Hehi Test 3- Ob Emergencies 2/25/08

Front 1

What is the most significant cause of maternal mortality worldwide?

Back 1

obstetric hemorrhage, 1 death every 4 minutes and serious morbidity (ARDS< DIC). If the bleeding does not kill the patient, the complications might

Front 2

What are some important physiologic adaptations in pregnancy that are relevant to hemmorhage?

Back 2

* Increased blood volume to 6-7 L
* Increased plasma volume 40%
* Increased efficiency of clotting
* Impaired fibrinolysis (form clots faster and hold onto clots longer)

Front 3

Blood volume increases in pregnancy. How will this effect the signs and symptoms of shock from hemmorhage?

Back 3

Pregnant women will lose more blood before showing S&S of shock

Front 4

Hemorrhage classifications
Where will symptoms of shock begin?

Back 4

Class I: <900 cc, no clinical manifestation
Class II: 1200-1500cc, this is where symptoms begin with orthostasis
Class III: 1800-2100cc, hypotension
Class IV: 2400cc, shock

Front 5

Estimation of blood loss

Back 5

We are bad at estmating blood loss due to error, contamination with amniotic fluid
Rely on visual inspection, VS, (hypotension, dizziness, pallor, oliguria will not occur until blood loss is substantial)
BEST is to get a hematocrit

Front 6

Physiologic adaptations to hemorrhage are a response to what?

Back 6

Decreased O2 carrying capacity --> shunting of blood to the heart and brain (NOTE that uterus and placenta rank very low on priorities when O2 is low)

Front 7

What happen during primary physiologic adaptations to hemorrhage?

Back 7

Increased O2 release to tissues
Increased CO r/t vasoconstriction
*HR increases, mobilization of fluid, increased volume (preload)
* Movement of fluid from interstitial to intravascular space

Front 8

What are some additional physiologic adaptations to hemorrhage?

Back 8

*Systemic hypotension from reduced resistance (afterload)
*Increased stroke volume
*Selective arterial construction in circulatory beds (skin, kidneys, skeletal)
*Anaerobic metabolism releases fixed acids
*Systemic pH lowered
*Hyperventilation to compensate for metabolic acidosis
*Shunting of blood
NOTE that acidosis is in the tissues

Front 9

What are the goals of OB hemorrhage management? Why are these goals important?

Back 9

1. Maintain systolic BP> 90
2. Maintain adequate UOP
3. Maintain normal mental status
NOTE: treat the source of the hemorrhage
Goals are important because they indicate that kidney and brain are being perfused

Front 10

What would you do for significant bleeding management?

Back 10

IV access with large bore needle (so can get fluids in quickly
Uterine compression
Uterotonics
Draw blood for Hct, T&S or T&C, coag panel
Anesthesia must see pr on admission
Consider the location of the pt. Should you move her to the OR?

Front 11

What is the general function of uterotonics?

Back 11

Contract the uterus

Front 12

If bleeding continues, how do you manage it?

Back 12

Move to OR
Crossmatch 2 or more units
Notify surgeon (depending on cause of bleeding)
Must have a foley with at least 30cc/hr
Maintain pt temp
Consider interventional radiology (pt must have an MD and Rn with her)
Uterine packing (compresses the vessels to try and prevent blood loss)

Front 13

If bleeding is persistent, how is it managed?

Back 13

Interventional radiology for selective arterial emblization with RN and MD in attendance
Monitor O2 sat, ECG, O2
Surgical intervention (could include vessel ligation and hysterectomy)

Front 14

**List blood products that may be given in the case of hemorrhage and the expected effect they will have**

Back 14

1. Packed red blood cells (PRBC's): increase Hct 3% per unit
2. Platelets: increase platelets 5k-10k per unit
3. Fresh frozen plasma (FFP): increase fibrinogen 10mg/dl per unit
4. Cryoprecipitate (factor VIII): increase fibrinogen 10 mg/dl per unit

Front 15

What are key assessments in the case of OB bleeding?

