Post-Partum Hemorrhage .com
Common ordersNVD – Pre-deliveryOrderSignificanceAdmit G#P#A#L# for NVD (ROM, PROM, PPROM) at ## w GAAdmission parametersC: Stable D: NPOCan allow sips of waterCytotec ? tab vaginally (or sublingually)If Bishop score < 6 for cervical ripeningIV: 1L LR + 1 amp oxytocin at a rate of 24 ml/hSee oxytocin protocolsCBC (PT, PTT)PT, PTT if epidural anesthesia requestedFetal monitoringFetal cardiotocometryNVD Post opOrderSignificanceInsert all material used in delivery suite such as:Oxytocin 3 amp to infusionPrevention of PPHCytotec 2 tabs rectallyPrevention of PPHXylocaine 10 ml to perineumFor episiotomyKetalar 1 ml IVP STATTo put the patient to sleep while we learn / workMethergine 1 amp IM STATPrevention of PPHLeave one line blankTransfer patient to floor when stablePostpartum observationLeave one line blankContinue care S/P NVD (♂♀) ####gC: Stable D: RegularDC IV when patient urinatesWatch for vaginal bleedingVS Q ? h 1st 2h then Q8h when stableVitals to monitor for preeclampsiaPanadol 500 mg 2tab PO Q6hDorixina 125 mg 1 tab PO Q8hCesarean DeliveryOrderSignificanceAdmit G#P#A#L# for CS (ROM, PROM, PPROM) at ## w GAAdmission parametersC: Stable D: NPOIV: 1L LR over 8hFluid overload in preparation for spinal anesthesiaAugmentin 1.2g IVD on call to ORNot a pre-op recommendation but attendings insist on it.CBC, PT, PTTFetal monitoringFetal cardiotocometryGYN operationsOrderSignificanceAdmit for [OPNAME] Admission parametersC: Stable D: NPOIV: 1L LR over 8hFluid overload in preparation for spinal anesthesiaAugmentin 1.2g IVD on call to ORNot a pre-op recommendation but attendings insist on it.CBC, PT, PTTBUN, Cr, electrolytesONLY if > 40yEKG + consult cardiologyONLY if > 40yCXRONLY if > 40yNVD Operative NotePatient is scrubbed and draped in lithotomy position. Right mediolateral episiotomy. Neonate delivered: (♂♀) ####g. Placenta delivered completely. Episiotomy closure with 1 – 0 Caprosyn layer by layer. Uterus contracted. Hemostasis secured.LabsTrimesterTestNot pregnant1st2nd3rdHb12–15.8 11.6–13.99.7–14.89.5–15.0Hct35.4–44.431–4130–3928–40WBC3.5–9.15.7–13.65.6–14.85.9–16.9TrimesterTestNot pregnant1st2nd3rdPlat165-415174-391155-409146-429HbA1c4–64–64–64–7Progesterone (ng/mL)<1–208–4899–342EmergenciesPost-Partum HemorrhageAs a way of remembering the causes of PPH, several sources have suggested using the “4 T’ s” as a mnemonic: tone, tissue, trauma, and thrombosis.ToneUterine atony and failure of contraction and retraction of myometrial muscle fibers can lead to rapid and severe hemorrhage and hypovolemic shock. Poor myometrial contraction can result from fatigue due to prolonged labor or rapid forceful labor, especially if stimulated. It can also result from the inhibition of contractions by drugs such as halogenated anesthetic agents, nitrates, nonsteroidal anti-inflammatory drugs, magnesium sulfate, beta-sympathomimetics, and nifedipine.TissueUterine contraction and retraction leads to detachment and expulsion of the placenta. Complete detachment and expulsion of the placenta permits continued retraction and optimal occlusion of blood vessels.Retention of a portion of the placenta is more common if the placenta has developed with a succenturiate or accessory lobe. Following delivery of the placenta and when minimal bleeding is present, the placenta should be inspected for evidence of fetal vessels coursing to the placental edge and abruptly ending at a tear in the membranes. Such a finding suggests a retained succenturiate lobe.The placenta is more likely to be retained at extreme preterm gestations (especially < 24 wk), and significant bleeding can occur. This should be a consideration in all deliveries at very early gestations, whether they are spontaneous or inducedFinally, retained blood may cause uterine distension and prevent effective contraction.TraumaDamage to the genital tract may occur spontaneously or through manipulations used to deliver the baby. Cesarean delivery results in twice the average blood loss of vaginal delivery. Incisions in the poorly contractile lower segment heal well but are more reliant on suturing, vasospasm, and clotting for hemostasis.Uterine rupture