 |
|
| |
[ Pobierz całość w formacie PDF ]
glandin E 2from the cervi x. W eekly membrane stri p
ping begi nning at 38 w eeks of gestati on re sults i n
deliveryw ithinashorterperi odof time (8.6 versus15
days).
2. Amniotomyi san effectivem ethodofl abori nduction
when perform ed in w omen w ith parti ally di lated and
effaced cervi ces. Caution shoul d be ex ercised to
ensurethatthefetal vertex i sw ell-applied tothecervi x
andtheum bilicalcordorotherfetalpartisnotpresent
ing.
3. Foley cathe ter. A n uni nflated Fol eycatheter can be
passed throughanundi latedcervi xandthen inflated.
Thistechni que is aseffecti veasprostagl andinE 2gel .
The useofex tra-amnioticsal inei nfusion with a balloon
catheter or a doubl e bal loon cat heter (A tad ri pener)
alsoappearstobeeffecti veforcervi calri pening.
C. Prostaglandins
1. Localadm inistrationofpros taglandins tothevagi naor
theendocervi xi stheroute of choicebecauseoffew er
side effectsandacceptabl ecl inicalresponse. Uncom
mon side e ffects include fever, chills, vom iting, and
diarrhea.
2. Prepidil contains0.5m gofdi noprostonei n2.5m Lof
gel for i ntracervical adm inistration. T he dose can be
repeatedi n6to 12 hoursi ftherei si nadequatecervi cal
change and m inimal uterine acti vityfol lowing the fi rst
dose.T hem aximum cumulative dosei s1.5m g(i e,3
doses) w ithin a 24-hour peri od. T he ti me i nterval
betweenthefi naldose and initiationofox ytocinshoul d
be 6 to 12hours because of the potenti alfor uteri ne
hyperstimulationw ithconcurrentox ytocinandprosta
glandinadm inistration.
3. Cervidil is a vagi nal i nsert containing 10 m g of
dinoprostone i n a ti med-release form ulation. T he
vaginal insert administers the m edication at 0.3 m g/h
andshoul dbel eft in placefor12hours.Ox ytocinm ay
bei nitiated 30to60m inutesafterrem ovalofthei nsert.
4. Anadvantageofthevagi nal insert over thegel form u
lation i s that the i nsert can be rem oved i n cases of
uterine h yperstimulation o r abnormalities o f t he f etal
heartratetraci ng.
V. Complicationsofl abori nduction
A. Hyperstimulationandtachy systolem ayoccur w ith use
ofprostagl andincom poundsorox ytocin.H yperstimulation
is defined as uteri ne contracti ons l asting at l east tw o
minutesorfi veor more uterinecontracti onsi n10m inutes.
Tachysystole is defined as sixorm orecontracti onsi n20
minutes.
B. ProstaglandinE 2(P GE2) preparationshaveuptoa5
percent rate of uteri ne hy perstimulation. Fetal heart rate
abnormalitiescanoc cur,butusual lyresol veuponrem oval
of the drug. R arelyhy perstimulation or tachy systole can
causeuteri ne rupture. RemovingtheP GE2vagi nali nsert
willu suallyh elpr everseth e effects of the hyperstimulation
and tachy systole. C ervical and vaginal lavage after l ocal
applicationofprostagl andincom poundsi snothel pful.
C. If ox ytocin i s bei ng i nfused, i t shoul d be di scontinued to
achieveareassuri ngfetal heart rate pattern.P lacingthe
woman i nthe l eft l ateral po sition, adm inistering ox ygen,
and increasing intravenous fluidsm ayal sobeofbenefi t.
Terbutaline0.25 mg subcutaneously(atocol ytic)m aybe
given.
References:S eepage166.
PostpartumHe morrhage
Obstetric hem orrhage rem ains a l eading causes of m aternal
mortality.P ostpartumhem orrhagei sdefi ned as the lossofm ore
than 500 m Lof bl ood fol lowing de livery.H owever, the average
blood loss in anuncom plicatedvagi naldel iveryi sabout500m L,
with5% l osingm orethan1,000m L.
I. Clinicalev aluationofpostpar tumhem orrhage
A. Uterine atony i s the m ost com mon cause of postpartum
hemorrhage. C onditions associ ated w ith uteri ne a tony
include an overdi stended uterus (eg, pol yhydramnios,
multiplegestati on), rapi d or prol onged l abor, m acrosomia,
highpari ty,andchori oamnionitis.
B. Conditions associated with bleeding from tr auma
includeforcepsdel ivery,m acrosomia,preci pitousl aborand
delivery,andepi siotomy.
C. Conditionsas sociatedw ithb leedingf romc oagulopathy
and thr ombocytopenia i nclude abrupti o pl acentae,
amniotic fl uid em bolism, preecl ampsia, coagulation di sor
ders,autoi mmunethrom bocytopenia,andanti coagulants.
