Complete Placenta Previa. How much hemorrhage to expect ?
Even with the modest cervical dilatation, copious hemorrhage would be anticipated
What are the types of premature separation of the placenta ?
Apparent bleeding type and
Concealed bleeding type
Partial placental Previa and Complete abruptio have internal or external hemorrhage ?
External Hemorrhage
Explain the mechanism of concealed hemorrhage.
Extensive placenta abruptio but the periphery of the placenta and the membranes still adherent , result in completely CONCEALED hemorrhage.
What happens to the fetus in placental abruption
Fetus is now dead
Placenta Accreta means
Placenta adhesion TO uterine MYOMETRIUM WITHOUT invasion
Massive bleeding AFTER deliver
Accreta
Adhesion to myometrium without inversion
Bleed after delivery
Placenta Increta
Invision to myometrium
Increta=>Invasion
Massive bleeding after delivery
Placenta Percreta
Invision to myometrium , serous and adjacent structures .
Li Perce => Percreta
Invasion to myometrium
Increta
Adhesion to myometrium with no invasion
Accreta
Invasion to myometrium, serosa and adjacent structures
Percreta
What percentage of Accreta
75- 78%
What is the percentage of Increta ?
17%
What is the percentage of Percreta ?
5%
Placenta Accreta : placenta adhesion to uterine myometrium without invasion = massive bleeding after delivery . What history accompanies this type ?
H/O previous C/S, placenta Previa, uterine trauma
Placenta Increta :
Placenta invasion to myometrium =>massive bleed after delivery
Placenta Percreta
Placenta invasion of myometrium, serosa, and adjacent pelvic structures
How to diagnose the abnormal placental implantations?
Ultrasound
Or
MRI
What is the management of placental implementations ?
C- Section
or
Postpartum Hysterectomy
What are the two MCC of 3rd trimester bleeding ?
Placenta Previa
and
Placental abruption
What is placenta Previa ?
Abnormally implanted on the lower uterine segment
and
covers or borders on the cervical os
What are the 3 Types of placenta Previa ?
Marginal
Total
Partial
What is Marginal Placenta Previa ?
Within 2 cm of Os
What is Total Placenta Previa ?
Total is completely covering the OS
What is partial Placenta Previa ?
Partially covering the OS
What is the incidence of Placenta Previa ?
Incidence and mortality of 1%
What are the risk factors for Placenta Previa ( 6)
Accreta Advanced Maternal Age Large Placenta Multipara Malpresentation Previous C/S
How do you diagnose Placenta Previa ?
Ultrasound
MRI
NO VAGINAL EXAM
Signs and Symptoms of Placenta Previa ?
PAINLESS vaginal bleeding which stops automatically
Preterm labor
Maternal hemorrhage with hypotension
What is the management of Placenta Previa ?
- Expectant ( wait until delivery )
- Hospitalization with bed rest and OBSERVATION if <37 weeks with mild to moderate bleeding.
-IV fluids , T&C matching
-Maintain crit > 30
Await lung maturity (steroids shots) - Coagulopathy is common ; may need replacement
- Delivery
Do Lecithin/Sphingomyelin, ratio if immature give steroid to mom
ALWAYS C/S
What are the steps taken when an expectant with placenta Previa is awaiting delivery ?
Hospitalization, bedrest with observation if < 37 weeks with mild to moderate bleeding
IV fluids, T&C matching
Maintain HCT > 30
Await lung maturity ( steroid shots)
Coagulopathy s common , may need replacement
What are the steps taken for placenta Previa at delivery ?
Do a lecithin/sphingomyelin ratio and if immature give steroid to the mother .
Always deliver via C/S
What are the complications associated with Placenta Previa (3)
Premature delivery - MCC of neonatal Morbidity and Mortality
Placenta Accreta - so a hysterectomy
PPH ( Post partum Hemorrhage )
The 3 P’s complication of Placenta Previa
PPH
Premature delivery
Placenta Accreta
What is Placenta Abruptio?
