Podcast
Questions and Answers
Which of the following is the primary mechanism the body uses to control blood loss immediately after childbirth?
Which of the following is the primary mechanism the body uses to control blood loss immediately after childbirth?
- Local vasoconstriction in the placental bed
- Release of adenosine diphosphate by platelets
- Uterine contraction stimulated by oxytocic substances (correct)
- Activation of the coagulation cascade
A patient admitted to the ICU following obstetric hemorrhage is MOST at risk for which of the following complications?
A patient admitted to the ICU following obstetric hemorrhage is MOST at risk for which of the following complications?
- Deep vein thrombosis
- Appendicitis
- Pulmonary embolism
- Myocardial ischemia (correct)
What is the estimated percentage of pregnant women who experience antepartum vaginal bleeding?
What is the estimated percentage of pregnant women who experience antepartum vaginal bleeding?
- 75%
- 50%
- 25% (correct)
- 5%
In the context of hemostasis following vascular disruption, what role do activated platelets play?
In the context of hemostasis following vascular disruption, what role do activated platelets play?
Which process plays a crucial role in detaching the placenta from the uterine wall after childbirth?
Which process plays a crucial role in detaching the placenta from the uterine wall after childbirth?
What is the primary reason cited for the increasing rates of hemorrhage and severe morbidity related to hemorrhage in high-resource countries like the US?
What is the primary reason cited for the increasing rates of hemorrhage and severe morbidity related to hemorrhage in high-resource countries like the US?
Following the disruption of vascular integrity, which of the following is the correct sequence of coagulation mechanisms?
Following the disruption of vascular integrity, which of the following is the correct sequence of coagulation mechanisms?
What is the approximate percentage of live births globally that are complicated by severe hemorrhage, according to the WHO?
What is the approximate percentage of live births globally that are complicated by severe hemorrhage, according to the WHO?
Which of the following factors is LEAST likely to be associated with an increased risk of placenta previa?
Which of the following factors is LEAST likely to be associated with an increased risk of placenta previa?
What is the preferred method for diagnosing placenta previa?
What is the preferred method for diagnosing placenta previa?
A pregnant patient at 32 weeks gestation presents with painless vaginal bleeding. What condition should be HIGHLY suspected until proven otherwise?
A pregnant patient at 32 weeks gestation presents with painless vaginal bleeding. What condition should be HIGHLY suspected until proven otherwise?
Why is digital or speculum examination not recommended as the initial step when placenta previa is suspected?
Why is digital or speculum examination not recommended as the initial step when placenta previa is suspected?
What is the MOST significant risk to the fetus in cases of antepartum hemorrhage?
What is the MOST significant risk to the fetus in cases of antepartum hemorrhage?
In managing a patient with placenta previa, which of the following would be the STRONGEST indication for immediate delivery?
In managing a patient with placenta previa, which of the following would be the STRONGEST indication for immediate delivery?
What is the primary goal of expectant management in a patient with placenta previa who is experiencing bleeding episodes?
What is the primary goal of expectant management in a patient with placenta previa who is experiencing bleeding episodes?
Which of the following is TRUE regarding the use of tocolytics in patients with placenta previa?
Which of the following is TRUE regarding the use of tocolytics in patients with placenta previa?
A patient with known placenta previa at 28 weeks gestation is admitted for painless vaginal bleeding that has now stopped. She is hemodynamically stable and the fetus is doing well. Which of the following is the MOST appropriate next step in management?
A patient with known placenta previa at 28 weeks gestation is admitted for painless vaginal bleeding that has now stopped. She is hemodynamically stable and the fetus is doing well. Which of the following is the MOST appropriate next step in management?
Which statement is MOST accurate regarding placenta previa diagnosed early in pregnancy?
Which statement is MOST accurate regarding placenta previa diagnosed early in pregnancy?
Beyond the immediate risks associated with hemorrhage, what long-term fetal complications are associated with placenta previa?
Beyond the immediate risks associated with hemorrhage, what long-term fetal complications are associated with placenta previa?
What vital aspect of patient history is particularly relevant when evaluating a patient for placenta previa?
What vital aspect of patient history is particularly relevant when evaluating a patient for placenta previa?
What is the key difference in presentation that helps differentiate placenta previa from placental abruption?
What is the key difference in presentation that helps differentiate placenta previa from placental abruption?
A patient with placenta previa is being considered for outpatient management. Which of the following is the MOST important criterion for determining her eligibility?
A patient with placenta previa is being considered for outpatient management. Which of the following is the MOST important criterion for determining her eligibility?
Which of the following represents the two primary pathophysiologic processes that place the fetus at risk in cases of placenta previa?
Which of the following represents the two primary pathophysiologic processes that place the fetus at risk in cases of placenta previa?
Which factor is LEAST likely to be associated with fetal growth restriction in the presence of placenta previa?
Which factor is LEAST likely to be associated with fetal growth restriction in the presence of placenta previa?
A patient with placenta previa has a placental edge-to-internal os distance of 1.2 cm. According to expert recommendations, what is the most appropriate course of action?
A patient with placenta previa has a placental edge-to-internal os distance of 1.2 cm. According to expert recommendations, what is the most appropriate course of action?
Which of the following scenarios necessitates abdominal delivery in a patient with placenta previa?
Which of the following scenarios necessitates abdominal delivery in a patient with placenta previa?
Why is it crucial for an anesthesia provider to evaluate all patients admitted with vaginal bleeding?
Why is it crucial for an anesthesia provider to evaluate all patients admitted with vaginal bleeding?
What is the recommended initial fluid for volume resuscitation in a patient with placenta previa and active bleeding?
What is the recommended initial fluid for volume resuscitation in a patient with placenta previa and active bleeding?
According to the American Association of Blood Banks (AABB), how often should blood type and antibody screens be repeated in pregnant women with placenta previa?
According to the American Association of Blood Banks (AABB), how often should blood type and antibody screens be repeated in pregnant women with placenta previa?
Why might pharmacologic prophylaxis for venous thromboembolism be withheld in patients with placenta previa on bed rest?
Why might pharmacologic prophylaxis for venous thromboembolism be withheld in patients with placenta previa on bed rest?
In an RCT comparing epidural and general anesthesia for cesarean delivery in women with placenta previa without active bleeding, what advantage was associated with epidural anesthesia?
In an RCT comparing epidural and general anesthesia for cesarean delivery in women with placenta previa without active bleeding, what advantage was associated with epidural anesthesia?
Which anesthetic consideration is MOST crucial when managing a patient with suspected placental abruption?
Which anesthetic consideration is MOST crucial when managing a patient with suspected placental abruption?
Aside from active bleeding, what is a primary reason patients with placenta previa are at risk for increased intraoperative blood loss during cesarean delivery?
Aside from active bleeding, what is a primary reason patients with placenta previa are at risk for increased intraoperative blood loss during cesarean delivery?
Which of the following BEST describes the primary concern regarding fetal well-being in cases of placental abruption?
Which of the following BEST describes the primary concern regarding fetal well-being in cases of placental abruption?
In a patient with placenta previa and a history of prior cesarean delivery, what additional risk should be considered?
In a patient with placenta previa and a history of prior cesarean delivery, what additional risk should be considered?