is most common in patients with previous cesarean delivery scars. Routine transvaginal palpation of such scars is no longer recommended. Any uterus that has undergone a procedure resulting in a total or thick partial disruption of the uterine wall should be considered at risk for rupture in a future pregnancy.Trauma may occur following very prolonged or vigorous labor, especially if the patient has relative or absolute cephalopelvic disproportion and the uterus has been stimulated with oxytocin or prostaglandins.Cervical laceration is most commonly associated with forceps delivery, and the cervix should be inspected following all such deliveries. Assisted vaginal delivery (forceps or vacuum) should never be attempted without the cervix being fully dilated. Cervical laceration may occur spontaneously. In these cases, mothers have often been unable to resist bearing down before full cervical dilatation. Rarely, manual exploration or instrumentation of the uterus may result in cervical damage.ThrombosisIn the immediate postpartum period, disorders of the coagulation system and platelets do not usually result in excessive bleeding; this emphasizes the efficiency of uterine contraction and retraction for preventing hemorrhage. Fibrin deposition over the placental site and clots within supplying vessels play a significant role in the hours and days following delivery, and abnormalities in these areas can lead to late PPH or exacerbate bleeding from other causes, most notably, trauma.Abnormalities may be preexistent or acquired. Thrombocytopenia may be related to preexisting disease, such as idiopathic thrombocytopenic purpura, or acquired secondary to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), abruptio placentae, disseminated intravascular coagulation (DIC), or sepsis. Rarely, functional abnormalities of platelets may also occur. Most of these are preexisting, although sometimes previously undiagnosed.PreEclampsia and EclampsiaMild preeclampsia is defined as the presence of hypertension (BP ≥140/90 mm Hg) on 2 occasions, at least 6 hours apart, but without evidence of end-organ damage, in a woman who was normotensive before 20 weeks' gestation. In a patient with preexisting essential hypertension, preeclampsia is diagnosed if SBP has increased by 30 mm Hg or if DBP has increased by 15 mm Hg.Severe preeclampsia is defined as the presence of 1 of the following symptoms or signs in the presence of preeclampsia:SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher on 2 occasions at least 6 hours apartProteinuria of more than 5 g in a 24-hour collection or more than 3+ on 2 random urine samples collected at least 4 hours apartPulmonary edema or cyanosisOliguria (< 400 mL in 24 hours)Persistent headachesEpigastric pain and/or impaired liver functionThrombocytopeniaOligohydramnios, decreased fetal growth, or placental abruptionEclampsia is defined as seizures that cannot be attributable to other causes in a woman with preeclampsia. HELLP syndrome (hemolysis, elevated liver enzyme, low platelets) may complicate severe preeclampsia.DiagnosisAll women who present with new-onset hypertension should have the following tests:CBCSerum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levelsSerum creatinineUric acid24-hour urine collection for protein and creatinine (criterion standard) or urine dipstick analysisAdditional studies to perform if HELLP syndrome is suspected are as follows:Peripheral blood smearSerum lactate dehydrogenase (LDH) levelIndirect bilirubinAlthough a coagulation profile (prothrombin time [PT], activated partial thromboplastin time [aPTT], and fibrinogen) should also be evaluated, its clinical value is unclear when the platelet count is 100,000/mm3 or more with no evidence of bleeding.ManagementDelivery is the only cure for preeclampsia. Patients with mild preeclampsia are often induced after 37 weeks' gestation. Before this, the patient is usually hospitalized and monitored carefully for the development of worsening preeclampsia or complications of preeclampsia, and the immature fetus is treated with expectant management with corticosteroids to accelerate lung maturity in