- Indocin

- Terbutaline

- Nifedipine

- Betamethasone

- Magnesium sulfate (used primarily for seizure prophylaxis)

most commonly used w/ a nasty SE profile -> but effective tocolytic.

- B2: adrenergic receptor agonist

- SE Uterine relaxation, bronchodilation, vasodilation, muscle glycogenesis.

- CNS: dizzy, drowsy, HA, restlessness

- BP: widening PP

- HR: palpitations, tachycardia, chest pain

- GI: N/V

- Resp: SOB, sough, pulmonary edema

- Metabolic: maternal hyperglycemia

- Fetal: Tachycardia, hypoglycemia

Disseminated Intravascular Coagulation

- most common cause of abnormal hemmorhage tendency during pregnancy and the puerperium and reflects systemic activation of the coagulation cascade by circulating thromboplastic material, with secondary activation of the fibrinolytic system.

Heavy show: Close observation, anticipate birth. Monitor fetal status

Placenta Previa/ Abruptio Placentae: Report immediately, start IV, give O2, stop oxy if started, monitor blood loss, maternal staus, fetal response, anticipate blood replacement therapy, anticipate need for vasoactive drug therapy, medical ecaluation for timing andd route of delivery.

Utering Rupture: Report immediately, esstablish and verify patency of venous access, prepare cesarean birth.

Signs of DIC, report immediately, anticipate orders to correct underlying cause.

Placenta Previa

Symptoms / Care

Symptoms:

• Painless bleeding
• Uterus: soft, non-tender

Care:

• Stabilize mother / fetus
• VS, IV, CBC
• monitor FHR
• NO VAG exams
• Ultrasound
• Bedrest
• Unstable- deliver infant

• Complete Previa: the placenta completely covers the os; %20 - %43 of previia presentations
• Partial previa: placenta partially covers os: 31%
• Marginal Previa: placenta edge lesss than 2cm from internal os
• "Low-lying placenta": placenta in lower segment of uterus but appears to be at least 2 cm from cervical os

Most common and life threatening complication of placenta previa.

What do you do?

Maternal hemmorrhage

• Dx with US, NO VAG EXAM
• risk FACTORS: >35 yo, AA, increased gravidity/parity, prior uterine surgery (C/S), smoking, multiple gestation, prioor induced AB
• Higher incidence of malpresentations, preterm delivery, PPROM, IUGR (Intrauterine growth restrictions)
• Bright red, painless bleeding (minimal to hemorrhage) with uterine irritability.

Serious oB surgery

• Risk factors: 
• TOL for VBAC
• Induction, use of Pitocin
• Congenital uterine anomoly
• prior uterine surgery
• Multiparity: uterin wall is thinner
• trauma
• Signs and symptoms:
• Vary with the extent of rupture 
• Nonreassuring fetal tracing
• Loss of fetal station
• Signs of hypovolemic shock
• pain in chest
• Management
• Preventon is best
• surgical intervention

Abruptio Placenta

• Premature seperation of a normally implanted placenta from the uterine wall
• Hemorrhage can be completely concealed or obviious
• A leading cause of fetal and neonatal mortality
• (If abruption what might you "read" on the EFM?)

• Premature seperation of a normally implanted placenta from the uterine wall
• Hemorrhage can be completely concealed or obviious
• A leading cause of fetal and neonatal mortality
• (If abruption what might you "read" on the EFM?)

grades of Abruptio Placenta

Grade 1: 40%, can be allowed to labor naturally

Grade 2 (45%): C/S

Grade 3 (15%): C/S

Previa -> Painless bleeding

Abrupto -> pain andd tetanic contrx

• grand multiparity
• Pre ecclampsia or chronic hypertenssion
• PROM
• Pregestational DM
• substance abuse (esp cocaine)
• polyhydramnios
• blunt force trauma
• smoking
• uterine fibroids
• multiple gestations
• extremes of maternal age (but more about poor general health)
• vascular abnormalities in placental bed
• Hx of abruption
• uterine anomalies
• Thrombophilias
• sudden decompression of uterus (amniocentesis)
• unusually shaped placenta
• VAGINAL BLEEDING IS THE HALLMARK SIGN OF PLACENTAL ABRUPTION

Symptoms:

• Bleeding
• Tendernesss
• Backache, abdominal firmnessm
• uterine hypertonicity
• contractions
• shock

Care

• Stabilize Mother/Fetus
• VS, IV's, CBC
• NO VAG EXAMS
• Monitor FHR, UC's
• Observe
• Unstable- deliver C/S
• LABS: Prothrombin time (P/I), Activated thromboplastin (aPTT)

Disseminating Intravascular Coagulation

• Symtoms:
• Bleeding gums, nosebleed, petechiae, bruising w injections, venipuncture, tachy, diaphoresis
• Care:
• LAB: low platelets, fibrinogen, prolonged Pt, PTT
• Correct underlying problem (deliver)
• Volume/blood/blood product replacement
• Oxygen

PPH (Postpartum Hemorrhage)

• PPH drugs and contraindications

• Definition:
• EBL following delivery 
• Vaginal: 500ml
• C/S: 1000 ml
• >15% change in VS; HR >110; BP </= 85/45; O2 <%95, or increased bleeding postpartum

Pitocin–never give undiluted as a bolus injection IV

Cytotec–allergy, active CVD, pulmonary or hepatic disease

Prostin E2–active cardiac, pulmonary, renal, or hepatic disease

Methergine–if the woman is hypertensive, do not administer

Hemabate–contraindicated with asthma due to risk of bronchial spasm