Back 15

Trends, UOP, VS, cap refill, SaO2, ECG, ABG, labs

Front 16

What are the hematologic goals of hemorrhage management?

Back 16

Maintain fibrinogen > 100mg
Maintain platelets > 50,000
Maintain Hct > 28%

Front 17

What is placenta previa?

Back 17

Implantation of placenta over the cervical os, occurs in 1 in 200 pregnancies

Front 18

Define these types of placenta previa: total, partial, marginal, low

Back 18

1. Total: covers internal os- must have c-section
2. Partial: implants near or partially covers internal os
3. Marginal: implants near/does not cover any part of internal os- may move out of the way as the uterus grows
4. Low-lying: near region of internal os

Front 19

Placenta accreta

Back 19

Placenta implants abnormally deep, chorionic villi adhere TO the myometrium. Occurs in 75% of placenta previa cases

Front 20

Placenta increta

Back 20

invasion of chorionic villi INTO the myometrium (happens in 15-20% of placenta previa)

Front 21

Placenta percreta

Back 21

growth of chorionic villi THROUGH the myometrium (happens in 5-10% of placenta previa)

Front 22

If pt has placenta previa, she is at higher risk for...?

Back 22

Any type of placenta accreta (although this can happen even when the placenta is in the right place)

Front 23

Pathophysiology of placenta previa

Back 23

Unclear, but 50% increased risk with endometrial scarring, higher risk with impeded vascularization (htn, dm, smoking), increased risk with increased placental mass (twins)

Front 24

What predisposes a woman to placenta previa?

Back 24

Age >35
increased parity
previous c/s
prior placenta previa
multiple gestation (scarring from prior placentas in earlier pregnancies)
smoking
previous uterine surgery/scar

Front 25

**What is the hallmark of placenta previa?**

Back 25

*PAINLESS, BRIGHT RED, VAGINAL BLEEDING.
* DO NOT DO A DIGITAL EXAM UNTIL PLACENTA PREVIA IS RULED OUT
may also see evidence of uterine activity (20%)

Front 26

How do you diagnose placenta previa?

Back 26

transvaginal sonography

Front 27

How do you manage placenta previa?

Back 27

determine gestational age, monitor blood loss, assess maternal hemodynamic status, assess fetal well being, plan for c/s

Front 28

What is abruptio placentae?

Back 28

premature separation of the normally implanted placenta, can be revealed or concealed
Happens in 1 in 100 pregnancies, significant perinatal morbidity and mortality. NOTE that both mom and baby are losing blood

Front 29

What are the grades of abruptio placentae?

Back 29

Grade O: <100cc, mother asymptomatic, no fetal distress
Grade 1: 100-500cc blood lost, mother will have mild uterine tenderness, no fetal distress
Grade 2: 500cc of blood lost, mother will have pain, fetal distress is evident
Grade 3: >500cc lost, mother in extreme pain, fetal death

Front 30

Placental abruption happens in __% of all preterm births with incidence highest at __ wks

Back 30

10%
24-26 weeks

Front 31

How much blood is being pumped to the placenta per minute?

Back 31

600cc

Front 32

What are risk factors for abruptio placenta?

Back 32

*Strongly liked to previous placental abruption, cocaine and drug use, chronic HTN with preeclampsia
*Linked to cigarette smoking, multiple gestations, chronic HTN or preeclamsia, PROM, chorioamnioitis
* thrombophilias, maternal age and parity, trauma (always monitor pregnant trauma patient for minimum of 4 hrs)

Front 33

How does abruptio placentae present? *What is the hallmark?*

Back 33

RIGID, "BOARD LIKE", PAINFUL ABDOMEN, MAY OR MAY NOT HAVE VAGINAL BLEEDING
varies widely, based on location and degree
maternal tachycardia
fetal stress can lead to fetal death

Front 34

What do you do for abruptio placentae?