A patient with a known history of preeclampsia presents with vaginal bleeding and abdominal pain at 36 weeks gestation. Which of the following diagnostic steps should be prioritized?
A patient with a known history of preeclampsia presents with vaginal bleeding and abdominal pain at 36 weeks gestation. Which of the following diagnostic steps should be prioritized?
In cases of placenta previa with active preoperative bleeding, what is the preferred induction technique for general anesthesia?
In cases of placenta previa with active preoperative bleeding, what is the preferred induction technique for general anesthesia?
Which statement accurately describes the utility of ultrasonography in diagnosing placental abruption?
Which statement accurately describes the utility of ultrasonography in diagnosing placental abruption?
In a patient with placental abruption presenting for vaginal delivery and severe coagulopathy with fetal demise, which analgesic approach is most appropriate?
In a patient with placental abruption presenting for vaginal delivery and severe coagulopathy with fetal demise, which analgesic approach is most appropriate?
In a patient with severe hypovolemic shock due to placenta previa, what modification to the standard rapid sequence induction may be necessary?
In a patient with severe hypovolemic shock due to placenta previa, what modification to the standard rapid sequence induction may be necessary?
In a patient with placental abruption and evidence of consumptive coagulopathy, which laboratory finding would be MOST consistent with disseminated intravascular coagulation (DIC)?
In a patient with placental abruption and evidence of consumptive coagulopathy, which laboratory finding would be MOST consistent with disseminated intravascular coagulation (DIC)?
Which of the following factors is MOST likely to influence the decision to proceed with cesarean delivery in a patient with placental abruption?
Which of the following factors is MOST likely to influence the decision to proceed with cesarean delivery in a patient with placental abruption?
For an urgent cesarean delivery in a patient with placental abruption and unstable maternal status, what is the generally preferred type of anesthesia?
For an urgent cesarean delivery in a patient with placental abruption and unstable maternal status, what is the generally preferred type of anesthesia?
In a patient with modest bleeding from placenta previa and no fetal compromise, which anesthesia maintenance regimen is most appropriate before delivery?
In a patient with modest bleeding from placenta previa and no fetal compromise, which anesthesia maintenance regimen is most appropriate before delivery?
Following delivery in a patient with placenta previa, what is the rationale for discontinuing the volatile halogenated agent and substituting with 70% nitrous oxide and an intravenous opioid if bleeding continues?
Following delivery in a patient with placenta previa, what is the rationale for discontinuing the volatile halogenated agent and substituting with 70% nitrous oxide and an intravenous opioid if bleeding continues?
A patient at 32 weeks gestation presents with placental abruption and fetal demise. What is the preferred route of delivery in this scenario?
A patient at 32 weeks gestation presents with placental abruption and fetal demise. What is the preferred route of delivery in this scenario?
Why might propofol be avoided as an induction agent in patients with placental abruption undergoing cesarean delivery?
Why might propofol be avoided as an induction agent in patients with placental abruption undergoing cesarean delivery?
Following delivery in a patient with placental abruption, which intervention is most important to initiate promptly to address the risk of postpartum hemorrhage?
Following delivery in a patient with placental abruption, which intervention is most important to initiate promptly to address the risk of postpartum hemorrhage?
Why is oxytocin administered immediately after delivery in patients with placenta previa?
Why is oxytocin administered immediately after delivery in patients with placenta previa?
Which of the following conditions is MOST closely associated with an increased risk of placental abruption?
Which of the following conditions is MOST closely associated with an increased risk of placental abruption?
In the context of placental abruption, what is the significance of 'concealed hemorrhage'?
In the context of placental abruption, what is the significance of 'concealed hemorrhage'?
In the management of severe hemorrhage related to placental abruption, what is the primary benefit of inserting an intra-arterial catheter?
In the management of severe hemorrhage related to placental abruption, what is the primary benefit of inserting an intra-arterial catheter?
Which of the following interventions is MOST appropriate for managing a patient with placental abruption who is hemodynamically unstable?
Which of the following interventions is MOST appropriate for managing a patient with placental abruption who is hemodynamically unstable?
What is the critical distinction between uterine scar dehiscence and uterine rupture?
What is the critical distinction between uterine scar dehiscence and uterine rupture?
Which of the following statements BEST describes the relationship between placental abruption and disseminated intravascular coagulation (DIC)?
Which of the following statements BEST describes the relationship between placental abruption and disseminated intravascular coagulation (DIC)?
Which factor is LEAST likely to increase the risk of uterine rupture during a trial of labor after cesarean (TOLAC)?
Which factor is LEAST likely to increase the risk of uterine rupture during a trial of labor after cesarean (TOLAC)?
A patient with known placental abruption is undergoing continuous fetal heart rate monitoring. Which fetal heart rate pattern is MOST concerning and indicative of severe fetal compromise?
A patient with known placental abruption is undergoing continuous fetal heart rate monitoring. Which fetal heart rate pattern is MOST concerning and indicative of severe fetal compromise?
Why is the rupture of a classical uterine incision scar associated with greater morbidity than the rupture of a low transverse uterine incision scar?
Why is the rupture of a classical uterine incision scar associated with greater morbidity than the rupture of a low transverse uterine incision scar?
What is often the first sign of uterine rupture?
What is often the first sign of uterine rupture?
Which of the following statements accurately reflects the obstetric management of placental abruption when the fetus is preterm and the maternal and fetal status are reassuring?
Which of the following statements accurately reflects the obstetric management of placental abruption when the fetus is preterm and the maternal and fetal status are reassuring?
What is the MOST important reason for inserting a large-bore IV catheter in a patient with suspected placental abruption?
What is the MOST important reason for inserting a large-bore IV catheter in a patient with suspected placental abruption?
What is the significance of 'breakthrough pain' during neuraxial labor analgesia in the context of uterine rupture?
What is the significance of 'breakthrough pain' during neuraxial labor analgesia in the context of uterine rupture?
Which obstetric intervention is LEAST likely to be used in the management of uterine rupture?
Which obstetric intervention is LEAST likely to be used in the management of uterine rupture?
A patient with placental abruption is hypotensive despite initial fluid resuscitation. What further intervention should be considered to assess and manage her hemodynamic status?
A patient with placental abruption is hypotensive despite initial fluid resuscitation. What further intervention should be considered to assess and manage her hemodynamic status?
What should an anesthesiologist prioritize when managing a patient with placental abruption undergoing cesarean delivery?
What should an anesthesiologist prioritize when managing a patient with placental abruption undergoing cesarean delivery?
In a patient with uterine rupture, what finding would be LEAST expected?
In a patient with uterine rupture, what finding would be LEAST expected?
A patient with a history of prior classical cesarean section is in labor. What is the most appropriate management approach?
A patient with a history of prior classical cesarean section is in labor. What is the most appropriate management approach?
What is the primary rationale for monitoring postpartum patients with prolonged hypotension or coagulopathy in a multidisciplinary intensive care unit (ICU)?
What is the primary rationale for monitoring postpartum patients with prolonged hypotension or coagulopathy in a multidisciplinary intensive care unit (ICU)?
Why might arterial ligation be considered a less than ideal initial intervention for postpartum hemorrhage?
Why might arterial ligation be considered a less than ideal initial intervention for postpartum hemorrhage?
