and KOH>> color stays red??fetal blood.
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| when does fetal bleeding occur | vasa previa? umblical cord vessels inserted into the membrane with the vessels overlying internal os.
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