Back 34

IV access
Monitor hemodynamic status
Monitor fetal well-being
Corticosteroids- prn for lung maturity
If severe:
O2
Continuous fetal monitoring
T and C blood products available
Plan for c-section

Front 35

What is the definition of postpartum hemorrhage (PPH)?

Back 35

Blood loss > 500 cc after birth
10% change in Hct between admission and PP
Need for transfusion
Early= w/in first 24 hrs
Late= between 24hrs and 6 wks pp

Front 36

What is average blood loss?

Back 36

Vaginal= 500 cc
c/s= 1000cc
c/s and hysterectomy= 1500 cc
Note: typically underestimated by 30-50%

Front 37

80% of PP hemorrhages involve uterine atony. Who is at risk and why?

Back 37

-Grand multiparity b/c overdistention of the uterus
-Overdistention of the uterus
-Precipitous labor or delivery
-Prolonged labor b/c uterus has been contracting for so long that when the baby is born it is too worn out to contract anymore
-Oxytocin induction/augmentation
-Previous history of uterine atony
-full bladder after delivery

Front 38

What are some causes of postpartum hemorrhage?

Back 38

lacerations and trauma
retained placental fragments
infection
uterine inversion (uterus cannot contract well if inverted)
placental abnormalities
coagulation disorders
uterine manually exploration to check for placental fragments

Front 39

How do you manage postpartum hemorrhage?

Back 39

1. Manipulate: bladder drainage, uterine massage, uterine exploration
2. Pharmacologic: oxytocin, methergine, prostaglandin, misoprestel

Front 40

Oxytocin, a uterotonic agent

Back 40

Given prophylactically at delivery to prevent pp hemorrhage
**DO NOT BOLUS!**
dose is 10-40 U in 1L NS of LR, routes are IV, IM or IMM
Side effects include n/v, H20 toxicitiy

Front 41

Methylergonovine (methergine), a uterotonic agent

Back 41

Can be directly injected into uterus for PP hemorrhage
dose is 0.2 mg, IM, IMM **NO IV** q2-4hrs
Side effects: n/v, HTN, myocardial ischemia
Contraindicated in HTN, coronary insufficiency
**NOTE: do not give to preeclamptic patient

Front 42

Carcoprost, Hemabate, uterotonic agents

Back 42

Dose= 0.25 mg, IM or IMM every 15-90 minutes with max 8 doses
Side effects include n/v/d, flushing, fever, vasospasm, bronchospasm
Contraindicated in cardiac, pulmonary, renal or hepatic disease

Front 43

Dinoprostone, a uterotonic agent

Back 43

20 mg, rectal or vaginal, q2h
Side effects: n/v/d, HA, fever, vasodilation
Contraindicated in hypotension
Not used anymore

Front 44

Misoprostol, a uterotonic agent

Back 44

400 mcg rectal for prevention of PPH
1000mcg rectal to treat PPH (takes effect in 3 minutes)
600 mcg oral prevention
This med is new and good b/c it is cheap, placed by the nurse, not contraindicated for asthma and HTN like other uterotonics

Front 45

Surgical management of postpartum hemorrhage (if meds don't work)

Back 45

-D&C for retained placental fragments
-Laceration repair
-Uterine packing
-Uterine/hypogastric artery ligation
-Selective arterial embolization
-Hysterectomy

Front 46

What are MAST trousers?

