Obs and Gynae Flashcards
Obs and Gynae Hx Checklist
PC and HPC
- Gynae: relationship of symptoms to menstrual cycle
- Obs: EDD and LMP. PLanned pregnancy? Assisted conception? Complications so far? tests and results so far?
Important symptoms:
Gynae
- Bleeding: Menarche, LMP, cycle length, days of bleeding, regular cycle? Bleeding between periods (PCB, IMB, PMB)? Menorrhagia? dysmenorrhoea? Discharge? Clots? flooding? menopause?
- Sex: Currently sexually active? Dyspareunia (superficial or deep)?
- Contraception: Current method? Happy with it?
- Smears: When was last one? was it normal? ever had an abnormal smear? How was that investigated?
- STIs: Ever been tested for one? Ever positive? how was it treated? Symptoms (itching? burning? discharge? (colour? smell?)
- Urogynae: Frequency? Urgency? Incontinence (stress vs urge)? Prolapse (heavy feeling of uterus inside vagina)
Obs:
- Gravidy and parity
- Planned pregnancy
- Assisted or natural conception
- How far along currently? Tests and results? any complications?
- For Previous pregnancies:
- Planned pregnancy?
- Did it reach term? if not what happened
- Complications in pregnancy, labour, birth (how delivered and birth weight)
- How is mum and baby now (post-natal depression)?
- Same partner each time? consanguinity?
- Plans for future pregnancies
PMHx
DHx - esp folic acid for pregnancy
FHx:
- Gynae: Cancer (especially bowel or breast are associated with gynae), VTE, Clotting/bleeding disorders (recurrent miscarriage)
- Obs: Complications during pregnancy (Pre-eclampsia, diabetes, miscarriage), Twins or multiple pregnancy
SHx
- support network at home? domestic abuse? EtOH? Smoking?
ROS
- Gynae: Bowel or Bladder symptoms? any other abdo or pelvic symptoms.
- Obs: Headache, RUQ pain, nausea (pre-eclampsia)
- Itching hands and feet (cholestasis of pregnancy)
Obstetrics: Examination
1) General inspection
- Anaemia? Jaundice? Hydration (vomiting?), Oedema, BMI
2) Abdominal inspection
- Is there an abdominal mass consistent with pregnancy?
- Striae, excoriations, scars, linea nigra, fetal movements
3) Symphasis-Fundal height
- Back of tape measure, go from pubic symphysis to fundus.
- Between 24-36 weeks, height in cm should be no. of weeks +/- 2cm
- 12 weeks: palpable at pelvic inlet. 20 weks: palpable at umbilicus. 36 weeks: Palpable at xyphisternum
4) Abdominal palpation
- Keeping one hand still, “ballot” down other side, feeling for baby’s back. do this on both sides
- Then feel near pelvic inlet if late stages for engagement
- Foetal lie (vertical/horizontal/oblique), presentation (cephalic or breech) and fifths engaged
- If too easy to feel baby: Oligohydramnios. If too tense and difficult to feel baby: polyhydramnios.
5) Foetal heart beat
- Listen over baby’s anterior shoulder (usually midpoint between mother’s ASIS and pubic symphysis) with pinard stethoscope or Sonicaid
6) Maternal Pule, BP, urinalysis
Gynae: examination
1) General inspection
- Anaemia, Jaundice, Hydration (vomiting), Oedema, BMI
2) Abdominal inspection
- Scars (umbilical, pubic hair line), masses, tenderness
3) Speculum examination
- Consent, wash hands, gloves, exposure
- Sim’s speculum to look at vaginal walls (vaginal atrophy or prolapse)
- Cusco’s speculum to look at cervic and fornices (warts, ectropion, neoplasia, polyps, trauma, liquor)
- Pt’s feet together & towards bottom, knees bent, then slowly drop knees to either side
- Inspect vulva for bleeding, trauma, discharge
- Lubricate speculum, place on posterior fourchette with handle pointing sideways
- warn patient, then insert speculum, rotating and opening as you go in so the handle points upwards
- Visualise cervical os (open/closed)
- Visualise fornices
- Take smear if needed at this point: brush goes into external os, rotate 5x, then put in labelled bottle for liquid based cytology
- Also take any required swabs at this point
- Remove speculum, inspecting vaginal walls on way out
- Inspect the speculum for blood or discharge
4) Bimanual
- Warn patient, insert 1 gloved, lubricated finger into the vagina, followed by another
- Feel the cervix for cervical excitability. Palpate fornices for any masses or tenderness
- With other hand on abdomen, palpate the uterus for size, shape (ante/retroverted), mobility, tenderness)
- Remove fingers, inspect for blood or discharge
Swabs: Types, indications and conditions/results
1)High vaginal swabs
Candida albicans
