PPH

Question 1

Blood changes in preg physiologic

Answer 1

40% increase plasma volume

25% increased red cell mass

Question 2

Def of PPH

Answer 2

Not much agreed upon:

1. 500 in SVD, 1000 in C/S
2. 10% reduction in Hct

Question 3

How much of blood volume loss before hypotension, dizziness, pallor, oliguria occur?

Answer 3

10%

Question 4

Main sx of genital tract hematomas

Answer 4

pelvic/rectal pressure/pain

Question 5

Primary vs Secondary PPH

Answer 5

Primary w/in 24 hrs s/p delivery

Secondary 24hrs to 12 wks pp

Question 6

Causes of Primary PPH

Answer 6

Uterine atony
Retained products (accreta)
Defects in coagulation
Uterine inversion

Question 7

Causes of Secondary PPH

Answer 7

Subinvolution
Retained Products
Infection
Inherited coag defects

Question 8

Red tube test

Answer 8

5mL of pts blood into tube, should clot in 8-10 min if fibrinogen is normal…if fibrinogen is low (

Question 9

What conditions can cause clotting abnormalities?

Answer 9

HELLP
prolonged fetal demise
sepsis
AFE
placental abruptions
significant hemorrhage (consumes clotting factors)

Question 10

Risk factors for PPH

Answer 10

1. Prolonged labor
2. Rapid labor
3. Augmented labor
4. H/o PPH
5. Distended uterus (twins, macrosomia, hydramnios)
6. Operative delivery
7. Episitomy esp Mediolateral
8. Asian/hispanic
9. Chorio
10. PreE

Question 11

Large bore iv

Answer 11

16 gauge

Question 12

Uterotonics/doses

Answer 12

1. methergine 0.2mg IM (maybe IU) q2-4 hrs; max 5 doses?
2. hemabate (PGF2a) 0.25mg IM (IU?) q15-90 min, max 8 doses
3. Cytotec (misoprostol/PGE1): 800-1000mcg/rectum (sublingual 10, 100mcg tabs or 5 200mcg tabs)
4. Pitocin 10-40 units in 1L NS or LR continuous rapid infusion or 10 units IM
5. Dinoprostone (PGE2) 20mg per rectum/vagina q 2 hrs

Question 13

Uterotonic contraindication or side effects

Answer 13

1. methergine (HTN)
2. hemabate (asthma; relative CI renal, cardiac, hepatic disease; can cause diarrhea, fever, tachy)
3. cytotec: can cause fever
4. dinoprostone: avoid with HYPOtension, fever common; stored frozen, must be thawed to room temp
5. pit: avoid undiluted rapid iv infusion –> hypotension

Question 14

B-Lynch suture?

Answer 14

1-#2 catgut on large mayo needle, something that absorbs quickly so bowel does not get caught when uterus involutes

Question 15

Oleary stitch

Answer 15

#0 polygycolic acid suture (vicryl), large blunt needle (5 Mayo)--into lower uterine segment as close to cervix as possible laterally come out around uterine artery or uetero ovarian artery branches through the broad ligament--good if uterine artery has been ligated...will not stop bleeding for uterine atony/accreta...may decrease blood loss while other interventions attempted.
Identify the ureter!!

Question 16

What if Oleary stitch does not slow bleeding?

Answer 16

Similar stitch across utero-ovarian arcade right by cornua

Question 17

Uterine packing/tamponade techniques

Answer 17

1. foley bulb: fill 60-80cc NS, 1 or more bulbs
2. Blakemore-Sengstaken tube
3. Bakri: 300-500ml NS
4. uterine tamponade
5. packing: cornu to cornu, 4 inch gauze (soak 5K units of thrombin in 5 mL sterile saline

Question 18

When would you consider packing/tamponade?

Answer 18

when uterotonics fail to cause sustained uterine ctxns and satisfactory control of hemorrhage after vaginal delivery, temporizing, but if prompt response not seen, preparations should be made for XLAP

Question 19

Hypogastric artery ligation successful?

Answer 19

Now found to be less successful than previously thought difficult, more for ppl with experience in this technique

Question 20

Risk factors for placenta accreta

Answer 20

1. over 35yo
2. asherman’s
3. previous uterine surgery: c/s; myomectomy
4. submucous fibroids

Question 21

How do you do a hypogastric artery ligation?

Answer 21

1. open anterior leaf of broad ligament and lyse areolar tissue of the retroperitoneum
2. identify external iliac, follow up to common
3. now find internal iliac (about 4cm before splits into ant/post), identify anterior/posterior branches
4. You try to ligate the anterior branch…but a lot of the time you will just ligate the whole internal iliac
5. use permanent suture (polypropylene) or #1 silk go from lateral to medial, tie artery securely

Question 22

What are some major complications of internal iliac artery ligation?

Answer 22

1. you can ligate the external iliac –> ipsilateral leg (check dorsalis pedis/posterior tibial pulse!)
2. accidentally lacerate internal iliac vein (just behind and medial to internal iliac artery) or external iliac artery (lateral) = exangunation

Question 23

Heparin works on what pathway
Warfarin works on which pathway
PT/PTT? pathways?
Factors that start off each pathway?

Answer 23

PET=Extrinsic –> Warfarin –> VII

PITT = Intrinsic –> Heparin –> XII

Question 24

Packed RBC Volume, increase hgb/hct?

Answer 24

240mL

3% hct, 1g/dL Hgb

Question 25

Platelets volume, increase plts?

Answer 25

50mL | 5-10,000 increase

Question 26

FFP, volume, factors it contains, raise in Fibrinogen

Answer 26

250mL Fibrinogen, Factor VIII and V, antithrombin III 10 mg/dL raise

Question 27

Cryoprecipitate, volume, factors, raises what?

Answer 27

40mL Fibrinogen, Factor VIII and XIII, von Willebrand factor 10mg/dL raise FIBRINOGEN

Question 28

Risk of prior c/s with accretas

Answer 28

0. 2% s/p 1st c/s 0. 3% 2nd 0. 6% 3rd - --------------- 2. 1 % 4th 2. 3% 5th 7. 7% 6th

Question 29

Risk of accreta with Previa present and prior c/s

Answer 29

``` 1st 3% 2nd 11% 3rd 40 % 4th 61% 5th 67% ```

Question 30

When can you call IR for arterial embolization?

Answer 30

stable vitals, persistent bleeding (and if it is not excessive) Can be used to preserver fertility

Question 31

In what situation is autologous transfusion considered?

Answer 31

Person with rare antibodies

Question 32

Risk factors for uterine rupture

Answer 32

``` small uterine horn operative delivery placenta accreta abnormal labor prior c/s ```

Question 33

Should you repair uterine rupture?

Answer 33

If possible to preserve fertility

Question 34

Inverted uterus management

Answer 34

Try to push it back up: holding a tennis ball, palm to fundus May need to relax uterus: mag, terb, halogenated anesthetics, nitroglycerin

Question 35

What happens if cannot manually revert uterus?

Answer 35

Rare situation OR for exploration: Huntington's: use babcocks/allis clamps on fundus and pull up Haultain: cervical ring incision posteriorly, then digital repositioning of inverted corpus