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MRCOG Intrapartum/Management of labour/Postpartum Part 2 Revision - Hay > APH/PPH > Flashcards

APH/PPH Flashcards

1
Q

What % of pregnancies are effected by APH?

A

3-5%

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2
Q

Definition minor APH

A

<50mls settled

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3
Q

Definition Major APH

A

50-1000mls, no signs of shock

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4
Q

Definition Massive APH

A

> 1000mls and or signs of shock

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5
Q

Risk factor abruption after 1 abruption?

A

4.4%

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6
Q

Risk factor abruption after 2 abruption?

A

20-25%

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7
Q

Other RF for placental abruption?

A

PET, FGR, Non-vertex presentation, polyhydramnios, advanced mat age, multiparity, PROM, abdominal trauma, smoking/drug misuse, 1st trimester bleeding, intrauterine haematoma, maternal thrombophilia.

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8
Q

What % of placental abruption in low risk pregnancy?

A

70%

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9
Q

What preventative measure for APH can be suggested?

A

Stop smoking & drugs use (cocaine, amphetamines)
If placenta praevia, avoid vaginal and rectal examinations.

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10
Q

Specific Qs to ask APH

A

Pain ?continous
FM
Recent SI
Previous trauma to abdomen
Previous cerival smear
Rh status

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11
Q

How to approach examination of patient with significant APH?

A

A-E approach
Abdo palpation - woody/tense
Speculum Dilation/cause of APH
Assess fetus - CTG or USS

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12
Q

Initial Ix for APH

A

IV access x 2 - Hb, coag, U+E, LFT, G+S, cross match 4 units, VBG
Kleihauer test if Rh -ve
USS - placenta position
Assess foetus - CTG if mother stable

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13
Q

Where to care for women
1) Spotting, placenta high, no active bleeding
2) Ongoing bleeding/heavier than spotting

A

1) discharge
2) Admit until bleeding stops

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14
Q

What % of placental abruption will have abnormal CTG?

A

69%

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15
Q

When to consider steroids

A

If risk of preterm labour 24-34+6

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16
Q

Should you give tocolysis if contracting?

A

Not in major APH, contraindicated in abruption

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17
Q

How should AN care be changed after unexplained APH/APH from abruption?

A

High risk
Review cons ANC and serial growth USS

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18
Q

If fetal death confirmed what MOD?

A

Vaginal delivery

CS if foetus compromised but discuss with Cons

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19
Q

If >37 weeks with minor or major APH but patient/baby stable when should delivery be recommended?

A

IOL from presentation, to avoid adverse outcomes associated with APH

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20
Q

When should continuous CTG be considered?

A

Active APH
Previous major APH
Recurrent minor APH

If 1 episode minor APH, intermittent is appropriate

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21
Q

What delivery complication should you expect in someone with APH? How to minimise this?

A

PPH, active 3rd stage

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22
Q

If APH immediately after ARM, which cause of APH? How to manage?

A

Vasa praevia
Cat 1 EMCS, clamp cord immediately after delivery and leave the long part attached to neonate

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23
Q

If recurrent APH how often should Anti-D be given if required?

A

> 20 weeks 6 weekly

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24
Q

If APH what should be arranged post partum?

A

Assess VTE
Debrief
Incident report
Consider FU with Obstetric Cons within 4-6 weeks
If fetal demise consider informing GP

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25
Q

What 3 things to consider when estimating blood loss

A
  • Measured blood loss
  • Signs/symptoms of shock
  • Patients weight
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26
Q

What utertonic to use
- Low risk
- High risk no BP concerns
- High risk BP concern

A
  • Oxytocin
  • Syntometrine
  • Oxytocin

Oxytocin can be given 5IU or 10IU

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27
Q

When should oxytocin be given?

A

After delivery of the anterior shoulder/baby before cord is clamped

28
Q

If blood loss 1000-1500mls, what could you see on the observations?

A

Tachycardia, Tachyponea, Fall in SBP

29
Q

If blood loss >1500mls, what could you see on the observations?

A

SBP <80, worsening Tachycardia/Tachyponea, altered mental state

30
Q

Who should be called if blood loss 500-1000mls + no sign of shock

A
  • 1st Line obstetric + anaesthetic Dr
31
Q

Who should be called if >1000mls or signs of shock or ongoing bleeding

A

Experienced MW + MW in charge
Obs middle grade
Anaesthetic middle grade
On call haematologist
Porters
Inform Obs/anaesthetic cons
Inform Blood lab

32
Q

When should the consultants attended?

A

> 1500mls patient unstable

33
Q

Management of minor PPH 500-1000ml

A
  • IV access x 1 14-guage
  • Urgent bloods – FBC, G+S, Coag including fibrinogen
  • Obs every 15mins (HR, RR, BP)
  • Commence warm crystalloid IV
34
Q

What will happen if insufficient FFP and platelets are given?

