Obs and Gynae

Question 1

what is anteapartum haemorrhage?

Answer 1

defined as perceived vaginal blood loss of > 250mls at greater than 24 weeks gestation

Question 2

2 most important causes of APH to consider?

Answer 2

placenta praevia and placental abruption (although these are not the most common causes)

Question 3

Any antepartum haemorrhage carries a risk of post-partum haemorrhage

Answer 3

good to know

Question 4

what is placenta praevia?

Answer 4

a condition where the placenta is close to or covering the internal cervical os - typically causes painless vaginal bleeding It is often detected antenatally using ultrasound.

Question 5

what is plancetal abruption and how may it present?

Answer 5

premature separation of the placenta - usually associated with pain. On examination, the abdomen may be tender and tense, especially if the placenta is anterior. Bleeding may be concealed but should be suspected if there is severe abdominal pain and/or signs of hypovolemic shock. There may also be signs of fetal distress on the cardiotocograph (CTG).

Question 6

Management?

Answer 6

1. Call for help (alert Obstetric and Anaesthetic Consultants if out-of-hours)
2. Alert BTS (stating ‘Major obstetric haemorrhage’ Tell them when you need blood (immediately/ in 15 mins/ when ready). Use O negative blood if patient profoundly shocked
3. Resuscitate using an ABCDE approach
4. Monitoring/ Ix
5. Treatment

Question 7

Talk through the ABCDE components in these patients

Answer 7

• A: open airway, place patient in left lateral tilt
• B: high flow oxygen (15L/min) Assess breathing (rate and O2 sats).
• C: CRT, peripheral skin temperature, HR and BP. Gain IV access- 2 x 16g (grey) cannulae. Give fluids: max 2L normal saline/Hartmanns (once max reached you should be giving blood. Can give blood sooner if available.) Give O negative blood if profoundly shocked. Order shock pack if required (4 units FFP, 4 units group specific PRC, 1 unit platelets.)
• D: Maintain normothermia- use bair hugger and blood warmer

Question 8

what monitoring/ Ix should be undertaken?

Answer 8

Maternal:

• FBC, U&Es, coag, fibrinogen
• Continuous obs (pulse, RR, BP, O2 Sats, ECG)
• Insert Foley catheter and monitor urine output hourly
• Accurate fluid balance
• Consider use of CVP/arterial line
• Start HDU chart

Fetal: (ask midwife)

• Doppler fetal heart auscultation
• Continuous CTG
• Ultrasound Scan

Question 9

What treatment to consider once stabilised?

Answer 9

Mother stable + fetus is viable –> consider delivery by induction of labour or by caesarean section.

Fetus is nonviable (e.g. no fetal heart detected or < 24 weeks gestation) –> consider induction of labour when the maternal condition is stable if vaginal bleeding continues

Question 10

Follow up considerations?

Answer 10

Anticipate Postpartum Haemorrhage.

Consider transfer to ITU following severe haemorrhage.

Question 11

what is major PPH defined as?

Answer 11

perceived blood loss of >1000ml from the genital tract within the first 24hrs of delivery

(is a leading cause of maternal mortality)

Question 12

what are the 4 main causes of excessive blood loss post delivery? (the 4 Ts)

Answer 12

1. Tone (i.e. an atonic uterus. The uterus should contract post-delivery to prevent bleeding.)
2. Trauma (e.g. a bleeding episiotomy or cervical tear)
3. Tissue (i.e. retained placenta)
4. Thrombin (i.e. disseminated intravascular coagulation or DIC)

Question 13

depending on the degree of shock, how might a PPH pt appear?

Answer 13

• pale
• peripherally cool
• confused/drowsy
• tachypnoeic (RR>25)
• tachycardic (HR>100/min)
• hypotensive (this is a late sign and usually indicates at least 25-30% blood loss- approximately 2 litres in a pregnant woman)