In a patient with a known uterine rupture undergoing emergency laparotomy, which monitoring technique could be used to assess intravascular volume status when uncertainty exists?
In a patient with a known uterine rupture undergoing emergency laparotomy, which monitoring technique could be used to assess intravascular volume status when uncertainty exists?
What is the primary risk associated with vasa previa that leads to high fetal mortality?
What is the primary risk associated with vasa previa that leads to high fetal mortality?
What is the approximate fetal blood volume at term, which is crucial to consider in cases of vasa previa?
What is the approximate fetal blood volume at term, which is crucial to consider in cases of vasa previa?
What specific finding during ultrasonography should raise suspicion for vasa previa?
What specific finding during ultrasonography should raise suspicion for vasa previa?
A patient at 31 weeks gestation is diagnosed with vasa previa. According to the guidelines, what is the recommended course of action?
A patient at 31 weeks gestation is diagnosed with vasa previa. According to the guidelines, what is the recommended course of action?
Why is amniocentesis not typically recommended in the management of vasa previa?
Why is amniocentesis not typically recommended in the management of vasa previa?
What is the most appropriate anesthetic approach for an emergency cesarean delivery due to ruptured vasa previa?
What is the most appropriate anesthetic approach for an emergency cesarean delivery due to ruptured vasa previa?
According to ACOG, what criteria define postpartum hemorrhage?
According to ACOG, what criteria define postpartum hemorrhage?
Which of the following factors is least likely to be associated with an increased rate of postpartum hemorrhage?
Which of the following factors is least likely to be associated with an increased rate of postpartum hemorrhage?
What percentage of postpartum hemorrhage cases are attributed to uterine atony?
What percentage of postpartum hemorrhage cases are attributed to uterine atony?
Which of the following physiological processes contributes directly to postpartum hemostasis?
Which of the following physiological processes contributes directly to postpartum hemostasis?
A patient presents with bleeding upon rupture of membranes accompanied by fetal bradycardia. What condition should be immediately suspected?
A patient presents with bleeding upon rupture of membranes accompanied by fetal bradycardia. What condition should be immediately suspected?
Which of the following is NOT a recognized risk factor for vasa previa?
Which of the following is NOT a recognized risk factor for vasa previa?
What threshold distance between fetal vessels and the internal os is commonly used to define vasa previa on ultrasound?
What threshold distance between fetal vessels and the internal os is commonly used to define vasa previa on ultrasound?
What is the primary reason for administering prophylactic oxytocin during the third stage of labor?
What is the primary reason for administering prophylactic oxytocin during the third stage of labor?
What is the most common finding during diagnosis of uterine atony?
What is the most common finding during diagnosis of uterine atony?
Why might unrecognized bleeding in a patient with uterine atony initially manifest as tachycardia?
Why might unrecognized bleeding in a patient with uterine atony initially manifest as tachycardia?
What is a potential adverse effect of administering high doses of oxytocin with large volumes of intravenous fluids?
What is a potential adverse effect of administering high doses of oxytocin with large volumes of intravenous fluids?
Why are ergot alkaloids typically reserved for postpartum use?
Why are ergot alkaloids typically reserved for postpartum use?
What should clinicians suspect in patients with vaginal bleeding despite a firm, contracted uterus?
What should clinicians suspect in patients with vaginal bleeding despite a firm, contracted uterus?
What is indicated when a placenta has adhered to the uterine wall?
What is indicated when a placenta has adhered to the uterine wall?
What is the primary reason for a multidisciplinary response to uterine atony?
What is the primary reason for a multidisciplinary response to uterine atony?
Why is it important to avoid a bolus dose of oxytocin and maintain the infusion rate below 1 unit/minute?
Why is it important to avoid a bolus dose of oxytocin and maintain the infusion rate below 1 unit/minute?
Which of the listed options is the LEAST appropriate initial step in managing postpartum uterine atony?
Which of the listed options is the LEAST appropriate initial step in managing postpartum uterine atony?
What is the significance of recognizing that an atonic uterus may contain over 1,000 mL of blood even in the absence of visible vaginal bleeding?
What is the significance of recognizing that an atonic uterus may contain over 1,000 mL of blood even in the absence of visible vaginal bleeding?
A patient with postpartum hemorrhage due to uterine atony is not responding to oxytocin. Which class of uterotonic agents should be considered next?
A patient with postpartum hemorrhage due to uterine atony is not responding to oxytocin. Which class of uterotonic agents should be considered next?
What is the estimated percentage of vaginal deliveries complicated by retained placenta?
What is the estimated percentage of vaginal deliveries complicated by retained placenta?
What is the most significant risk associated with failure to deliver the placenta within 30 minutes of the infant's delivery?
What is the most significant risk associated with failure to deliver the placenta within 30 minutes of the infant's delivery?
Prophylactic oxytocin administered before placental delivery is NOT associated with which of the following?
Prophylactic oxytocin administered before placental delivery is NOT associated with which of the following?
Which of the following is NOT typically considered a risk factor for retained placenta?
Which of the following is NOT typically considered a risk factor for retained placenta?
During the management of a retained placenta, a clinician might discontinue and then restart oxytocin. What is the rationale behind this action?
During the management of a retained placenta, a clinician might discontinue and then restart oxytocin. What is the rationale behind this action?
According to the WHO, prophylactic antibiotics are recommended during manual extraction of the placenta to reduce the risk of which complication?
According to the WHO, prophylactic antibiotics are recommended during manual extraction of the placenta to reduce the risk of which complication?
In the context of anesthetic management for retained placenta, under what condition might general anesthesia be deemed necessary?
In the context of anesthetic management for retained placenta, under what condition might general anesthesia be deemed necessary?
What is the primary mechanism by which nitroglycerin achieves uterine relaxation during manual removal of a retained placenta?
What is the primary mechanism by which nitroglycerin achieves uterine relaxation during manual removal of a retained placenta?
What is a potential adverse effect of using nitroglycerin for uterine relaxation that requires close monitoring and possible intervention?
What is a potential adverse effect of using nitroglycerin for uterine relaxation that requires close monitoring and possible intervention?
Which of the following factors is LEAST likely to be associated with uterine inversion?
Which of the following factors is LEAST likely to be associated with uterine inversion?
In cases of postpartum hemorrhage, what physical finding should raise suspicion for uterine inversion?
In cases of postpartum hemorrhage, what physical finding should raise suspicion for uterine inversion?
What is the initial treatment goal in managing uterine inversion?
What is the initial treatment goal in managing uterine inversion?
Why should uterotonic drugs be discontinued when attempting to correct a uterine inversion?
Why should uterotonic drugs be discontinued when attempting to correct a uterine inversion?
In the management of uterine inversion, what is the purpose of inserting an intrauterine balloon?
In the management of uterine inversion, what is the purpose of inserting an intrauterine balloon?
What is the defining characteristic of placenta accreta vera?
What is the defining characteristic of placenta accreta vera?
Which of the following best describes placenta increta?
Which of the following best describes placenta increta?
What differentiates placenta percreta from placenta increta?
What differentiates placenta percreta from placenta increta?
What is the correlation between cesarean delivery rates and the incidence of placenta accreta spectrum?
What is the correlation between cesarean delivery rates and the incidence of placenta accreta spectrum?
