OBS: Perinatal Medicine -- APH

Question 1

Risk factors for placenta praevia

Answer 1

• Previous CS
• Multiparity
• Advanced maternal age
• Previous PP / TOP
• Multiple pregnancies
• Previous uterine surgery

Question 2

How would you advise a patient with low-lying placenta discovered during morphology scan?

Answer 2

• OP
• Educate about PP (only diagnosed before 28w) and relevent risks
• Avoid coitus
• Repeat USG scan at 32-34w to see if PP persists
  [If persistent] CS at 38w (unless PP >2cm away from internal os)
• Admission if PV bleeding

Question 3

Risks for post-partum female sterilization

Answer 3

• Higher chance of regret (if fetus is subsequently ill) → risk of ectopic prenancy
• Higher failure rate (1/200) due to edematous tube after delivery
• Risks of the procedure (haemorrhage, damage of other organs, wound complications, anaesthetic risk)

Question 4

Laboratory investigations for placenta abruptio

Answer 4

• CBC for IDA
• Clotting profile for coagulopathy
• Cross match for transfusion

Question 5

Immediate management for placenta abruptio

Answer 5

• Admission, keep NPO
• Closely monitoring of BP/P, SaO2, I/O chart Q15min
• Hemocue → transfusion if necessary
• Resusitate if in shock
  [If fetus is alive] urgent CS (unless cervix is fully dilated)

Question 6

Management of placenta abruptio with IUD

Answer 6

• IOL
• Support maternal circulation & correct anaemia / coagulopathy if any
• pain relief

Question 7

Post-partum management of placenta abruptio after IUD

Answer 7

• check for retroplacental clot (placental swab + send placenta for histology)
• monitor for PPH (uterotonic agents, correct coagulopathy if any)
• discuss for post-mortem fetal examination
• suppress lactation (tight bra, bromocriptine)
• grief counselling, psychological support

Question 8

Precipitating factors for placenta abruptio

Answer 8

• PET
• Rapid decompression of uterus (ROM, amnioreduction)
• External force to uterus (trauma, ECV)
• Smoking, Cocaine

Question 9

Maternal complications of placenta abruptio

Answer 9

• PPH
• Haemorrhagic shock
• DIC
• Death

Question 10

DDx for pregnant lady G2P1, previous CS, GPH, cocaine user, presenting with PV bleeding + low abdominal pain at 30w
(1 risk factor + 1 physical sign for each DDx)

Answer 10

1. Uterine rupture: previous CS, peritoneal signs
2. Abruptio placentae: cocaine, woody hard uterus
3. Placenta praevia: previous CS, malpresentation

Question 11

Why GA is preferred over SA in some emergency CS?

Answer 11

• Haemodynamic instability / Massive bleeding is anticipated (risk of hypotension)
• Bleeding tendency (e.g. APH → coagulopathy)
• Slow onset of SA compared to GA

Question 12

Common finding in TVS for placenta abruptio

Answer 12

Retroplacental clots

Question 13

Fetal complications from placenta abruptio

Answer 13

• Fetal bradycardia
• Birth asphyxia
• IUD
• Prematurity

Question 14

Name a sign that is usually find on the anterior surface of the uterus in placenta abruptio

Answer 14

Woody hard uterus

Question 15

Mechanism behind woody hard uterus

Answer 15

• severe concealed bleeding → blood retained in myometrium
• hypertonic uterine contraction tense up the uterus

Question 16

What is the difference in the origin of blood between placenta praevia and vasa praevia? How to differentiate?

Answer 16

• PP: maternal
• VP: fetal
• differentiate by Apt test

Question 17

Describe velamentous cord insertion

Answer 17

umbilical cord inserts into fetal membrane rather than directly on placenta → cord not covered by Wharton’s jelly and thus exposed → high risk of haemorrhage