- Thick white, curd-like discharge. Filaments on microscopy
- Rx: clomitrazole cream OR oral fluconizole
Bacterial vaginosis
- Whitish/clear discharge, fishy smell, pH<4.5, clue cells on microscopy, whiff test +ve
- Rx: Metronidazole or clindamycin cream
Trichomonas vaginalis
- green discharge, strawberry cervix. Flagellated protozoa on microscopy
- Rx: Metronidazole
2)Endocervical swabs
Chlamydia trachomatis
- Often asymptomatic. Nucleic Acid Amplification Tests (NAATS) via urine
- Rx: Stat. azithromycin followed by oral doxycycline (unless pregnant, sue erythromycin instead of doxy)
Neisseria gonorrhoea
- Often asymptomatic, can get purulent discharge + PCB. Gram negative diplococci seen on microscopy
- Rx: Ceftriaxone
Cervical screening: Procedure, results, follow-up/Rx
UK smear programme:
- If 25-49YO, smear recommended every 3 years
- If 50-65YO: smear recommended every 5 years
- If >65YO: Smear only done if previous abnormalities found or if never previously had a smear test
Smear looks for abnormal cell divisions (dyskaryosis), using liquid based cytology, taking cells from the transitional zone
Abnormalities looked for:
- Abnormal mitotic figures
- Abnormal nucleus:cytoplasm ratio
- Clumping of chromatin
- Pleomorphism
Results
- Normal - routine follow up (as per above)
- Insufficient/inadequate - Repeat smear in 3/12
- Borderline dyskaryosis - HPV test and if positive, colposcopy
- Mild dyskaryosis - HPV test and if positive, colposcopy (mild dyskaryosis usually but not always corresponds to CIN I (Cervical Intraepithelial Neoplasia) on colposcopy
- Moderate dyskaryosis - colposcopy (usually corresponds to CIN II on colposcopy)
- Severe dyskaryosis - colposcopy (usually corresponds to CIN III on colposcopy)
If colposcopy is positive (CIN I, II or III), repeat smear and HPV in 6 months)
Management:
- CIN I: watch and wait, usually returns to normal spontaneously
- CIN II or III: LLETZ procedure (Large Loop Excision of Transitional Zone)
History
- Last smear date, results
- LMP?
- Reason for smear? as it taken correctly? by who? (GP, OPD)
- Currently pregnant, postnatal (<12 weeks), IUD? taking hormoned?
- Was cervix visualised during procedure
Urogynae (Incontinence and prolapse)
Incontinence
Stress incontinence
- Weak bladder neck –> incontinence on activity
- Rx: Lose weight, stop smoking, pelvic floor exercises, surgery (Tension-free Vaginal Tape)
Urge incontinence
- Involuntary detrussor activity –> day and night incontinence
- Rx: Avoid caffiene, bladder retraining, anti-cholinergic drugs (oxybutynin), botox
Prolapse:
- Anterior (cystocele), posterior (rectocele) or apical (uterovaginal or vault)
- Symptoms: General (Vaginal mass, dyspareunia, Abnormal bleeding) or specific (bowel/bladder symptoms for rectocele/cystocele respectively)
- Rx: Conservative: Pelvic floor exercises, ring pessaries
- Surgical: Apical: Sacrocolpopexy (abdominal approach) or sacro-spinous ligament fixation(vaginal approach)
- Surgical: Anterior/posterior: wall repair
Definition & Stages of Labour
Definition: Onset of regular, painful contractions leading to progressive effacement and dilation of the cervix
Stage 1
- Latent: Onset of contractions to full effacement of the cervix
- Active: Full effacement of cervix to full dilation of the cervix (10cm)
- Augmentation of labour is inefficient during the latent phase
Stage 2
- Full dilation of the cervix to delivery of the baby
Stage 3
- Delivery of the baby to delivery of the placenta
- Routine use of syntometrin during stage 3 reduces PPH by 50% (should occur within 30 mins)
- Physiological 3rd stage (no drugs) - PPH should occur within 60 mins
- For either, CCT (Controlled Cord Tension) is used, guarding the uterus always to prevent inversion
Cardiotocography (CTG) Checklist and Indications
Checklist: DR C BRAVADO
- Define Risk (indications)
- Contractions
- Baseline RAte
- Variability
- Accelerations
- Decelerations
- Overall
Indications Maternal - Previous C-section - Pre-eclampsia - Significant maternal disease (e.g. diabetes) - >42 weeks - Prolonged rupture of membranes - Antepartum haemorrhage Foetal - Pre-term - Oligohydramnios - Intrauterine growth restriction - Breech - Multiple pregnancy - Meconium stained liquor Intrapartum - Oxytocin - Epidural - Maternal pyrexia
Cardiotocography (CTG): Interpretation
Contractions
- Height of line DOES NOT MEAN strength of contraction
- Should see 4 every 10 mins in active labour