A patient with placenta previa and a history of one prior cesarean delivery has approximately what percentage risk of also having placenta accreta?
A patient with placenta previa and a history of one prior cesarean delivery has approximately what percentage risk of also having placenta accreta?
Why is antenatal diagnosis of placenta accreta considered beneficial?
Why is antenatal diagnosis of placenta accreta considered beneficial?
According to ACOG, what is the recommended course of action for clinicians in smaller hospitals without adequate blood bank supplies when faced with a patient with placenta accreta?
According to ACOG, what is the recommended course of action for clinicians in smaller hospitals without adequate blood bank supplies when faced with a patient with placenta accreta?
What gestational age has decision analysis indicated as the preferred time for planned delivery in most clinical circumstances involving placenta accreta?
What gestational age has decision analysis indicated as the preferred time for planned delivery in most clinical circumstances involving placenta accreta?
In cases of known placenta accreta, what is the generally recommended surgical approach?
In cases of known placenta accreta, what is the generally recommended surgical approach?
What is a potential risk associated with attempting manual extraction of the placenta in cases where placenta accreta diagnosis is unclear?
What is a potential risk associated with attempting manual extraction of the placenta in cases where placenta accreta diagnosis is unclear?
Why might a midline vertical skin incision be preferred in surgical management of placenta accreta?
Why might a midline vertical skin incision be preferred in surgical management of placenta accreta?
What is a potential complication associated with the placement of internal iliac artery balloon catheters?
What is a potential complication associated with the placement of internal iliac artery balloon catheters?
According to the Society for Maternal-Fetal Medicine (SMFM), for which patient population should prophylactic intra-arterial balloon catheters be reserved?
According to the Society for Maternal-Fetal Medicine (SMFM), for which patient population should prophylactic intra-arterial balloon catheters be reserved?
What is a potential method for conservatively managing selected patients with partial placenta accreta involving small, focal areas of placental invasion?
What is a potential method for conservatively managing selected patients with partial placenta accreta involving small, focal areas of placental invasion?
In the context of placenta accreta management, what is meant by 'expectant management'?
In the context of placenta accreta management, what is meant by 'expectant management'?
What is a primary consideration when deciding on the timing of delivery for a patient with placenta accreta who experiences vaginal bleeding remote from term?
What is a primary consideration when deciding on the timing of delivery for a patient with placenta accreta who experiences vaginal bleeding remote from term?
What is the significance of multidisciplinary collaborators being present during planned delivery for patients with placenta accreta?
What is the significance of multidisciplinary collaborators being present during planned delivery for patients with placenta accreta?
Which of the following scenarios presents the HIGHEST risk for placenta accreta?
Which of the following scenarios presents the HIGHEST risk for placenta accreta?
What is a disadvantage of using internal iliac artery balloon catheters during the management of placenta accreta?
What is a disadvantage of using internal iliac artery balloon catheters during the management of placenta accreta?
In a hospital setting prepared for managing significant obstetric hemorrhage, which setup reflects the MOST comprehensive approach?
In a hospital setting prepared for managing significant obstetric hemorrhage, which setup reflects the MOST comprehensive approach?
Considering the factors contributing to maternal morbidity and mortality due to obstetric hemorrhage, what is the MOST critical area for improvement in high-resource countries?
Considering the factors contributing to maternal morbidity and mortality due to obstetric hemorrhage, what is the MOST critical area for improvement in high-resource countries?
Why might relying solely on visual estimation of vaginal bleeding be inadequate in assessing the severity of obstetric hemorrhage?
Why might relying solely on visual estimation of vaginal bleeding be inadequate in assessing the severity of obstetric hemorrhage?
In the context of obstetric hemorrhage, what does the rapid onset of coagulopathy, potentially disproportionate to the observed blood loss, primarily indicate?
In the context of obstetric hemorrhage, what does the rapid onset of coagulopathy, potentially disproportionate to the observed blood loss, primarily indicate?
Which scenario BEST illustrates the need for managing a patient with placenta accreta in a facility with multidisciplinary specialists?
Which scenario BEST illustrates the need for managing a patient with placenta accreta in a facility with multidisciplinary specialists?
What is the MOST likely reason for the increased frequency of peripartum hysterectomy?
What is the MOST likely reason for the increased frequency of peripartum hysterectomy?
In a setting where allogenic blood is limited or refused by the patient, when would intraoperative blood salvage be MOST appropriate?
In a setting where allogenic blood is limited or refused by the patient, when would intraoperative blood salvage be MOST appropriate?
How does the use of Tranexamic Acid (TXA) in postpartum hemorrhage management differ between low-resource and high-resource settings?
How does the use of Tranexamic Acid (TXA) in postpartum hemorrhage management differ between low-resource and high-resource settings?
According to ACOG, what is the preferred management strategy for patients diagnosed with placenta accreta?
According to ACOG, what is the preferred management strategy for patients diagnosed with placenta accreta?
During a peripartum hysterectomy, what should the anesthesia provider be prepared for, given a preoperative suspicion of placental implantation abnormalities?
During a peripartum hysterectomy, what should the anesthesia provider be prepared for, given a preoperative suspicion of placental implantation abnormalities?
What is a primary concern when using an intrauterine balloon tamponade for postpartum hemorrhage?
What is a primary concern when using an intrauterine balloon tamponade for postpartum hemorrhage?
In which clinical scenario are uterine compression sutures MOST likely to be effective?
In which clinical scenario are uterine compression sutures MOST likely to be effective?
What is the mechanism by which angiographic arterial embolization helps to control postpartum hemorrhage?
What is the mechanism by which angiographic arterial embolization helps to control postpartum hemorrhage?
What is the primary reason for the variability in success rates reported for surgical ligation of the uterine arteries in controlling postpartum hemorrhage?
What is the primary reason for the variability in success rates reported for surgical ligation of the uterine arteries in controlling postpartum hemorrhage?
When might angiographic arterial embolization be considered as an intervention for postpartum hemorrhage?
When might angiographic arterial embolization be considered as an intervention for postpartum hemorrhage?
What is the definitive treatment for postpartum hemorrhage that is unresponsive to both medical management and other invasive therapies?
What is the definitive treatment for postpartum hemorrhage that is unresponsive to both medical management and other invasive therapies?
Which of the following factors contributes MOST significantly to the increased rate of hysterectomies performed for placental abnormalities?
Which of the following factors contributes MOST significantly to the increased rate of hysterectomies performed for placental abnormalities?
In the context of uterine compression sutures (e.g., B-Lynch suture), what is a potential risk associated with their placement?
In the context of uterine compression sutures (e.g., B-Lynch suture), what is a potential risk associated with their placement?
What is a limitation of using gelatin sponge pledgets (gel foam) in angiographic arterial embolization for postpartum hemorrhage?
What is a limitation of using gelatin sponge pledgets (gel foam) in angiographic arterial embolization for postpartum hemorrhage?
What should be considered when managing a patient undergoing angiographic arterial embolization for postpartum hemorrhage?
What should be considered when managing a patient undergoing angiographic arterial embolization for postpartum hemorrhage?
Why is internal iliac artery ligation considered a more complex procedure than uterine artery ligation for controlling postpartum hemorrhage?