When the normally implanted placenta separates from Decidua Basalis prior to delivery
Describe the location of the bleeding in placenta abruptio
It can be concealed or overt.
What is the incidence of Placenta Abruptio
1/100
One in 1 hundred
6 risk factors of Placenta Abuptio
- Smoking* or Cocaine
- Maternal HTN
- Trauma
- Preterm Premature Rupture of membrane
- Hypertonic Uterus
- Previous History
Smoking, Cocaine/ Maternal HTN/ Previous Hx/Hypertonic Uterus/ Trauma/ Preterm PROM are risk factors for
Placenta Abruptio
Placenta Abruptio Risk Factors in alphabetical order ..lol…
Cocaine, Smoking Hypertonic Uterus Maternal HTN Previous Hx Preterm Premature Rupture of Membrane Trauma
How do you Dx Placenta Abruption
Clinical Suspicion
Or
MRI
9 S/S of placenta Abruptio
- Painful vaginal bleeding; Large volume; Concealed Vs revealed
- Uterine Tenderness
- Hypovolemia
- Retroplacental Hematoma ( 2500ml )
- Contractions - low amplitude , high frequency
- Abdominal/ back pain
- Fetal bradycardia ( fetal distress)
- due to loss of maternal gas exchange area - Fetal Demise - Most common cause
- Maternal Coagulopathy- MC of DIC
- Replacement of clotting factors and platelets .
4 Complications of Placenta Abruptio
DIC
SHOCK
ARF
Loss of Fertility - uterine stony secondary to “couvelaire uterus”
6 Management of Placenta Abruptio
- Expectant- preterm fetus without signs of distress ; follow coagulation profile .
- C-section - if fetal distress ( fix mother’s coagulopathy first )
- Massive blood transfusion
- No delay
- Replacement if clotting factors, Platelets
- NO EPIDURAL If concerns over volume coag
Placental abruptio + placental separation
Prompt delivery
Placental abruption + Maternal hemorrhage
Vigorous transfusion and prompt deliver
Placental Abruptio + Fetal hemorrhage
Immediate delivery and Infant transfusion
Placental abruption + Uterine Hypertonus
Prompt delivery
Compare pathophysiology of placenta abruptio vs placenta previa
Abruptio = premature separation of normally implanted placenta
Placenta Previa = Abnromal implantation near or AT os
Incidence of abruptio vs Previa
Abruptio = 1/ 100
Previa = 1/200
Risk factors of abruption vs Previa
Abruptio : HTN, Abd trauma , Tobacco, Cocaine
Previa: Prior C/S, grand multiparous
Symptoms of previa vs abruptio
Abruptio = PainFUL vaginal bleeding m interior hyperactivity, fetal distress
Previa = PainLESS vaginal bleeding
Diagnosis of Abruptio vs Previa
Abruptio = Transabdominal / Transvaginal Ultrasound
Previa = Transabdominal/ Transvagibnal US ????
Management of ABruption vs Previa
Abruptio: Stabilize the pt with premature fetus; EXPECTANT MANAGEMENT with frequent monitoring
And moderate to severe = immediate delivery
Previa: NO VAGINAL exam , Stabilizem Mag Sulf, Fetal lung maturity , Delivery if unstable , Bleeding
Complications abruptio vs Previa
Abruptio = DIC, Shock, Ischemis necrosis of distal organs, Fetal anemia
Previa = Placenta Accreta, Fetal anemia
What is Prematurity
Birth before 37 weeks of gestation
What are the 9 complications due to immature organ ( in prematurity )
- Respiratory Distress Syndrome
- PDA
- Hypoxia or Shock
- Infections
- High bilirubin, hypoglycemia
- Intracranial Hemorrhage
- Hypothermia
- Congenital anomalies
- Retinopathy = visual loss
Congenital anomalies Infection ( CMV following blood tx) Intracranial Hemorrhage Hypothermia Hypoxia or Shock ( cause gut ischemia ) High Bilirubin and hypocalcemia PDA Resp. Distress syndrome ( give surfactant ) Retinopathy = visual loss Are complications due to
Immature organs
- treatment in prematurity
- B2 agonist i.e. ritodrine to stop contraction
What are the 2. S/E of ritodrine in
Mom and fetus
Mom: Hypokalemia, Hyperglycemia , tachycardia
Fetus : Hypokalemia , Hyperglycemia , tachycardia ( +/-)
What medication to avoid with ritodrone and why ?