D. Uteriner upturei sassoci atedw ith previous uterinesurgery ,
internal podal icversi on, breech ex traction, m ultiplegesta
tion, and abnorm al fetal presentati on. H igh pari tyi s a ri sk
factorforbothuteri neatony andrupture.
E. Uterinein version is detectedby abdom inalvagi nalex ami
nation, w hich w ill reveal a uterus w ith an unusual shape
afterdel ivery.
II. Managementofpostpar tumhem orrhage
A. Followingd eliveryof the pl acenta, the uter us should be
palpated to determ ine w hether atony is present. If atonyi s
present,vi gorousfundal m assage should be administered.
Ifbl eedingconti nuesdespi te uterinem assage,i tcanoften
becontrol ledw ithbi manualuteri necom pression.
B. Genitaltr actlacer ations shouldbesuspectedi npati ents
who have a fi rm uter us, but w ho conti nue to bl eed. T he
cervixand vagi na shoul d be i nspected to rul e out l acera
tions. I fno laceration is f ound but bleeding is still profuse,
theuterusshoul dbem anuallyex amined to excluderupture.
C. The placenta and uter us should be ex amined for re
tained p lacental f ragments. P lacenta a ccreta i s u sually
manifestby fai lureofs pontaneouspl acentalseparati on.
D. Bleedingfr om non-genitalar eas(venouspuncturesi tes)
suggests coagul opathy. Laborator y tests that confi rm
coagulopathy i nclude I NR, parti al throm boplastin ti me,
platelet c ount, f ibrinogen, f ibrin s plit p roducts, and a cl ot
retractiontest.
E. Medicalm anagementofpostpar tumhem orrhage
1. Oxytocin(P itocin)i susual lyg ivenrouti nelyi mmediately
after deliverytosti mulateuteri nefi rmnessand diminish
blood l oss. 20 uni ts of ox ytocin in 1,000 m L of norm al
saline or R inger's lactate i s adm inistered at 100
drops/minute. Ox ytocinshoul d n ot be given as a rapi d
bolus i njection because of the potenti al for ci rculatory
collapse.
2. Methylergonovine (M ethergine) 0.2 m gcan be given
IM if uterine m assage and ox ytocinare not effecti ve i n
correcting uterine atonyand providedtherei snohy per
tension.
3. 15-methyl pr ostaglandin F2-al pha (H emabate), one
ampule(0.25m g),canbegi ven IM,withrepeat injections
every20m in,upto 4 doses canbegi veni fhy pertension
ispresent;i ti scontrai ndicatedi nasthm a.
TreatmentofP ostpartumH emorrhageS econdaryto
UterineA tony
Drug Protocol
Oxytocin 20U i n1,000m Lofl actated
Ringer'sasI Vi nfusion
Methylergonovine 0.2m gI M
(Methergine)
Prostaglandin(15 0.25m gasI Mevery 15-60
methylP GF2-alpha minutesasnecessary
[Hemabate,
Prostin/15M])
F. Volumer eplacement
1. Patientsw ith postpartumhem orrhagethati srefractory
to m edical ther apy requi re a second l arge-bore I V
catheter. I f the pati ent has had a m ajor bl ood group
determinationandhas a negativei ndirectC oombstest,
type-specificbl ood m aybe gi ven w ithout w aiting for a
complete cross-m atch. Lactated R inger's sol ution or
normalsal ine i sgenerousl yi nfused unti lbl ood can be
replaced. R eplacement consi sts of 3 m Lof cry stalloid
solutionper1m Lofbl oodl ost.
2. A Foleycatheter i s pl aced, and uri ne output i s m ain
tainedatgreaterthan30m L/h.
G. Surgical m anagement of postpar tum hem orrhage. I f
medicaltherapy fai ls,l igationof the uterine oruteroovari an
artery,i nfundibulopelvicvessel s,orhy pogastricarteri es,or
hysterectomym aybei ndicated.
H. Managementofuter inei nversion
1. Thei nverteduterusshoul dbei mmediatelyreposi tioned
vaginally.B loodand/orfl uidsshoul d be administered. If
the placenta is still attached, it should not be rem oved
untiltheuterushasbeenreposi tioned.
2. Uterinerel axationcan be achievedw ithahal ogenated
anestheticagent.T erbutalinei sal souseful for relaxing
theuterus.
3. Followingsuccessful uteri nereposi tioningandpl acental
[ Pobierz całość w formacie PDF ]
zanotowane.pldoc.pisz.plpdf.pisz.plcs-sysunia.htw.pl
|
| |
|
|
|
| Podobne |
| |
|
| |
|