Why is internal iliac artery ligation considered a more complex procedure than uterine artery ligation for controlling postpartum hemorrhage?
What is a significant risk associated with intrauterine balloon tamponade, particularly if the cervix is partially open?
What is a significant risk associated with intrauterine balloon tamponade, particularly if the cervix is partially open?
Following a successful arterial embolization to control postpartum hemorrhage, what long-term outcome is generally expected regarding fertility?
Following a successful arterial embolization to control postpartum hemorrhage, what long-term outcome is generally expected regarding fertility?
Compared to non-obstetric hysterectomy, what is a significant risk associated with obstetric hysterectomy?
Compared to non-obstetric hysterectomy, what is a significant risk associated with obstetric hysterectomy?
What is a potential advantage of performing a subtotal hysterectomy compared to a total hysterectomy in peripartum cases?
What is a potential advantage of performing a subtotal hysterectomy compared to a total hysterectomy in peripartum cases?
When is a subtotal hysterectomy NOT an appropriate option?
When is a subtotal hysterectomy NOT an appropriate option?
What physiological effect is achieved by manual compression of the aorta during obstetric hemorrhage?
What physiological effect is achieved by manual compression of the aorta during obstetric hemorrhage?
What potential complication should anesthesia providers anticipate if aortic cross-clamp time exceeds 50 minutes?
What potential complication should anesthesia providers anticipate if aortic cross-clamp time exceeds 50 minutes?
What is the likely anesthetic choice for peripartum hysterectomy when significant blood loss is already ongoing?
What is the likely anesthetic choice for peripartum hysterectomy when significant blood loss is already ongoing?
Why might central venous access be particularly advantageous in cases of massive transfusion during peripartum hysterectomy?
Why might central venous access be particularly advantageous in cases of massive transfusion during peripartum hysterectomy?
What is MOST important for anesthesia providers to communicate to patients at risk for peripartum hysterectomy who are managed with neuraxial anesthesia?
What is MOST important for anesthesia providers to communicate to patients at risk for peripartum hysterectomy who are managed with neuraxial anesthesia?
What considerations guide the choice of induction agents for general anesthesia in peripartum hysterectomy complicated by severe hemorrhage?
What considerations guide the choice of induction agents for general anesthesia in peripartum hysterectomy complicated by severe hemorrhage?
What is the PRIMARY goal of manual compression of the aorta in the setting of catastrophic obstetric hemorrhage?
What is the PRIMARY goal of manual compression of the aorta in the setting of catastrophic obstetric hemorrhage?
Why does a history of multiple cesarean deliveries increase the risk of peripartum hysterectomy?
Why does a history of multiple cesarean deliveries increase the risk of peripartum hysterectomy?
What is a critical consideration when extending an epidural blockade for a patient who delivered vaginally and now requires a peripartum hysterectomy?
What is a critical consideration when extending an epidural blockade for a patient who delivered vaginally and now requires a peripartum hysterectomy?
What is the potential danger of inducing sympatholysis after significant hemorrhage has already occurred?
What is the potential danger of inducing sympatholysis after significant hemorrhage has already occurred?
Considering the unique challenges of anesthesia during peripartum hysterectomy, what is paramount for a successful outcome?
Considering the unique challenges of anesthesia during peripartum hysterectomy, what is paramount for a successful outcome?
In the context of managing catastrophic obstetric hemorrhage, what is the role of an endovascular aortic balloon?
In the context of managing catastrophic obstetric hemorrhage, what is the role of an endovascular aortic balloon?
Flashcards
Obstetric Hemorrhage
Obstetric Hemorrhage
Bleeding during pregnancy or after childbirth.
Uterine Atony
Uterine Atony
Failure of the uterus to contract adequately after delivery.
Primary Hemostasis Mechanism
Primary Hemostasis Mechanism
Uterine contraction after delivery, controlled by oxytocin.
Uterine Tetany
Uterine Tetany
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Contraction Constriction
Contraction Constriction
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Coagulation Mechanisms
Coagulation Mechanisms
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Activated Platelets
Activated Platelets
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Antepartum Hemorrhage
Antepartum Hemorrhage
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Placenta Previa
Placenta Previa
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Placenta Previa Definition
Placenta Previa Definition
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Low-Lying Placenta
Low-Lying Placenta
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Placenta Previa Common Cause
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Placenta Previa Risk Factors
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Placenta Previa Risks
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Placenta Previa Diagnosis
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Placenta Previa Clinical Sign
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Placenta Previa Examination Caution
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Placenta Previa vs. Abruption
Placenta Previa vs. Abruption
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Placenta Previa Monitoring
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Placenta Previa Prevention
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Placenta Previa: Lung Maturity
Placenta Previa: Lung Maturity
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Use of Tocolytics
Use of Tocolytics
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Placenta Previa & Fetal Growth Restriction
Placenta Previa & Fetal Growth Restriction
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Trial of Labor
Trial of Labor
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Abdominal Delivery (C-Section)
Abdominal Delivery (C-Section)
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Initial Volume Resuscitation Fluid
Initial Volume Resuscitation Fluid
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Repeat Antibody Screens
Repeat Antibody Screens
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Sequential Compression Devices
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Pharmacologic Thromboprophylaxis
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Epidural Anesthesia Benefits
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Reasons for Increased Blood Loss
Reasons for Increased Blood Loss
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Blood Product Availability
Blood Product Availability
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Preferred Anesthetic for Bleeding Patients
Preferred Anesthetic for Bleeding Patients
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IV Induction Agent Choice
IV Induction Agent Choice
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Severe Hypovolemic Shock Induction
Severe Hypovolemic Shock Induction
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Anesthesia Maintenance Agent
Anesthesia Maintenance Agent
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Anesthetic for Ongoing Bleeding
Anesthetic for Ongoing Bleeding
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Placental Abruption
Placental Abruption
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Neuraxial Analgesia & Volume
Neuraxial Analgesia & Volume
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Abruption & Coagulopathy
Abruption & Coagulopathy
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Anesthesia for Abruption
Anesthesia for Abruption
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General Anesthesia
General Anesthesia
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Hypovolemia & Induction
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Arterial Catheter
Arterial Catheter
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Postpartum Management
Postpartum Management
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Severe Postpartum Abruption
Severe Postpartum Abruption
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Uterine Rupture
Uterine Rupture
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Uterine Dehiscence
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Rupture Risk Factors
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TOLAC Rupture Risks
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Classical Incision Rupture
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First Sign of Rupture
First Sign of Rupture
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Classic Abruption Presentation
Classic Abruption Presentation
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Abruption Complications
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Abruption Treatment
Abruption Treatment
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Anesthetic Concerns in Abruption
Anesthetic Concerns in Abruption
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Initial Abruption Management
Initial Abruption Management
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Urethral Catheter Use (Abruption)
Urethral Catheter Use (Abruption)
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Neuraxial Analgesia (Abruption)
Neuraxial Analgesia (Abruption)
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Placental Abruption Definition
Placental Abruption Definition
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Fetal Compromise (Abruption)
Fetal Compromise (Abruption)
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Ultrasound in Abruption
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Ultrasound Accuracy
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Major Fetal Risks (Abruption)
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Vaginal Delivery (Abruption)
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Arterial Ligation Disadvantage
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Uterine Rupture First Steps
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Vasa Previa Definition
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Vasa Previa Type 1
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Vasa Previa Type 2
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Vasa Previa Risk
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Vasa Previa Risk Factors
