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23 Cards in this Set
- Front
- Back
How many deliveries are complicated by "PPH"
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5%
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How many worldwide maternal deaths per minute result from PPH?
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4
(99% in developing countries) |
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List possible sequelae of PPH
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Death
Shock Organ damage/failure kidney, liver, GI, brain, heart, lungs Sheehan's syndrome/poor lactation Coagulopathy VTE/PE Blood product transfusion Anemia Iron deficiency Increased medical and surgical interventions |
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List the causes of PPH
(in general, e.g. 4Ts) |
Tone
Tissue Trauma Thrombin |
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What is the most common cause of PPH?
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Atony (~80%)
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What uterine/systemic mechanisms prevent PPH after delivery?
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Myometrial contraction
(contraction around bleeding vessels) Hemostatic factors Decidual (e.g. tissue factor) Systemic - coags/platelets |
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List causes for post-delivery uterine atony
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Overdistension
multiple gestation polyhydramnios macrosomia Infection Abruption (Couvelaire uterus) Drugs nitroglycerin tocolytics MgSO4 Fatigue prolonged labour oxytocin augmentation Uterine Inversion Retained placenta |
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List causes for post-delivery "Thrombin"-related PPH
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Bleeding diathesis (congenital)
Coagulopathy (acquired) Drugs (heparin) HELLP IUFD Infection/sepsis Consumption (PPH) Abruption AFE Thrombocytopenia Congenital (e.g. ITP) HELLP Consumption Drugs |
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What labour/delivery characteristics have been associated with PPH?
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Retained placenta (OR 3.5)
FTP 2 (OR 3.4) Accreta (OR 3.3) Lacerations (OR 2.4) Operative delivery (OR 2.3) LGA >4000g (OR 1.9) Hypertensive disorders (OR 1.7) Labor induction (OR 1.4) Oxytocin augmentation (OR 1.4) |
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Define PPH
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1)
VD: blood loss >500ml C/S: blood loss >1000ml 2) 10% decrease in post-partum Hb 3) early: <24h PP; late: >24h PP |
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True or False:
Active management of the third stage of labour has been shown to decrease PPH and it's complications |
True
PPH > 500ml: OR 0.4 PPH > 1000ml: OR 0.3 need for transfusion: OR 0.3 need for more uterotonics: OR 0.2 |
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What interventions comprise Active management of the third stage of labour?
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Uterotonic with delivery of anterior shoulder (oxytocin IM preferred)
Delayed cord clamping PTB neonate reduces anemia Controlled cord traction to delivery placenta |
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What uterotonics are considered acceptable for active management of the third stage of labour?
(i.e. prophylaxis against PPH) |
Oxytocin
10IU IM preferred 5IU IV push at VD, but not C/S Ergonivine 0.2mg IM contraindicated in HTN > nausea, retained placenta) Misoprostol (if others not available) 600-800ug oral/subL preferred side effect is pyrexia |
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What adverse reaction to 5-10IU IV bolus oxytocin has been observed in partuients at C/S?
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Transient EKG changes consistent with myocardial ischemia (all resolved within 5min)
(If given IV at C/S, oxytocin should go in over 5min not 30s) |
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What is the recommendation for uterotonic at C/S?
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Carbetocin 100ug IV over 1 min
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What interventions can be done for a retained placenta, and when should they be done?
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1) Manual removal
2) Umbilical vein injection Consider at 30-45min as waiting this long does not appear to increase the risk for PPH |
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What medications are available for umbilical vein injection for retained placeta at vaginal delivery?
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1) 10-30IU oxytocin in 30ml saline
2) 800ug misoprostol in 30ml saline |
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What is the Pipingas technique and how is it done?
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Used to inject the umbilical vein during retained placenta at vaginal delivery.
Size 10 NG catheter threaded through umbilical vein Alternative is to inject and then milk up cord |
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For established PPH with uterine atony, what dose of oxytocin is recommended?
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IV 40-80IU in 500ml, run at 500-1000ml/h
(with max dose that is 16U/min and may cause cardiac effects) May give 10IU IM again. |
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For established PPH with uterine atony, what dose of hemabate is recommended?
What maternal condition is a relative contraindication to hemabate? |
250ug IM q15min x 8 doses max
Asthma |
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For PPH at vaginal delivery, has carbetocin been found to be superior to oxytocin?
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No
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What surgical techniques are available to control PPH?
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Compression sutures
B-Lynch Cho Ligation of vessels Uterine (O'Leary stitch) Ovarian Internal Iliac Hysterectomy |
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Outline an approach to treating an established PPH
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1) Get Help: anesth, nursing, blood bank, lab
2) Assess ABCs - conscious, breathing 3) Quickly review history of gravida, pregnancy, delivery for medical hx, risk factors, allergies. 4) Vital signs 5) Blood loss (more accurate to go by clinical signs then observation of blood) 6) IV access - 2 large IVs 7) Oxygen 8) Uterine massage 9) IV fluids - RL 1-2L 10) Bloodwork: CBC, Coags, fibrinogen, T&S, Crossmatch 12) Oxytocin IV 12) Determine Cause and treat appropriately 13) Consider further management: tamponade, embolization, laparotomy 14) Massive transfusion protocol if necessary |