- More frequent contractions (tachysystole) suggests uterine hyperstimulation, may cause foetal distress
Baseline rate
- Should be 100-160bpm
- Tachycardia: Maternal pyrexia, foetal hypoxia or infection, exogenous beta agonists (e.g. salbutamol), prematurity
- Bradycardia: could be severe foetal distress due to placental abruption or uterine rupture. Foetal hypoxia, foetal hypotension, post maturity, maternal sedation
- Acute, prolonged change in rate sugegsts acute foetal distress
Variability
- Should be at least 5bpm
- Reduced variability could be due to sleep (<45min), early gestation, drugs (BD, opiates)
- Long term reduced variability –> foetal hypoxia
Accelerations
- >15bpm above baseline for >15s
- Usually normal and seen with contractions
Decellerations
- >15bpm below baseline for >15s
- Early: begin with contractions and end when contractions end. Normal reaction to head compression. Usually uniform in size, shape
- Variable: begin and end in variable timing with contractions. Classically reflect cord compression
- Late: begin with contractions but persist after contractions. suggestive of foetal hypoxia
CTG: Overall and Rx
1) Baseline rate
- Normal: 100-160bpm
- Non-reassuring: 161-180bpm
- Abnormal: <100bpm or >180bpm
2) Variability
- Normal >5bpm
- Non-reassuring: <5bpm for 30-90mins
- Abnormal: <5bpm for >90mins
3) Decellerations
- Normal: None or early decellerations
- Non-reassuring:
- Variable decellerations <60bpm (below baseline) for <60s for >90 mins on >50% of contractions
- Variable decellerations >60bpm OR >60s for 30-90mins on >50% of contractions
- Late decellerations for <30mins on >50% of contractions
- Abnormal
- Non-reassuring decellerations, not responding after 30mins of conservative measures, >50% of contractions
- Late decellerations >30mins, not responding to conservative measures, >50% of contractions
- Bradycardia/single deceleration of >3 mins
Overall: CTG is normal if all 3 catergoies are normal, non-reassuring if 1 is non-reassuring and 2 normal, Abnormal if 1 is abnormal or 2 are non-reassuring
Rx:
- Non-reassuring CTG: Conservative measures: Left lateral position, monitor BP, HR, Temperature. Give fluids PO/IV, stop oxytocin
- Abnormal: Conservative measures + foetal blood sampling
- Single deceleration >3 mins: Conservative measures. If no response within 9 mins of start of brady: expedite delivery
Foetal blood sampling - if indicated but impossible: expedite delivery
- pH>7.25 & trace is still abnormal, repeat in 60s
- pH7.2-7.25: repeat in 30 mins
- pH<7.2: expedite delivery
Routine antenatal care appointments: First trimester
ASAP: First visit to healthcare professional
- Give information on:
- Folic acid (400mcg/day or 5mg/day if high neural tube defect (NTD) risk (e.g. previous NTD, on anti-epileptic medication, sickle cell disease)
- Increase vit D intake (Pregnacare has both)
- Nutrition & diet, food hygiene, smoking & ETOH
- Antenatal screening, risks and benefits
- Screen for domestic abuse/social circumstances, FGM
<10 weeks: booking appointment
- Booking BP, BMI, Risk for pre-eclampsia and GDM
- Info on antenatal screening, risks and benefits
- Pelvic floor exercises
- Pregnancy care plans, where and how to deliver, breastfeeding, antenatal classes, maternity benefits
- IF SHE WANTS ANTENATAL SCREENING:
- Bloods (anaemia, haemoglobinopathies, red cell alloantibodies, Hep B, HIV, syphilis serology, bloood group and RhD status)
- Urine: dipstick and MC&S for UTI, haematuria and asymptomatic bacteruria
- Dating and anomily scans
- Down’s risk (and other chromosomal tests): Combine test at 10-14 weeks, also triple or quadruple tests
10-14 weeks: Dating scan
- Gestational age, viability, nuchal translucency, multiple pregnancy
Routine antenatal care: second triemster
16 weeks
- Discuss previous tests and results
- BP, Proteinuria, OGTT if previous GDM
- Consider Fe supplementation if anaemic
18-20 weeks: Anomily scan
- Looks for physical abnormalities, foetal growth, liquor volume, placental position
- Repeat at 32 weeks if placenta is low
25 weeks (NULLIPAROUS WOMEN ONLY)
- BP, proteinuria, Symphasis-fundal height
Routine antenatal care: third trimester
28 weeks
- BP, proteinuria, SFH (Symphasis-fundal height)
- OGTT if GDM risk but no previous GDM
- Bloods (screening for sickle cell and RBC alloantibodies)
- Give first dose of anti-D to RhD negative women
31 weeks (Nulliparous only)
- BP, proteinuria, SFH
- Discuss 28 week results
34 weeks