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Vasa Previa Suspicion
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Vasa Previa Management
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Vasa Previa Delivery Timing
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Ruptured Vasa Previa Action
Ruptured Vasa Previa Action
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Postpartum Hemorrhage Definition
Postpartum Hemorrhage Definition
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ACOG Postpartum Hemorrhage Definition
ACOG Postpartum Hemorrhage Definition
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Primary Postpartum Hemorrhage
Primary Postpartum Hemorrhage
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Previous uterine surgery
Previous uterine surgery
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Previa + Prior C-section
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Previa + Repeat C-sections
Previa + Repeat C-sections
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Accreta Diagnosis (Historically)
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Antenatal Accreta Diagnosis
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Ultrasonography
Ultrasonography
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Accreta & Small Hospitals
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Planned vs. Emergency Delivery
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Emergency Delivery Preparedness
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Expectant Management
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Preferred Delivery Timing
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Usual Accreta Management
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Ureteral Stents
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Iliac Artery Balloon Catheters
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Conservative Accreta Therapy
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Uterine Atony Signs
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ACOG's Uterine Atony Prophylaxis
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Prophylactic Oxytocin
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Exogenous Oxytocin Side Effects
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Mitigating Oxytocin Side Effects
Mitigating Oxytocin Side Effects
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High-Dose Oxytocin Complications
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Atony Resuscitative Measures
Atony Resuscitative Measures
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Restoring Uterine Tone
Restoring Uterine Tone
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Uterotonic Agent Classes
Uterotonic Agent Classes
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Ergot Alkaloid Drugs
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Ergot Alkaloid Action
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Common Prostaglandin Medications
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Common Childbirth Injuries
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Retained Placenta Definition
Retained Placenta Definition
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Retained Placenta
Retained Placenta
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Risk factors for retained placenta
Risk factors for retained placenta
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Treatment for retained placenta
Treatment for retained placenta
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Manual extraction of placenta risks
Manual extraction of placenta risks
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Anesthetic management of retained placenta
Anesthetic management of retained placenta
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Nitroglycerin for uterine relaxation
Nitroglycerin for uterine relaxation
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Uterine Inversion
Uterine Inversion
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Risk factors for uterine inversion
Risk factors for uterine inversion
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Symptoms of uterine inversion
Symptoms of uterine inversion
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Initial management of uterine inversion
Initial management of uterine inversion
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Uterine relaxation for inversion
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Placenta Accreta
Placenta Accreta
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Placenta Accreta Vera
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Placenta Increta
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Placenta Percreta
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Placenta Accreta Management
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Accreta: Anesthesia Risks
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Invasive Procedures
Invasive Procedures
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Intrauterine Balloon Tamponade
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Uterine Compression Sutures
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Angiographic Arterial Embolization
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Arterial Embolization Material
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Arterial Embolization Requirements
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Surgical Ligation
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Collateral Circulation Challenges
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Peripartum Hysterectomy
Peripartum Hysterectomy
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Hysterectomy Indications
Hysterectomy Indications
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Uterine Blood Supply
Uterine Blood Supply
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Peripartum Hysterectomy
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Hysterectomy Complications
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Hypotension and Tachycardia
Hypotension and Tachycardia
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Visual Estimation of Bleeding
Visual Estimation of Bleeding
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TXA (Tranexamic Acid)
TXA (Tranexamic Acid)
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Coagulopathy in Obstetric Hemorrhage
Coagulopathy in Obstetric Hemorrhage
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Intraoperative Blood Salvage
Intraoperative Blood Salvage
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Risk Factor: Prior C-Sections
Risk Factor: Prior C-Sections
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Challenges of Peripartum Hysterectomy
Challenges of Peripartum Hysterectomy
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Post-Hysterectomy Risks
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Mortality Rate: Peripartum Hysterectomy
Mortality Rate: Peripartum Hysterectomy
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Emergency vs. Planned Hysterectomy
Emergency vs. Planned Hysterectomy
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Subtotal Hysterectomy
Subtotal Hysterectomy
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Subtotal Hysterectomy: Benefits and Risks
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Subtotal Hysterectomy: Contraindications
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Manual Aortic Compression
Manual Aortic Compression
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Purpose of Aortic Compression
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Aortic Cross-Clamp
Aortic Cross-Clamp
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Prolonged Aortic Clamping Risks
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Endovascular Aortic Balloon
Endovascular Aortic Balloon
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Peripartum Hysterectomy Anesthesia Complexity
Peripartum Hysterectomy Anesthesia Complexity
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Study Notes
- Obstetric hemorrhage is a leading cause of maternal mortality globally, accounting for about 15% of maternal deaths.
- Severe hemorrhage complicates 10.5% of live births worldwide, with a case-fatality rate of 1%.
- In the US, hemorrhage is responsible for 11.4% of pregnancy-related deaths which is approximately 1.9 per 100,000 live births.
- Obstetric hemorrhage is the most common reason for ICU admission in obstetric patients and increases the risk of myocardial ischemia, infarction, and stroke
- Organ dysfunction occurs in 16% of obstetric hemorrhage cases when a transfusion of 5 or more units of packed red blood cells is needed.
- Hemorrhage and severe morbidity from hemorrhage are increasing in the US, mainly due to a rise in postpartum hemorrhage.
- The increase in postpartum hemorrhage is associated with rising rates of uterine atony and abnormal placentation, which coincides with increasing cesarean delivery rates.
- The majority of adverse outcomes related to hemorrhage are considered preventable.
- Endogenous oxytocic substances are released to stimulate uterine contraction, which is the primary mechanism to control blood loss during parturition.
- Uterine contraction helps cleave the placenta and constricts spiral arteries and placental veins.
- Coagulation after vascular disruption involves platelet aggregation, local vasoconstriction, clot polymerization, and clot fortification with fibrous tissue.
- Platelet activation releases factors like adenosine diphosphate and serotonin, which promote vasoconstriction and hemostasis and activate the coagulation cascade.
- The coagulation cascade results in the conversion of fibrinogen to fibrin, stabilizing the clot.
- Antepartum vaginal bleeding occurs in up to 25% of pregnant women, but only a small fraction experience life-threatening hemorrhage.
- Most antepartum hemorrhage cases occur during the first trimester.
- Causes of antepartum hemorrhage range from cervicitis to placenta previa and placental abruption.
- The greatest threat of antepartum hemorrhage is to the fetus.
- Antepartum bleeding from placenta previa and placental abruption results in fewer neonatal deaths than previously reported.
Placenta Previa
- Placenta previa occurs when the placenta covers the cervix.
- The classification of placenta previa used to be based on the placenta's relation to the cervical os, using terms like total, partial, and marginal.
- With advances in transvaginal ultrasonography, if any part of the placenta overlies the os, it is termed a previa, and any placenta near the os is termed low-lying.
- In placenta previa the incidence is estimated to be 1 in 200 pregnancies at term.
- Prior uterine trauma (scar from prior cesarean section) is a common finding in placenta previa.