Avoid atropine
Can cause tachy»> Pulmonary edema
5 anesthetic consideration in Prematurity
- Airway, Fluid and Temperature control
- High risk of Postanesthetic apnea ( give aminophylline or caffeine )
- Avoid Fluctuation in PaO2 level ( Normal = 60-80 mmHg ) = Monitor pulse ox constantly, avoid excessive oxygenation .
- Vitamine E prevent retinopathy
- Fentanyl with low requirement is favored
Early Deceleration 💣
- Decelerations begin and end at approximately the same time as the uterine contraction
- HEAD COMPRESSION
- NO fetal distress
Late declaration
- Persist after contraction is over
- Associated with fetal hypoxia - decrease Uteroplacental perfusion
- Possibly due to maternal hypotension or abruption
4.Assess fetal pH
5.Deliver the baby ASAP when
A) persistent
B) Fetal Bradycardia
Possibly due to maternal hypotension or abruptio, Late or early Decel
Late
NO fetal distress. Early or Late Decel ?
Early
Persist After contraction is over . Early or Late Decel
Late Decel
The deceleration begin and end at approx the same time as the uterine contraction
Early Decel
Associated with fetal hypoxia - decrease Uteroplacental perfusion . Early or Late Decel ?
Late Decel
The Decel is persistent and fetal bradycardia is present , what must be done ASAP ?
Deliver the baby
Late Decel
In which deceleration do we assess fetal pH ?
Late
Variable Decelaration (7)
- Variable in shape , severity and timing
- Occur at any time during contraction
- Umbilical cord compression and low blood flow
- Associated with fetal hypoxia
- Respiratory acidosis - with good fetal reverse, metabolic acidosis does not occur.
- Occurs in oligohydromnios
- Change mother position back to side
Incidence of gestational diabetes
3- 5 %
Gestitional Diabetes Risk factors are (6)
- Large fetus
- Obesity
- Past Hx
- Prior abortions
- Still births
- Maternal age >30
What do you see on H&P of Gestational Diabetes ?
1) Asymptotic,
2) fetus larger for gestational age
What lab abnormalities accompany Gestational Diabetes?
Glycosuria
Fastening Hyperglycemia
Abnormal Glucose Tolerance Test
What is the treatment for Gestational Diabetes?
Diet control
Insulin
Avoid oral hypoglycemia agent = fetal hypoglycemia
What are the maternal complications with gestational diabetes?
C/S for macrosomia DM type II Preterm Labor Polyhydramnios Preeclampsia/eclampsia
What are the Fetal complications with gestational diabetes?
Congenital defects Hypoglycemia Macrosomia Perinatal mortality 2-5 % Shoulder dystocia
Ectopic Pregnancy is
Any pregnancy outside the uterine cavity
3 risk factors for ectopic pregnancy
Pelvic Inflammatory Disease
Pelvic surgery
IUD
H&P in patients with ectopic pregnancy
Abdominal/ pelvic pain “knife-like”
Abnormal vaginal bleeding
Pelvic Mass
Shock if ruptures
How to diagnose to ectopic pregnancy ?
Elevated HCG w/o intrauterine pregnancy on US
Surgery vs Medical with methotrexate
What are the complications with ectopic pregnancy ?
Shock
Infertility
Maternal Death
What is the normal FHR ?