A

Dilutional coagulopathy

35
Q

Major PPH >1000mls, ongoing bleeding, shock

A
  • ABC
  • Position patient flat, keep woman warm
  • Transfuse blood, until blood available infuse up to 3.5 L warmed clear fluids, initially 2 L warmed isotonic crystalloid, then isotonic crystalloid colloid
  • Bloods X-Match 4 units, FBC, Coag including fibrinogen, U+E, LFT
  • Continous BP, HR, RR
  • Temp every 15mins
  • Give high flow oxygen
  • Foley catheter to monitor UO
  • 2 x 14 gauge cannula
  • MOEWs chart
  • Document fluid balance, blood, blood products and procedures
  • Consider: Arterial line, ITU once bleeding controlled
36
Q

What pharmacological methods can be given to control PPH?

A

Rub fundus
Empty bladder
Oxytocin 5IU IV - can repeat
Erymetrine 0.5mg IV (caution HTN)
Oxytocin infusion 40 IU in 500mls saline (unless fluid restriction)
Carboprost 0.25mg IM every 15 mins, max 8 dosa (caution asthma)
Misoprostol 800mcg (1-2.5hrs)

37
Q

What is the maximum amount of fluid that can be given before RBCs?

A

Max 3.5 litres clear fluids (2L warmed isotonic crystalloid, 1.5 warmed colloid)

38
Q

What can hypothermia (from cold fluids) do?

A

Exacerbate acidosis

39
Q

When transfusing what are we aiming for:
Hb

A

> 80

40
Q

When transfusing what are we aiming for:
Platelets

A
  • Platelet > 50 x 10-9
41
Q

When transfusing what are we aiming for:
PT

A
  • PT < 1.5 x normal
42
Q

When transfusing what are we aiming for:
APTT

A
  • APTT < 1.5 normal
43
Q

When transfusing what are we aiming for:
Fibrinogen

A
  • Fibrinogen > 2g/l
44
Q

Which blood should be given in an emergency setting?

A

Start with O -ve, K-ve blood

Switch to ‘Group specific blood’ as soon as possible

CMV negative if AN

45
Q

How much does intra-operative cell salvage reduce risk of blood transfusion?

A

38→21%

46
Q

How regularly should bloods be sent in uncontrolled MOH, to asses blood products?

A

Every 30 mins

47
Q

What blood often becomes abnormal first in MOH?

A

Fibrinogen

48
Q

If no blood results when should FFP be given? At what rate?

A

After 4 units RBCs
15ml/kg/hr
Consider earlier if suspected coagulopathy
Given in ration 6:4
Order ASAP as need to be thawed

49
Q

If PPH stopped, do you need to give FFP? (if not suspecting coagulopathy)

A

No

50
Q

If ongoing bleeding, PT/APTT < 1.5 greater than normal

A

Give FFP 12-15 ml/kg aiming to maintain <1.5 PT/APTT

51
Q

If ongoing bleeding, PT/APTT >1.5 normal

A

Higher dose FFP, increased risk TACO

52
Q

Would you give FFP if ongoing bleeding and PT/APTT normal?

A

No, ongoing testing

53
Q

If no blood results, when should Cryopreciptates and platelets be given?

How much?

A

If > 8 units
2 pools cryoprecipitate
1 pool platelets

54
Q

At which blood level should fibrinogen be given?

A

If falls <2

2 pools will increase by 1

55
Q

At which blood level should platelets be given?

A

If <75

56
Q

If using 1st line surgical - uterine balloon tamponade, how long should it be left in for?
What is the maximum amount of saline needed?

A

4-6 hours, remove in daylight hours
Mx 500mls

57
Q

What are contraindications to uterine balloon tamponade?

A

Uterine malformations
Uterine rupture
Placenta retention
Endometrial infection

58
Q

Which haemostatic suture required a hysterotomy?

A

B-Lynch

59
Q

What % of haemostatic sutras will require hysterectomy? What is the biggest RF?

A

25% will require hysterectomy
Biggest RF is prolonged delay between delivery and uterine compression

60
Q

Describe stepwise uterine devascularisation

A

Succssive ligation of
1) 1 uterine artery
2) both uterine arteries
3) Low uterine arteries
4) 1 ovarian artery
5) Both ovarian artiees
6) Internal iliac (vascular surgeon must be present)

61
Q

How successful is selective arterial occlusion/embolisation by IR at controlling bleeding?

A

86.5% success

62
Q

In which cases should hysterectomy be considered sooner?

A

Bleeding associated with placenta accreta/uterine rupture

Decision by experienced Cons

63
Q

Which patients should be considered for ITU

A

> 2500mls
5units transfused
Tx coagulopathy

64
Q

How to assess 2nd PPH

A

Vaginal swab (HVS and endocervical)
Abx for endometritis
Pelvic USS ?RPOC

65
Q
A

MRCOG Intrapartum/Management of labour/Postpartum Part 2 Revision - Hay (32 decks)

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