- Risk factors for placenta previa include multiparity, advanced maternal age, smoking, male fetus, previous cesarean delivery or uterine surgery, and previous placenta previa.
- Asian-American women have an increased risk for placenta previa.
- Placenta previa increases the likelihood of fetal anomalies, neurodevelopmental delay, sudden infant death syndrome, and the need for peripartum hysterectomy.
- Transvaginal ultrasonography is the "gold standard" for diagnosing placenta previa.
- Classic sign of placenta previa is painless vaginal bleeding during the second or third trimester.
- Digital or speculum examination should be avoided until ultrasonography excludes abnormal placentation.
- Placenta previa diagnosed in asymptomatic patients before the third trimester frequently resolves as pregnancy progresses.
- 90% of placentas identified as low lying in early pregnancy will normalize by the third trimester.
- Placenta previa can be distinguished from placental abruption by the absence of abdominal pain and abnormal uterine tone.
- Obstetric management depends on the severity of bleeding and the maturity and status of the fetus.
- Active labor or a mature fetus should prompt delivery.
- Fetus may experience placental separation that causes uteroplacental insufficiency and preterm delivery.
- The first bleeding episode typically stops spontaneously and rarely causes maternal shock or fetal compromise.
- Expectant management in the hospital can prolong pregnancy by an average of 4 weeks after the initial bleeding episode.
- Maternal vital signs and hemoglobin concentration should be assessed frequently.
- Fetal evaluation includes non-stress tests, biophysical profiles, and ultrasonographic assessment of growth.
- Limitations on physical activity and avoidance of vaginal examinations and coitus may prevent hemorrhage.
- Outpatient management can result in good outcomes in carefully selected patients.
- Corticosteroids may be administered in the event of preterm labor.
- Avoid the use of tocolytic therapy for patients with uncontrolled hemorrhage or suspected placental abruption.
- Fetuses of women with placenta previa may be at risk for fetal growth restriction.
- Trial of labor may be offered with a placental edge-to-internal os distance greater than 1 cm but abdominal delivery will be required with less than 1 cm.
- Volume resuscitation should be initiated with a non-dextrose-containing balanced salt solution.
- IV Catheters should be maintained is bleeding is recurrent or imminent delivery is anticipated.
- Cross-Matched blood should be ensured.
- AABB suggests repeating tests every 3 days in pregnant women due to risk of developing alloantibody during pregnancy.
- Lower-extremity sequential compression devices may decrease VTE risk.
- Epidural anesthesia during cesarean delivery in women with placenta previa was associated with stable BP after delivery and lower transfusion rates and volumes.
- Patients with placenta previa are at risk for increased intraoperative blood loss and placenta accreta.
- Patients with preoperative bleeding need evaluation, resuscitation, and operative delivery simultaneously.
- Rapid-sequence induction of general anesthesia is preferred for bleeding patients.
Placental Abruption
- Defined as a complete or partial separation of the placenta from the decidua basalis before delivery of the fetus.
- Maternal hemorrhage may be revealed or may be concealed behind the placenta.
- Fetal compromise results from loss of placental surface area for maternal-fetal exchange.
- Placental abruption complicates 0.4% to 1.0% of pregnancies.
- The causes of abruption are not well understood
- Classic presentation includes vaginal bleeding, uterine tenderness, and increased uterine activity.
- In concealed abruption, vaginal bleeding may be absent, and gross underestimation of maternal hypovolemia can occur.
- Diagnosis is primarily clinical, but ultrasonography may help confirm it.
- Ultrasonography is highly specific for placental abruption (96%), but it is not very sensitive (24%).
- Complications of placental abruption include hemorrhagic shock, coagulopathy, and fetal compromise or demise.
- 1/3 of coagulopathies in pregnancy are attributable to abruption, leading to DIC.
- The major risks for the fetus are hypoxia and prematurity.
- The increased perinatal mortality rate associated with placental abruption reflects a high risk of fetal death and the consequences of preterm birth.
- The definitive treatment is delivery of the infant and placenta, but the timing and route of delivery depend on the level of compromise to the mother and fetus.
- If the patient is preterm, the extent of abruption is minimal, and the mother and fetus show no signs of compromise, the patient may be hospitalized, and the pregnancy allowed to continue to optimize fetal maturation.
- Vaginal delivery is preferred for patients with intrauterine fetal demise.
- Insert a large-bore IV catheter and assess hemoglobin, coagulation status, and blood product preparation.
- The placement of a urethral catheter to monitor urine output may help assess the adequacy of renal perfusion.
- Neuraxial analgesia may be offered if hypovolemia has been treated, and coagulation status is normal.
- Spinal, CSE, or epidural anesthesia may be administered in stable patients in whom intravascular volume status is adequate and coagulation studies are normal.
- General anesthesia is preferred for most cases of urgent cesarean delivery accompanied by unstable maternal status, a nonreassuring FHR pattern,
- Propofol may precipitate severe hypotension in patients with unrecognized hypovolemia.
- Oxytocin should be infused promptly after delivery.
- Early replacement of coagulation factors to minimize the risk of developing coagulopathy.
- Prolonged hypotension or coagulopathy, and who need massive blood volume and blood product replacement, are best monitored in a multidisciplinary intensive care unit.
Uterine Rupture
- Rupture of the gravid uterus can be disastrous for both the mother and the fetus.
- Uterine scar dehiscence: uterine wall defect that does not result in excessive hemorrhage or FHR abnormalities and does not require emergency cesarean delivery or postpartum laparotomy.
- Uterine rupture: uterine wall defect with maternal hemorrhage and/or fetal compromise that requires emergency cesarean delivery or postpartum laparotomy.
- Uterine rupture occurs very rarely in women with an unscarred uterus.
- After cesarean delivery it occurs at a rate of less than 1%.
- Additional risk factors for uterine rupture during TOLAC include an inter-delivery interval of less than 12 to 16 months, multiple previous cesarean deliveries, post-term gestation, maternal age older than 35 years, and previous delivery with severe postpartum hemorrhage.
- Previous vaginal delivery and prior successful vaginal delivery after cesarean confers decreased rupture risk.
- Rupture of a classical uterine incision scar is associated with greater morbidity and mortality than the rupture of a low transverse uterine incision scar.
- An FHR abnormality is the first sign of uterine rupture in more than 80% of patients.
- The triad of abdominal pain, abnormal FHR pattern, and vaginal bleeding is seen less frequently (9% of patients with rupture).
- Treatment for uterine rupture includes repair of the uterus, arterial ligation, and hysterectomy.
- Aggressive volume replacement is essential, and transfusion may be necessary.
Vasa Previa
- Occurs when the fetal blood vessels transverse the fetal membranes covering the internal cervical os.
- Type 1 vasa previa: vessels are associated with a velamentous umbilical cord.
- Type 2 vasa previa: vessels connect the lobes of a multilobed placenta or the placenta and a succenturiate lobe.
- Many clinicians use a threshold of 2 cm when describing vasa previa.
- Associated with a high fetal mortality rate (nearly 60% if vasa previa is unrecognized).
- Delivery reflects a balance between the risks associated with preterm delivery and the risk of vessel rupture if the pregnancy is allowed to continue.
- Experts advocate antenatal steroid administration between 30- and 32 weeks gestation.