- BP proteinuria, SFH
- Discuss 28 week results
- Second dose of Anti-D for RhD negative women
- Info on preparation of labour & pain control
36 weeks
- BP, proteinuria, SFH
- Check foetal lie, confirm abnormal lie on USS
- Offer external cephalic version for uncomplicated, singleton breech
- Info on breastfeeding technique, baby care, vit K prophylaxis and newborn screening
- Info on maternal care, post-natal depression, baby blues
38 weeks
- BP, proteinuria, SFH
- Specific information on management of prolonged pregnancy
40 weeks (Nulliparous only)
- BP, proteinuria, SFH
- Further discussion of management options for prolonged pregnancy
41 weeks
- BP, proteinuria, SFH
- Offer membrane sweep/induction of labour
42 weeks
- BP, proteinuria, SFH
- Offer induction of labour OR increased monitoring (2x/week CTG and USS for max amniotic fluid depth)
Maternal wellbeing is monitored by vitals: BP, HR, Temperature, SpO2
Foetal wellbeing is monitored by continuous CTG monitoring or intermittent monitoring
Quantifying/screening for post-natal depression
Edinburgh post-natal depression scale
- 10 questions, important woman fills it out herself, based on what she’s been feeling in the last 7 days
- Important not to discuss her answers with anyone as she fills it out
- Each question is scored from 0-3 (either 0=not at all and 3=always/very often or other way round, 3 is worst)
- Max score - 30, score of 10 or more is possible depression. Always look at the answer for Q10 (self harm)
Questions:
1) I have been able to laugh and see the funny side of things
2) I have been looking forward with enjoyment to things
3) I have blamed myself unnecessarily for things that went wrong
4) I have felt anxious or worried for no good reason
5) I have felt scared or panicky for no good reason
6) Things have been getting on top of me
7) I’ve felt so sad I’ve had difficulty sleeping
8) I’ve felt sad or miserable
9) I’ve felt so sad I’ve been crying
10) The thought of harming myself has occurred to me
Perinatal mortalitiy: definitions and causes/risk factors
Definitions
- Miscarriage: death <24 weeks gestation
- Stillbirth: death >24 weeks gestation
- Neonatal death: death <28 days after birth
- Early: 0-7 days, Late: 8-28 days
- Perinatal mortality: sum of neonatal death and still births per 1000 births
Causes
- Commonest: Antepartum stillbirth
- Common: Pre-eclampsia, foetal abnormalities, intrapartum hypoxia, antepartum haemorrhage
- Rare: Infection, trauma, foetal/maternofoetal haemorrhage
Risk factors
- Age <17 or >40
- Asian or Afro Caribbean race
- poor nutritional status
- Smoking, EtOH or recreational drugs
- Medical illness
- Multiple pregnancy
- Multiparity
Maternal mortality: Definitions, stats and causes
DEFINITIONS:
- Maternal death: Death of mother <42 days after delivery, directly caused by pregnancy or indirectly aggrevated by pregnancy
- Late maternal death: As above, but between 42 days and 1 year after delivery
- Direct: caused directly by pregnancy or obstetric complications
- Indirect. Caused by increased physiological stress during pregnancy PLUS some other underlying disease which may have begun during pregnancy (e.g.g GDM) or not
STATS
- UK maternal mortality = 9/100k live births
- Africa maternal mortality = 510/100k live births
CAUSES
Indirect:
- Heart disease (commonest cause of death outside pregnancy anyway), other medical disease
Direct
- Amniotic fluid embolism
- Thromboembolism
- Hypertensive disease
- Haemorrhage
- Anaesthetic related
- Post-natal depression/suicide
- Fatty liver of pregnancy
- Ectopic pregnancy
- Genital tract sepsis
Abortion Law
Abortion act 1967
One can abort a pregnancy if it falls under one of these categories:
A) Continuing the pregnancy is more dangerous to the mother’s life than abortion
B) Abortion is necessary to prevent grave, permanent physical or mental injury to the mother
C) Continuing is more likely to cause injury to the physical or mental health of the mother than abortion
D) continuing is more likely to cause injury to the physical or mental health of the mother’s other children than abortion
E) The baby is likely to be born with a serious physical or mental handicap
*C and D have a time limit of 24 weeks, all others have no time limit
Each case requires 2 doctors to agree on the use of the abortion act
Fraser guidelines and Gillick competence
Fraser guidelines refer specifically to guidance on prescribing contraception to those under 16.