Back 46

Used for PPH, compression device to keep blood up at brain and heart, these are a last resort

Front 47

Pelvic pressure pack

Back 47

Used for PPH when uterotonics fail

Front 48

Risk factors for uterine rupture

Back 48

-Previous c/s (worse with classical than low transverse)
-5 or more births
-Advanced maternal age
-Undiagnosed fetopelvic disproportion with obstructed labor
-Prior instrumental abortion
-Placenta previa
-Midtrimester version: to move baby when it is breech
-Uterine abnormalities

Front 49

Signs of uterine rupture

Back 49

-Abnormal FHR tracing MOST COMMON
-Change in uterine activity
-Abdominal pain (if epidural then she will not feel this pain)
-Loss of fetal station (baby was low and suddenly is higher)
-Palpable fetal parts
-Vaginal bleeding
-Sudden anxiety and restlessness
-Maternal tachycardia
**CAN BE ASYMPTOMATIC**

Front 50

Management of uterine rupture

Back 50

-Emergency c/s
-Volume resuscitation
-Blood replacement
-Uterine artery ligation
-Hypogastric artery ligation
-Hysterectomy

Front 51

What is umbilical cord prolapse?

Back 51

Protrusion of the umbilical cord past the presenting part and through the cervical os, high perinatal mortality rate b/c nothing is getting through to the baby when the cord is compressed

Front 52

Risk factors for umbilical cord prolapse

Back 52

-Fetal malpresentation (if baby is presenting breach it is easier for the cord to slip through)
-PROM
-Low birth weight (easier for the cord to slip through)
-Long umbilical cord
-Multiple gestation
-Cepahlo-pelvic disproportion
-Low-lying placenta
-Multiparity

Front 53

What obstetrical interventions pose risk for umbilical cord prolapse?

Back 53

-Manipulation or elevation of the presenting part
-AROM
-FSE or IUPC placement
-Forceps or vacuum placement
-External version

Front 54

How will umbilical cord prolapse present?

Back 54

-EFM with persistent variable decelerations or bradycardia
-Felt on VE if overt
-May not be identified if occult

Front 55

How is umbilical cord prolapse managed?

Back 55

Oxygen
Elevation of fetal presenting part
Maternal positioning (all four in knee chest to decrease pressure to the cord)
Preparation for emergent c/s
Tocolytics (if gap before can do c/s b/c they will decrease contractions and pressure on the cord)

Front 56

What is shoulder dystocia?

Back 56

Impaction of the fetal shoulders w/in the maternal pelvis (they get stuck on the pubic bone after the head delivers)
-Look for turtle sign, after the head delivers the head will suck back a bit b/c the shoulder is stuck
-Baby is not breathing in this time, must get delivered fast
-Hugely litigated

Front 57

Risk factors for shoulder dystocia?

Back 57

think of "A DOPE"
Advanced maternal age
Diabetes
Obesity
Posterm, Prior macrosomia
Excessive maternal weight gain

Also at risk are short stature, abnormal pelvic anatomy, assisted delivery, protracted first or second stage of labor

Front 58

What are maternal and fetal complications of shoulder dystocia

Back 58

Maternal: PPH, 3rd or 4th degree episiotomy (won't do any good b/c shoulder is stuck on bone), uterine rupture
Fetal: brachial plexus injury, clavicle fracture, humerous fracture, hypoxia (not getting O2, *pH will drop 0.14 per minute during delivery of the trunk*, death

Front 59

How would you anticipate and manage shoulder dystocia?

Back 59

Assess labor pattern
Squatting position
Empty bladder
Anesthesia and pediatrics at delivery
Newborn assessment
Prepare for PPH
DOCUMENT

Front 60

***What is the pneumonic HELPERR? ***

Back 60

For shoulder dystocia
H: call for Help
Evaluate for episiotomy
Legs- McRoberts maneuver (maternal thighs to abdomen)
Enter maneuvers (such as suprapubic pressure)
Remove posterior arm
Roll the patient on all fours
Note: NO FUNDAL PRESSURE EVER!!

Front 61

What are the last resorts for shoulder dystocia?

Back 61

Deliberate clavicle fracture
General anesthesia for musculoskeletal and uterine relaxation
Zavanelli maneuver (cephalic replacement followed by c/s)

Front 62

**What do you need to document in a case of shoulder dystocia?**

Back 62

Specifics about maneuvers performed
Duration of event
Team members involved
Which arm is impacted
Cord pH