- Hospitalization of the patient between 30- and 34 weeks gestation to ensure prompt delivery should rupture of membranes occur.
- The best fetal outcomes will occur with elective delivery between 34- and 35-week gestation.
- Amniocentesis is not recommended.
- Ruptured vasa previa requires immediate delivery of the fetus by cesarean delivery.
- Choice of anesthetic technique depends on the urgency of the cesarean delivery but general anesthesia is typical.
Postpartum Hemorrhage
- Most accepted definition is blood loss of more than 500 mL after vaginal delivery or more than 1,000 mL after cesarean delivery.
- ACOG defines hemorrhage as blood loss greater than or equal to 1,000 mL, or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours of birth.
- Primary postpartum hemorrhage occurs during the first 24 hours, and secondary postpartum hemorrhage occurs between 24 hours and 6 weeks after delivery.
- The current rate of postpartum hemorrhage is approximately 3%.
Uterine Atony
- Most common cause of severe postpartum hemorrhage, accounting for approximately 80% of cases.
- An atonic, poorly contractile uterus and vaginal bleeding are the most common findings.
- The absence of vaginal bleeding does not exclude this disorder.
- General resuscitative measures include large-bore IV access, intravenous administration of crystalloid and colloid solutions and vasopressors, laboratory determination of hemoglobin concentration or hematocrit and assessment of coagulation status, and blood blank preparation of blood products for transfusion.
- Multidisciplinary response to atony is imperative.
- Bimanual compression and massage of the uterus and continued infusion of oxytocin may help restore uterine tone.
- Three classes are currently available: oxytocin, ergot alkaloids, and prostaglandins.
- ACOG recommends active management of the 3rd stage of labor, including uterine massage and prophylactic oxytocin administration to decrease blood loss and transfusion requirements compared with expectant management.
- Oxytocin is the first-line drug for prophylaxis of uterine atony after delivery of a third-trimester pregnancy.
- Endogenous oxytocin is a nine-amino acid polypeptide produced in the posterior pituitary gland.
- Exogenous oxytocin can be associated with serious side effects, including vasodilation, tachycardia, hypotension, coronary vasoconstriction, myocardial ischemia, and rarely, even death, especially in hypovolemic or other hemodynamically compromised women.
- Administration of phenylephrine with oxytocin can mitigate the adverse hemodynamic consequences of oxytocin.
- High doses of oxytocin with large volumes of intravenous fluids, especially those containing free water, can lead to hyponatremia, seizures, and coma because of oxytocin’s structural similarities to vasopressin.
- Methylergonovine are the 2 ergot alkaloids currently available for use which produce tetanic uterine contractions.
- Prostaglandins of the E and F families are escalation therapy when high-dose oxytocin is inadequate.
- Concentrations of endogenous prostaglandins increase during labor, and levels peak at the time of placental separation.
- Increase prostaglandin treatment with 15-Metyhl prostaglandin F (Carboprost) & Misoprostol.
Genital Trauma
- Lacerations and hematomas of the perineum, vagina, and cervix.
- Genital tract lacerations should be suspected in all patients who have vaginal bleeding despite a firm, contracted uterus.
Retained Placenta
- Failure to deliver the placenta completely within 30 minutes of delivery of the infant and occurs in approximately 3% of vaginal deliveries.
- Retained placenta typically results from incarcerated placenta, placenta adherens, or placenta accreta.
- Risk factors for retained placenta include preterm delivery, oxytocin use during labor, preeclampsia and Nulliparity
- Treatment of retained placenta often involves gentle cord traction, uterine massage, manual removal, and inspection of the placenta.
- Administration of local anesthetic through an indwelling catheter, de novo neuraxial anesthesia may be considered in patients who are not bleeding severely and are hemodynamically stable.
- Rapid-sequence induction of general anesthesia, followed by the administration of a high dose of a volatile halogenated agent to relax the uterus.
- Alternatively, nitroglycerin may be administered for uterine relaxation.
- Prophylactic antibiotic administration after extraction.
Uterine Inversion
- The turning inside-out of all or part of the uterus.
- Associated with severe postpartum hemorrhage, and hemodynamic instability.
- Recent reports suggest an incidence of approximately 1:3,400 deliveries.
- Risk factors include uterine atony, a short umbilical cord, uterine anomalies, and overly aggressive management of the third stage of labor, including inappropriate fundal pressure or excessive umbilical cord traction.
- Discontinue all uterotonic drugs.
- Immediate replacement of the uterus, even before removal of the placenta, is the treatment goal, but it may be difficult to achieve.
- Administer nitroglycerin.
Placenta Accreta Spectrum
- Placenta that invades the uterine wall and is inseparable from it.
- Placenta accreta vera: adherence to uterine myometrium without an intervening decidual layer.
- Placenta increta: chorionic villi invade the myometrium.
- Placenta percreta: invasion through the myometrium into serosa and sometimes into adjacent organs, most often the bladder.
- Previous cesarean delivery or other uterine surgery increases the risk of both placenta previa and placenta accreta.
- The combination of placenta previa with previous cesarean delivery synergistically increases the risk for coexisting placenta accreta, particularly if the placenta is anterior and overlies the uterine scar.
- Antenatal diagnosis of placenta accreta facilitates effective planning.
- Ultrasonography is a useful screening tool in patients with placenta previa and/or previous cesarean delivery; it is the primary imaging modality to diagnose placenta accreta.
- ACOG recommends that patients with placenta accreta be transferred to a tertiary care facility due to the predictable need for massive transfusion.
- Planned delivery with the necessary multidisciplinary team present is associated with less maternal morbidity.
- Decision analysis indicates that 34 weeks gestational age is the preferred time for planned delivery in most clinical circumstances involving the placenta and evidence of placenta accreta.
- Most patients with known placenta accreta should undergo planned preterm cesarean delivery and hysterectomy with the placenta left in situ because attempts to remove the placenta are likely to initiate hemorrhage.
- Preoperative placement of ureteral stents may minimize urinary tract injury.
- Optimally, the internal iliac artery balloon catheters are inflated after delivery.
- Prophylactic use of resuscitative endovascular balloon occlusion of the aorta (REBOA) reduces blood loss during placenta accreta surgery.
- ACOG considers planned peripartum hysterectomy to be the management of choice for patients with placenta accreta. Reserve uterine conservation strategies for hemodynamically stable patients w strong desire for future fertility.
Invasive Treatment Options
- Intrauterine Balloon Tamponade can reduce rates of hysterectomy. May fail if there is cervical prolapse, or continuous bleeding behind balloon.
- Uterine Compression Sutures have a 92% success rate and are most useful in cases of refractory uterine atony.
- Angiographic arterial embolization requires rapid access to angiography facility and skilled interventional radiologist with 70-100% success.
- Bilateral Surgical Ligation can be used to control to bleeding at laparotomy with variable success.
- Manual Compression of the Aorta is a life saving procedure that can reduce the blood flow by compression against a vertebral body in upper abdomen.
- Peripartum Hysterectomy is a technically challenging operation that has an increased risk of mortality and morbidity.
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This covers postpartum hemorrhage, focusing on mechanisms the body uses to control blood loss, hemostasis, and factors contributing to hemorrhage. It emphasizes recognizing and managing obstetric hemorrhage.