Gillick competence refers to how we assess whether someone under 16 has the capacity to consent to medical treatment
Fraser guidelines:
- doctor can prescribe contraception/offer advice to under 16 year olds, without parental consent, if the following 5 criteria are met
1) Child can understand your advice
2) Unable to convince the child to inform their parents
3) The child is likely to continue to have unprotected sex otherwise
4) Not giving contraception will likely cause the child physical or mental harm
5) Prescribing without parental consent is in the child’s best interests
Obstetric cholestasis (symptoms –> Rx)
Signs/symptoms:
- Itchy hands and feet during pregnancy
- Pruritus without rash
- Causes increased risk of spontaneous preterm labour or foetal death
Diagnosis
- Raised LFTs and/or bile acids
- Once diagnosed, weekly LFTs until birth
Treatment
- No evidence for any specific treatment
- Induction of labour @ 37 weeks to reduce chance of stillbirth
Amniotic fluid embolism (symptoms –> Rx)
Symptoms/signs: - Acute SoB + hypotension --> cardiorespiratory failure & coagulopathy --> convulsions --> coma Diagnosis - Clinical diagnosis Management - Emergency - Stabilise the mother ASAP - C-section ASAP - CPR, and if unsuccessful, do abdo delivery - O2, intubate, more CPR if needed - Monitor foetus - Treat coagulopathy with FFP, cryoprecipitate and platelets
Pre-eclampsia: Symptoms –> Rx (NOT severe)
Signs/symptoms:
- HTN, headache, RUQ/epigastric pain, nausea, blurred vision
- Can progress to HELLP syndrome or eclampsia
Diagnosis
- BP>140/90, at least 1+ proteinuria
- headache, swelling of face, hands, feet, blurred vision
Investigations
- If these symptoms are increasing, suggests severe pre-eclampsia
- Admit for urinalysis (MC&S), 24hr urinary protein
- Bloods (FBC, U&E, LFTs, renal function)
Rx:
- Only definitive treatment is delivery. No need to deliver before 34 weeks unless haemodynamically unstable
- USS foetus (growth, amniotic fluid volume, doppler of umbilical arteries)
- GTC
- Mild (BP 140/90-149/99): 4x daily BP and 2x weekly bloods (LFTs, U&Es, FBC)
- Moderate (BP 150/100-159/99): as above, 3x weekly bloods and BP control (labetolol or nifedipine if contraindicated, e.g. asthma)
- Severe: As above, but >4x daily BP
- Repeat CTG if lack of foetal movements, vaginal bleeding, abdo pain or disorientation
Severe pre-eclampsia and eclampsia: Rx
Severe pre-eclampsia:
- Consider antihypertensives at lower BP threshold if there are other symptoms
- MgSO4: used to prevent seizures if worried about them, also used to treat seizures. 4g stat loading dose over 5-10 mins, followed by 1g/hr infusion. Can increase to 1.5-2g/hr if needed. Keep giving until 24hrs after last seizure
- Fluid restrict to 80ml/hr
- Consider early delivery, before 34 weeks with corticosteroids. Consult senior support
Eclampsia
- Left lateral position
- High flow O2
- May need intubation to preserve airway
- Management as above, delivery is more important, usually ASAP
Placenta praevia
Signs/symptoms
- Painless PV bleed in late pregnancy
- Increased risk of preterm delivery
Diagnosis
- High index of suspicion for any PV bleeding in late pregnancy
- USS shows leading edge of placenta. Suspicious cases confirmed by transvaginal USS
- Further TV US done for all women with low lying placenta on anomily scan
- @36 weeks for minor placenta praevia
- @32 weeks for major placenta praevia
Management:
- Minor: may deliver vaginally, unless leading edge <2cm from os. C-section @ 38 weeks
- Major: Needs C-section.
