Term
| 2 common causes of antepartum bleeding: |
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Definition
- Placenta previa
- Abrutio placentae |
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Term
| look up terms like antepartum and perperiunium |
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Definition
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Term
| Uncommon causes of antepartum bleeding: |
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Definition
- uterine rupture
- fetal chorionic vessel rupture
- cervical/vaginal lacerations
- cervical/vaginal lesions like cancer
- congenital bleeding disorders |
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Term
| Placenta previa is the implantation of the placenta over the __ __. |
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Definition
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Term
| 3 types of placenta previa: |
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Definition
- Total/complete placenta previa
- Partial previa
- Marginal previa |
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Term
| A __ __ can give false appearance of placenta previa. |
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Definition
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Term
| 1 in 200 live births - placenta previa |
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Definition
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Term
| Risk factors for placenta previa: |
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Definition
- Previous placenta previa
- Previous C section
- 4 prior C sections
- Multiparity
- Advanced maternal age
- Smoking
- Asian or African
- Previous D&C |
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Term
| Suspect previa in all patients with __ __ after __ weeks. |
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Definition
| - vaginal bleeding after 24 weeks |
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Term
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Definition
| - ultrasound: abdominal (7% false positive rate) or transabdominal |
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Term
| Management of expectant pregnant woman with placenta previa? |
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Definition
1. Hospitalization
2. Daily fetal monitoring
3. Steroids for fetal lung maturation
5. Tocolysis |
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Term
| Management for delivery of mother with placenta previa? |
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Definition
- Elective at greater than 37 weeks or positive fetal lung maturation
- Emergent: threat to mother and nonreassuring fetal status |
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Term
| Complications of placenta previa: |
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Definition
1. Fetal morbidity b/c preterm delivery
2. Maternal morbidity: shock, PPH, pituitary necrosis, and placenta accreta |
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Term
| Placenta accreta is growth of the placenta into the ___. |
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Definition
- myometrium
- 4% incidence of accreta with previa
- 16-25% incidence of accreta with C section |
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Term
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Definition
an abnormal placental implantation in which the anchoring placental villi attach to the myometrium, rather than being contained by decidual cells. This results in a placenta that is abnormally adherent to the uterus.
Placenta Increta
Placenta Percreta |
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Term
| Placenta Increta and Placenta Percreta, look up difference: |
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Definition
Placenta percreta has gone past the myometrium and into the serosa
look up differences |
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Term
| Placenta accreta occurs when there is abnormal placental implanation in which the anchoring __ __ attach to the ___, rather than being contained in the __ __. This placenta is abnormally ___ to the uterus. |
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Definition
- placental villia
- myometrium
- decidual cells
- adherent |
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Term
| A 26 year old G2P1 with previous C/S, presents to labor and delivery at 32 weeks gestation with complaints of vaginal bleeding. She reports that she had a gush of bright red blood prior to arrival. She denies abdominal pain or contractions. A small amount of bright red blood is noted at the introitus and there is no free bleeding. Her BP is 120/80, pulse 92, fetal status is reassuring, no contractions are noted. Labs: Hgb of 9.2, hct 27, elevated fibrinogen and nl coags. The next step in her evaluation should be: |
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Definition
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Term
| The patient is hospitalized and placed on bed rest. Her pregnancy progresses to 35 weeks gestation and she begins to bleed profusely. A C/S is performed and the placenta is noted to extend through the uterine serosa to the bladder. This is most consistent with: |
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Definition
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Term
| The umbilical cord normally starts in the middle of the uterus and is covered in Wartons jelly. If vessels start on the __ of the ___ and are ___, it is called a __ __ insertion. When the __ cord passes over the cervical os, it called ___ __. |
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Definition
- edge of the placenta and is unprotected, it is called a vilamentous cord insertion
- vilatmentous cord passes over the cervical os it is called vasa previa
SO IF YOU FEEL PULSE> DO NOT RUPTURE MEMBRANES B/C WOULD CAUSE FETAL BLEED |
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Term
| A Velamentous cord placental insertion is __. The vessels are only surrounded by __ __, not Wharton's jelly. |
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Definition
- membranous
- fetal membranes |
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Term
| Velamentous cord insertion is more common with __. |
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Definition
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Term
| Placental abruption is __ __ of a __ __ placenta after __ weeks of gestation. |
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Definition
- premature separation
- normally implanted placenta
- after 20 weeks of gestation |
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Term
| premature abruption occurs in 1 in 75 to 200 births |
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Definition
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Term
| Placental Abruption risk factors: |
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Definition
- maternal HTN
- Cocaine
- PPROM
- Maternal trauma
- Sudden decompression
- Cigarette smoking
- Fibroids
- Thrombophilias |
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Term
| Placental abruption after 20 wks gestation becomes ___, anything before this becomes __ __. |
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Definition
delivery
spontaneous abortion |
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Term
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Definition
| Blood accumulating around placenta> will have vaginal bleeding But not every abruption will present with bleed b/c may be concealed bleeding. Pain, contractions, vaginal bleeding, and feta distress. |
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Term
| Triad of placental abruption: |
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Definition
PAIN
BLEEDING
FETAL DISTRESS |
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Term
| Placental abruption is a __ __, whereas placenta previa is diagnosed via __. |
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Definition
- clinical diagnosis
- ultrasound |
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Term
| Diagnosis of placental abruption: |
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Definition
- Fetal Heart Rate
- Premature uterine contractions
- Ultrasound
- Lab tests: low platelets, low fibrinogen, and anemia |
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Term
| what abnormal lab findings could be indicative of placental abruption? |
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Definition
- low platelets
- low fibrinogen
- anemia
These patients are at risk for DIC |
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Term
| placental abruption puts one at risk for: |
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Definition
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Term
| Placental abruption management: |
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Definition
Admit to L&D
Delivery may be delayed if Fetus stable.