120 to 160
Head compression
Early deceleration
Hydatidiform Mole
V
Rule of nine anterior and posterior head and neck
9%
- 5% anterior
- 5 posterior
Anterior and posterior upper limbs
18%
Ant 9
Post 9
Anterior and posterior trunk rule of nine
36%
Anterior 18%
Posterior 18%
Perineum rule of nine
1%
Anterior and posterior lower limbs
36%
Right anterior 9%
Left anterior 9%
Right Posterior 9%
Left Posterior 9%
pediatric rule of nine . Head
9% ant
9% posterior
Upper limbs pediatrics rule of nine
18%
Right anterior 4.5%
Right posterior 4.5%
Left anterior 4.5 %
Left anterior 4.5%
Right limb 9%
Left limb 9%
Upper trunk peds rule of nine
36%
18% anterior trunk
13 % back
each buttock 2.5 % ( 5% Bc x2)
Rule of nine peds lower limbs
Anterior right 7%
Posterior left 7%
Anterior left 7%
Posterior right 7%
Burn injury per year
2.5 millions
burn hospitalization per year
100,000
Burns deaths per year
10,000
How types of burns
Thermal
Chemical
Radiational
Electrical
First degree
superficial, limited to epidermis
Second degree
Partial thickness
Extends to the dermis
Third degree
Full thickness
No pain
Inhalation injury ;direct insult thermal insult leads to
- Pulmonary edema and ARDS
- Smoke
- Deactivation of surfactant leads to atelectasis
- CO poisoning
Hypovolemia and shock due to burns
Total body edema due to increase permeability
pulmonary loss
Burn ; Hyperkalemia due to
tissue destruction
What is the primary cause of death in burn ?
Loss of skin barrier
Inhalation injury and pulmonary infection
Initial treatment in burns
Thermal = roll or cover chemical = profuse irrigation Electrical = remove the source
Resuscitation in burns
Treat the Shock first.
If no Shock fluid administration aims to replace the DEFICIT and SUPPLY the maintenance fluid.
Evaluate Total Body Surface Area burned by rule of nines
Formula for burn fluid replacement
3ml/kg/%BSA burned. Of crystalloid/ 24 hr
40% burn, 70kg
3mlx70x40 = 8400 ml in 24 hrs
First 1/2 over 8 hrs
2nd 1/2 over 16 hrs
Wound care of burns
Gentle debridement
partial thickness - cover with topical antibiotics
Full thickness :
Topical antibiotics
Excise burn wound to remove necrotic tissues
Cover with skin graft
Keep extremities elevated
Complete thickness
Topical antibiotics
exice burn wound to remove necrotic tissues
Cover with skin graft
keep extremities elevated
Infections in burn
Sputum c/s
Wound infection : respect the viable tissue . And antibiotics injected in the tissue and IV.
Metabolic changes
Requirement is increased. Bc catabolic state.
What is formalu for calories to meet metabolic changes in burns
25kcal/kg/day + 40kcal/% bsa burned/day
Higher protein : calorie ratio
Long term care of burns (3)
Splints- opposes the contracture
Pressure garment - prevent scars and edema
Range of Motion - prevent contracture
anesthesia consideration
Intubate before edema develops
Sux is contraindicated due to hyperthermia = cardiac arrest
Higher doses of non depolarizing muscle relaxant
Halothane is best avoided If epinephrine is being used to stop bleeding
Complete Mole
46 XX all from father
HCG = increase increase increase increase
Uterine size = Increase
2% convert choriocarcinoma
No Fetal parts
2 Sperms + empty egg
Risk of complications : 15 - 12% malignant trophoblastic disease
Complete Mole uterine size
Increased
Incomplete Mole Uterine size
Does not increase
Complete Mole HCG
Increase increase increase increase
Incomplete mole HCG
Increase ( 1)
Fetal parts in Complete Moles ?
NO
Fetal Parts in incomplete mole ?
Yes
< 5 % in malignancy, which mole
Incomplete Mole
Malignant Trophoblastic Disease , which mole
Complete Mole
15 - 20 %
What is spontaneous abortion ?
Non selective termination of pregnancy at < 20 weeks
What is a common cause of 1st trimester bleeding ?
Spontaneous Abortion
What is the H& P of someone having a spontaneous abortion
Vaginal bleeding and tissue passage
Closed vs open Os
What evaluation for spontaneous abortion?
