Ante partum and Post partum haemorrhage

Question 1

What is a placenta previa?

Answer 1

The placenta is inserted partially or wholly in the lower uterine segment

Question 2

A women who is 30 weeks pregnant presents with bleeding. She describes passing bright red blood on 3 occasions and describes the volume as being the same a heavy period. There was no associated pain.What is the diagnosis?

Answer 2

Placenta Previa

Question 3

A women who is 30 weeks pregnant presents with bleeding. She describes passing bright red blood on 3 occasions and describes the volume as being the same a heavy period. There was no associated pain. What test would you perform?

Answer 3

Ultrasound

Question 4

A women who is 30 weeks pregnant presents with bleeding. She describes passing bright red blood on 3 occasions and describes the volume as being the same a heavy period. There was no associated pain. What test would you definately not perform?

Answer 4

Vaginal examination. Never perform this is late bleeding until postpartum haemmorhage

Question 5

What is placenta accreta?

Answer 5

All or part of the placenta attaches abnormally to the myometrium. The chorionic villi attach to the myometrium rather than being restricted to the decidua basalis

Question 6

A women who is 32 weeks pregnant presents with bruising on her abdomen. She also says she had some quite heavy and painful vaginal bleeding this morning. On examination her uterus is tense and tender and seems larger than her dates. What is the most likely diagnosis?

Answer 6

Placental abruption. (Bruising is concealed blood)

Question 7

What is vasa previa?

Answer 7

Fetal blood vessels cross or run near the external orifice of the uterus. This means that these vessels are at risk of rupture when the supporting membranes rupture. (the vessels lie before the baby in the birth canal, meaning they are in the way of the baby’s exit.

Question 8

You diagnose a vasa previa antenatally at 24 weeks. What should the treatment plan be?

Answer 8

An elective cesearean should be performed prior to rupture of the membranes. (Recomended at 35 - 36 weeks)

Question 9

A women who is 36 weeks pregnant presents because her membranes have ruptured and she has had a large amount of painless vaginal bleeding. On CTG there is severe fetal bradycardia. What is the most likely diagnosis?

Answer 9

Vasa previa

Question 10

A women who is 30 weeks pregnant presents with bleeding. She describes passing bright red blood on 3 occasions and describes the volume as being the same a heavy period. There was no associated pain. What should you do?

Answer 10

Placenta Praevia is the most likely diagnosis.

• Admit to ward and gain IV access
• FBC, Coag screen and rhesus status.
• Give steroids and observe
• Deliver baby by caesarean section at 38 weeks (or sooner if there is significant haemmorhage)

Question 11

A women who is 32 weeks pregnant presents with bruising on her abdomen. She also says she had some quite heavy and painful vaginal bleeding this morning. On examination her uterus is tense and tender and seems larger than her dates.

Answer 11

Placental abruprtion
- Admit to ward and gain IV access
- FBC, Coag screen and rhesus status.
- Deliver baby.
(Steroids if expectant management)

Question 12

What volume of blood is lost is a minor PPH?

Answer 12

Less than 500ml

Question 13

What volume of blood is lost in a moderate PPH?

Answer 13

500 - 1500ml

Question 14

What volume of blood is lost in a major PPH?

Answer 14

Over 1500ml

Question 15

A women loses 1000ml of blood 6 hours after delivery.. What kind of PPH is this?

Answer 15

Moderate primary PPH

Question 16

A women loses 1600ml of blood 52 hours after delivery.. What kind of PPH is this?

Answer 16

Major secondary PPH

Question 17

6 hours after deliver a women starts to bleed heavily. What should you do?

Answer 17

• Uterine massage
• 5 units IV Syntocinon
• 40 units Syntocinon in 500ml Hartmans

Question 18

6 hours after deliver a women starts to bleed heavily. You have already given uterine massage and syntocinon. You have confirmed that the placenta and membranes were completely evacuated. What do you do next?

Answer 18

• Insert catheter

- 500mg Ergometrine IV

Question 19

6 hours after deliver a women starts to bleed heavily. You have already given uterine massage and syntocinon and ergometrine IV. You have confirmed that the placenta and membranes were completely evacuated.

Answer 19

• Get senior help
• Transfer to operating theatre
  PGF2α IM

Question 20

What is the most common cause of primary post partum haemmorhage?

Answer 20

Atonic Uterus

Question 21

What is an atonic uterus?

Answer 21

Failure of the uterus to contract after childbirth . Closure of the uterus closes of the blood vessels in the placenta and id this doesn’t occur excessive bleeding takes place.

Question 22

Describe the two main drugs used to control post partum haemorrhage

Answer 22

• Oxytocin 10 units IV followed by an oxytocin infusion of 40 units in 0.5L of saline over 4 hours.
• Ergometrine 0.25mg IV

Question 23

What is the initial management of post partum haemorrhage?

Answer 23

Uterine massage

5 units IV Syntocinon stat then 50 unitls Syntocinon in 500 ml Hartmans at 125 ml/h

Question 24

What is the reason for performing uterine massage in PPH?

Answer 24

The most common cause of PPH is uterine atony. In this conditions the uterus fails to contract and close the spiral arteries which leads to excessive bleeding. Uterine massage can encourage contraction.

Question 25

What is the reason for giving oxytocin in PPH?

Answer 25

To treat the most common cause of PPH which is uterine atony. It initiates rhythmic contractions of the uterus, compressing the spiral arteries which should reduce bleeding.

Question 26

Why is ergometrine given in PPH?

Answer 26

It is a smooth muscle constrictor so should reduce blood flow