Deliver if maternal or fetal condition deteriorates, vaginal delivery desirable.
Tocolytic drugs; MgSo4, avoid B-mimetics (Terbutaline)and prostaglandin inhibitors. |
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Term
| 2 drugs to avoid with placental abruption: |
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Definition
beta agonists (terbutaline)
prostaglandin inhibitors |
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Term
| What type of delivery is best for placental abruption and why? |
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Definition
| vaginal delivery is best if possible b/c C section is more stress and bleeding |
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Term
| Placental Abruption complications: |
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Definition
- hemorrhagic shock
- DIC (consumptive coagulopathy)
- renal failure
- couvelaire uterus
- fetal maternal hemorrhage |
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Term
| Look for fetal cells in maternal circulation, if there are cells, you know some type of abruptioin happened. Trichlor V test with V stain |
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Definition
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Term
| A 36 yr old female G2P1 at 32 weeks gestation presents with a history of uterine tenderness and dark red vaginal bleeding. She has chronic hypertension and smokes ½ pack cigarettes/day. FHR tracing is reassuring, uterine irritability is noted. She has mild abdominal tenderness on exam and scant blood at the introitus. Ultrasound reveals anterior placenta, normal fluid, normal fetal status. A speculum exam reveals friable cervix but no free bleeding. Cervix is not dilated. Her hgb is 10.2 g/dl. |
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Definition
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Term
| A 24 year old female, G3 P2 at 40 weeks gestation, with one previous c/s presents to labor & delivery with severe abdominal pain and vaginal bleeding. She has had an uneventful pregnancy. An ultrasound in 2nd trimester revealed a fundal placenta. The cervix is 4 cm dilated and no presenting part is palpable. Fetal monitoring reveals a bradycardic fetus. At the time of C/S, most likely you will find |
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Definition
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Term
Abruptio Placenta
Predisposing factors
Maternal hypertension
Previous abruption
Trauma
Tobacco use
Diagnosis
Painful bleeding
Clinical
Maternal risks
Massive hemorrhage/DIC
Fetal risks
Perinatal mortality – 35%
Fetal demise
Neurologic sequelae |
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Definition
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Term
Placenta previa
Predisposing factors
Multiparity
Age > 35
Prior previa
Multiple gestation
Diagnosis
Painless bleeding
Ultrasound
Maternal risks
Accreta, increta, percreta
Massive hemorrhage/DIC
Fetal risks
Preterm morbidity/mortality
Fetal death |
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Definition
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Term
| Risk factors for uterine rupture: |
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Definition
- trauma
- prior uterine scar
- spontaneous |
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Term
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Definition
- sudden intense pain
- +/- vaginal bleeding
- retraction of fetal parts
- fetal distress |
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Term
Uterine rupture
Predisposing factors
Trauma
Prior uterine scar
Spontaneous
Diagnosis
Sudden intense pain
+/- vaginal bleeding
Retraction of fetal parts
Fetal distress
Maternal risks
Shock
Death
Fetal risks
32% mortality rate |
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Definition
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Term
Vasa Previa
Predisposing factors
Velamentous cord insertion
Multiple gestation
Diagnosis
Severe vaginal bleeding
Fetal distress
Apt test
Maternal risks
This is fetal bleeding
Fetal risks
75% mortality |
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Definition
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Term
| Postpartum hemorrhage is defined as occuring within the first __ hours after delivery. For a vaginal delivery it is more than ___. For a C/S it is more than ___. |
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Definition
- 24
- 500 cc EBL
- 1000 cc EBL |
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Term
| Causes of post-partum hemorrhage: |
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Definition
- UTERINE ATONY
- genital tract trauma
- retained placental tissue
- uterine inversion
- Coagulation d/o
- Abrupto placentae
- Amniotic fluid embolism
- Retained dead fetus
- inheritid coagulopathy |
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Term
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Definition
top 3 causes:
Failure of compression of blood vessels at the implantation site of the placenta
(atonic ut., retention of placental tissue)
Trauma to genital tract
Coagulation defects. |
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Term