B HCG
U/S
Culdocentesis
Treatment for spontaneous abortion
- Stabilize
- D&C
- Antibiotics
- RhoGAM if appropriate
What are the complication of D& C
Perforation and Hemorrhage
Complete abortion
< 20 weeks
All POC expelled
Os closed
Uterine bleeding
Incomplete Abortion
< 20 weeks gestation
Some POC expelled
Open Os
Bleeding
Treatment for incomplete abortion
D&C
Threatened abortion
< 20 weeks gestations Intact Membrane Os closed Bleeding Viable Fetus
Threatened Abortion treatment
Complete rest
Inevitable abortion
< 20 weeks No POC expelled Rupture Membrane Os open Bleeding and cramps
Inevitable abortion
Emergent D&C
Missed abortion
No Fetal Heart tone No POC expelled Retain fetal tissue Os Closed No bleeding Nonviable tissue not expelled in 4 weeks
Missed abortion treatment
Evacuate uterus
D&C
Septic abortion
Infection associated with abortion ; endometritis
Septic abortion
D&C ; antibiotic
Intrauterine Fetal death
No Fetal Heart tone
Treatment for uterine Fetal death
No fetal heart tone
Do a D&C
Aspiration Pneumonia
Pathological consequences of abnormal entry of fluids particulate matter or secretions into lower airways
S/s of aspiration pneumonia
SOB
Bronchospasm
Fever
Pink and Frothy Sputum
Treatment for aspiration pneumonia
Tracheal suction and lavage
Antibiotics
Mechanical Ventilation
Postpartum Hemorrhage , how much blood is lost within the first 24 hrs of delivery ?
> 500 ml
Complications of PPH (2)
Hemorrhagic Shock
Transfusion related risks
Risk Factors for Uterine Atony
Over distention uterus ( multiple gestation , Macrosomia)
Prolong Labor
Uterine myoma
Mag sulfate
GA
Uterine Infection
Diagnosis of Uterine atony
Palpation of a softer , flaccid , boggy w/o a fundus
Treatment Uterine Atony ?
MCC of PPH ( 90%) Bimanual uterine message Oxytocin infusion Methylergonovine PGF2a if not hypertensive
Genital Tract Trauma Risk Factors are :
Precipitous labor
Forceps , Vaccum
Large INFANT
Inadequate episiotomy repair
Diagnosis of Genital Tract Trauma
Careful examination
Look for laceration
Genital Tract Trauma
Surgical repair of physical defect
Retained Placental Tissue
Placenta Accreta/Increta/Percreta
Preterm delivery
Placenta Previa
Previous C/S or D&C
Uterine Leiomyomas
Diagnosis of retained Placental Tissue
Careful inspection for missing part of placenta U/S.
Treatment for retained placental tissue
Manual removal of remaining placenta
D&C
Placenta acreta/Increta/Percreta require hysterectomy
Venous Air Embolism occurs when ?
Occurs at the time of placental separation
Where is the venous embolism in OB patients ?
It lodges in the pulmonary arteries
5 s/s of VAE
1.Mill - wheel murmur
2. Chest Pain
3. SOB
4. Low end tidal CO2
5 Elevated CVP
What position when patient has VAE
Anti - Trendelenburg position
Left lateral with a tilt of 15º
Why ?
Increased chances of trapping air in right atrium with a CV cath
Amniotic Fluid embolism , what is it ?
Rare but deadly ; 3rd leading cause maternal death
Amniotic Fluid gets into maternal circulation due to break in the Uteroplacental membrane . True or False
True
S/S of amniotic fluid embolism
Chills Sudden onset of dyspnea Hypotension Hypoxia Coma DIC Uterine atony Cardiopulmonary arrest
Treatment for Amniotic Fluid embolism
- Stabilize
- Resucitation
- Delivery ASAP
- DObutaime
- Lasix
- Check for DIC
- Hydrocortisone
- NaHCO2
Effects of valorous acid
Fetal anticonvulsant syndrome , neural tube defect
Phenytoin, carbamazapine
Cleft lip/ palate
Warfarin
Skeletal and facial abnormalities , mental retardation , stillbirth , IUGR
Isoretinoin
Multiple anomalies
Griseofulvin
Multiple anomalies
Sulfonamides effect
Kernicterus
Amniglycosides effects
VIII nerve damage
Fluroquinolones effects
Cartilage damage
Tetracycline effects
Decreased bone growth , small limbs , discoloration of teeth
Iodide effects
Congenital goiter , hypothyroidism , mental retardation .