preparation for early delivery.In patients with severe preeclampsia, induction of delivery should be considered after 34 weeks' gestation. In these cases, the severity of disease must be weighed against the risks of infant prematurity. In the emergency setting, control of BP and seizures should be priorities.Seizure treatment and prophylaxisThe basic principles of airway, breathing, and circulation (ABC) should always be followedMagnesium sulfate is the first-line treatment for primary and recurrent eclamptic seizuresTreat active seizures with IV magnesium sulfate[4] : A loading dose of 4 g is given by infusion pump over 5-10 minutes, followed by an infusion of 1 g/hr maintained for 24 hours after the last seizureTreat recurrent seizures with an additional bolus of 2 g or an increase in the infusion rate to 1.5 or 2 g per hourProphylactic treatment with magnesium sulfate is indicated for all patients with severe preeclampsiaLorazepam and phenytoin may be used as second-line agents for refractory seizuresAcute treatment of severe hypertension in pregnancyAntihypertensive treatment is recommended for severe hypertension (SBP >160 mm Hg; DBP >110 mm Hg). The goal of hypertension treatment is to maintain BP around 140/90 mm Hg.Medications used for BP control include the following:HydralazineLabetalolNifedipineSodium nitroprusside (in severe hypertensive emergency refractory to other medications)Fluid managementDiuretics should be avoidedAggressive volume resuscitation may lead to pulmonary edemaPatients should be fluid restricted when possible, at least until the period of postpartum diuresisCentral venous pressure (CVP) or pulmonary artery pressure monitoring may be indicated in critical casesA CVP of 5 mm Hg in women with no heart disease indicates sufficient intravascular volume, and maintenance fluids alone are sufficientTotal fluids should generally be limited to 80 mL/hr or 1 mL/kg/hrPostpartum managementMany patients will have a brief (up to 6 hours) period of oliguria following deliveryMagnesium sulfate seizure prophylaxis is continued for 24 hours postpartumLiver function tests and platelet counts must document decreasing values prior to hospital dischargeElevated BP may be controlled with nifedipine or labetalol postpartumIf a patient is discharged with BP medication, reassessment and a BP check should be performed, at the latest, 1 week after dischargeUnless a woman has undiagnosed chronic hypertension, in most cases of preeclampsia, the BP returns to baseline by 12 weeks’ postpartumPatients should be carefully monitored for recurrent preeclampsia, which may develop up to 4 weeks postpartum, and for eclampsia that has occurred up to 6 weeks after deliveryΒ-HCG LevelsGuideline To HCG Levels During Pregnancy:hCG levels in weeks from LMP:3 weeks LMP: 5 – 50 mIU/ml4 weeks LMP: 5 – 426 mIU/ml5 weeks LMP: 18 – 7,340 mIU/ml6 weeks LMP: 1,080 – 56,500 mIU/ml7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml9 – 12 weeks LMP: 25,700 – 288,000 mIU/ml13 – 16 weeks LMP: 13,300 – 254,000 mIU/ml17 – 24 weeks LMP: 4,060 – 165,400 mIU/ml25 – 40 weeks LMP: 3,640 – 117,000 mIU/mlNon-pregnant females: <5.0 mIU/mlPostmenopausal females: <9.5 mIU/mlIn a bout 85% of normal pregnancies, the hCG level will double every 48 – 72 hours. As you get further along in pregnancy and the hCG level gets higher, the time it takes to double can increase to about every 96 hours.Caution must be used in making too much of hCG numbers. A normal pregnancy may have low hCG levels and result in a perfectly healthy baby. The results from an ultrasound after 5 - 6 weeks gestation are much more accurate than using hCG numbers.An hCG level of less than 5mIU/ml is considered negative for pregnancy, and anything above 25mIU/ml is considered positive for pregnancy.A transvaginal ultrasound should be able to show at least a gestational sac once the hCG levels have reached between 1,000 – 2,000mIU/ml. Because levels can differentiate so much and conception dating can be wrong, a diagnosis should not be made by ultrasound findings until the hCG level has reached at least 2,000. ................
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