| Management of postpartum hemorrhage: |
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Definition
1. Vigorous massage trying to make it contract again to stop bleeding
2. Use of uterus contractile agents: Oxytocin (main one) or Methylergonovine, prostaglandin F2α, manual exploration, inspection, curettage, tamponade, hysterectomy. |
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Term
| A 27 year old gravida 6 para 5 presents for induction of labor at 38 weeks for hypertension. After 18 hours of pitocin, she has a spontaneous vaginal delivery of a 9 lb baby. Following delivery, she experiences a postpartum hemorrhage. The most common cause of postpartum hemorrhage is: |
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Definition
| uterine atony (number 1 cause) |
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Term
| While evaluating the possible causes of her bleeding, you note that the uterus is boggy despite vigorous fundal massage and the use of an oxytocin drip. You determine that she is in need of an additional uterine contractile agent. Which of the following is CONTRAINDICATED in this patient? She has HTN. |
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Definition
Methylergonovine (Methergine): DON'T GIVE THIS TO SOMEONE WITH HTN B/C IT IS A VERY POWERFUL VASOCONTSRICTOR
Also this drug is only PO or IM, if given IV> heart attack |
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Term
| What drugs could you give a lady with HTN to get her uterus to contract down again if oxytocin is not working? |
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Definition
B. Prostaglandin (Hemabate)
C. Dinoprostone (Prostin)
D. Misoprostol (Cytotec)
E. Continuation of oxytocin |
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Term
| A 22 year old gravida 2 para 1 with a previous c/s presents in labor. After an uneventful vaginal delivery of a 7 lb baby, you decide to manually remove the placenta after 35 minutes. Following removal the patient bleeds profusely. Fundal massage reveals firmness alternating with bogginess. Uterotonic agents are utilized without success. The most likely cause of her hemorrhage is: |
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Definition
retained products of conception (bogginess alternating with firmness)
treat with curettage |
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Term
| An 18 year old female presents in labor. She has a known history of VonWillebrands disease. Following delivery, she has profuse vaginal bleeding requiring replacement transfusions. Which product will replace the deficiency that causes VonWillebrand’s Disease? |
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Definition
| Cryoprecipitate (if that is not available give fresh frozen plasma- has all the factors) |
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Term
| FFP has all clotting factors, and NO platelets. |
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Definition
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Term
| Cryoprecipitate has __, factors __ and __, and __. |
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Definition
- fibrinogen
- VIII
- XIII
- vWF |
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Term
| An 18 year old gravida 1 presents in labor. Five minutes after an uneventful delivery the placenta is delivered. Excessive hemorrhage is noted. On exam, there is a purple mass at the introitus and the fundus is not palpable. The most common cause of this catastrophic event is: |
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Definition
| mismanagement of third stage of labor, She delivered the placenta really really fast so something happened. Probably pulled too hard on the cord. Should be gentle tension on the cord, not a jerk. This is a catastrophic event. Severe hypotension and bleeding results. Patient collapses. Immediately call anesthesia pple to help get bp up. |
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Term
| Management of uterine inversion: |
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Definition
- Nitroglycerin to relax
- Call anesthesia for backup
- Replace the uterus |
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Term
| what would be contraindicated with uterine inversion: |
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Definition
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Term
| A 32 year old female gravida 2 para 1 delivers a healthy 8 lb baby. After an uneventful vaginal delivery, the patient becomes cyanotic and experiences cardiopulmonary arrest. You begin CPR and the patient expires. The most likely diagnosis is: |
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Definition
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Term
| A 17 year old gravida 1 was delivered by forceps following a 2 hour second stage of labor. A midline episiotomy was performed to assist with delivery. The patient recovers and is transferred to the postpartum unit. Four hours later, the patient becomes hypotensive and tachycardic. She has minimal vaginal bleeding and her fundus is firm. The most likely cause is: |
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Definition
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