Ethanol Effect?
Fetal alcohol syndrome :
Microcephaly , mental retardation, abnormal face, limb dislocation, heart/lung fistulas
AMphetamine
Transposition of great vessels , cleft palate
Thalidomide
Limb abnormalities ( PHOCOMELIA) “seal limbs “
Diethylstilbestrol
Clear cell adenocarcinoma of vagina/ Cx , genital abnormalities
Most serious risk factor associated with surgery:
Uterine asphyxia is the during pregnancy
- Placental transfer - lipid soluble substances diffused rapidly
- Thromboembolism-prevent DVT with pneumatic compression stockings during C/S
- Hypotension is the most frequent complication of spinal and epidural; treated by
- Left Uterine displacement, IV hydration and ephedrine
Delayed gastric emptying -
prophylaxis with antacids
- Uterine displacement is to
To avoid supine hypotension
Preeclampsia has 8 s/s
- HTN
- Proteinuria
- Edema
- Oliguria
- Headache
- Visual Disturbance
- Hepatic Tenderness
- Hyperreflexia
Preeclampsia s/s with the numbers
HTN ( 160/110 ) Proteinuria >5g/day Edema : face,hand, and lung Oliguria <500ml/day Headache Visual disturbance Hepatic tenderness Hyperreflexia
Eclampsia
Seizures In preeclampsia
HELPP syndrome
High maternal and fetal mortality Call for immediate delivery Hemolysis Elevated Liver enzyme Low Platelet
Risk Factors Pregnancy Induced Hypertension.
Nulliparity Extreme age <15 or > 35 Multiple gestation Vascular disease due to SLE and DM \+ family history Chronic HTN HELLP Syndrome
Pathophys of PIH
Increased : Thromboxane A2 Endothelin 1 Renin Decreased : NO PGI2
S/S of PIH are
1.Uterine vasospasm»_space; Uteroplacental insufficiency
Low I/V volume
Low GFR, edema , CNS dysfunctions
2.Low uterine BF
Treatment PIH
- Only cure is delivery
- Monitor PT,PTT,Platelet, FSP
- Hydralazine and methyldopa to control HTN. Labetalol is drug of first choice.
- Esmolol should be avoided due to adverse fetal effects
- High dose of Nitroprusside = S/E cyanide toxicity WHY ??
- Seizures require mag sulfate and benzo
- Mag Sulf to prevent convulsion ( mag Sulf antagonizes calcium )
- Magnesium depresses CNS by decreasing acetylcholine release
- MOA of magnesium
Prevent CA++ entry into the cell= smooth muscle relaxation - Required level of magnesium 4-6 mEq/L
Treatment PIH , Mag toxicity : (6)
Magnesium Toxicity :
- Absent deep tendon reflexes
- Ventilatory failure (requires prompt intubation and ventilation )
- Heart Block = prolonged PQ, wide QRS , cardiac arrest
- Hypotension
- Drowsiness and Hypoventilation in fetus
- Atonic uterus
Treatment for Magnesium Toxicity
D/C Mag
Intubate
Ventilate
IV ca ++ gluconate
8 complications of Pregnancy Induced Hypertension:
- Pulmonary edema/ cerebral Hemorrhages ( leading cause of maternal death
- DIC
- Prematurity
- Prematurity/fetal distress
- Intrauterine growth retardation
- Placental Abruption
- ARF, cerebral edema
- Fetal/Maternal death; leading cause
Mild eclampsia
> 140/90
Headache, Somnolence blurred vision
Epi gastric pain
Rapid weight gain
Edema
JV distention
Hyperactive reflexes
Clonus
Proteinuria > 300mg/24 hrs