- If not bleeding: Careful counselling about outpatent care vs admision.
- Bleeding: Admit @ 34 weeks
- C-section done @ 38 weeks, unless placenta accreta is suspected, in which case deliver @ 36-37 weeks
- In acute bleed, DO NOT perform a vaginal exam
Placental abruption
Signs/symptoms:
- Acute, severe abdominal pain and PV bleed in late pregnancy
- Woody hard uterus
- 20% concealed (most severe, bleed reains inside uterus)
- 80% revealed
- May cause maternal collapse, foetal hypoxia or death
Diagnosis
- Clinical diagnosis
Management
- High flow O2
- FBC, Kleihauer test (foetal haemoglobin in maternal bloodstream), X-match 4 units of blood, left lateral position, keep mother warm
- If foetus is alive: C-section OR artificial rupture of membranes
- If foetus is dead: vaginal delivery, unless C section needed to control the bleeding
- If there’s time, give corticosteroids for foetus’ lungs
Uterine rupture
Signs/symptoms
- Acute, severe abdo pain and PV bleeding in labour
- If epidural: sudden maternal hypotension and foetal hypoxia
- Most occur in women who’ve had previous C-sections
Diagnosis
- Can be diagnosed before labour on USS (abnormal foetal position, haemoperitoneum, abnormally thin uterine wall)
Rx:
- Urgent delivery (usually surgical) and resuscitation as needed
- Uterine repair if possible, or hysterectomy if bleeding is uncontrolled
- 20% of uterine repairs will rupture again
- 6.2% associated with perinatal death
Shoulder dystocia
Shoulder damage of foetus due to traumatic birth
Rx (Prevention)
- Get MDT approach for difficult deliveries (get help of anaesthetist and paediatrician)
- Stop mother pushing, reduce downward traction on foetal head
- McRobert’s manoeuvre (hyperflex and adduct maternal hips against abdomen)
- Failing that, episiotomy and 2nd line manoeuvres
Cord presentation/prolapse
Cord presentation: umbilical cord below presenting part.
Cord prolapse: umbilical cord below the presenting part AFTER rupture of membranes
- Most cord presentation DOES NOT become cord prolapse
Diagnosis
- Clinical diagnosis
Management (overt prolapse)
- High flow O2, knee-chest position, facing bed
- avoid handling the cord
- urgent C-section or vaginal only if fully dilated and no contraindications
- Sub-cut terbutaline to reduce contraction if there is a delay in C-section
Management (occult prolapse)
- left lateral position, high flow O2
- Monitor foetal heart rate (CTG)
- If foetal heart rate is normal, keep monitoring
- If becomes abnormal –> C-section urgently
Post partum haemorrhage
Definitions:
- Primary = <24hrs after delivery. Secondary = 24hrs-12weeks
- Minor = 500-1000ml, Major > 1000ml
Rx (minor)
- IV access, bloods (FBC, Group & Save, coagulation screen)
- warmed crystalloid infusion
- Vital obs every 15 mins
Rx (Major)
- ABC, position flat and keep warm, transfuse ASAP if needed (so bloods: FBC, G&S, Coagulation screen)
- Infuse warmed isotonic crystalloid up to 3.5l
- Don’t use special blood filters as they slow infusion
Blood transfusion
- No specific guidelines on when to transfuse, best clinical and haematological judgement
- Give O-ve, K-ve blood until correct blood group is known
- FFP may be useful if 4 units RBS given or known/suspected coagulopathy or continued bleeding
- Platelets to keep plt>75, cryoprecipitate to keep fibrinogen>2g/l
MDT approach, anaesthetist to keep haemodynamically stable
Rx (Secondary PPH)
- Vaginal microbiology (endocervical and high vaginal swabs)
- Pelvic USS to exclude retained products of conception, this will need experienced surgical removal
