OBS: Perinatal Medicine -- PPH

Question 1

Routine management of 3rd stage of labour

Answer 1

1. Uterotonic agents: Syntometrin (if no asthma, HT, cardiac abnormalities), or Syntocinon
2. Controlled cord traction
3. No improper traction (fundal pressure)
4. [If placenta retained] Empty bladder
5. Placenta examination
   a. site of insertion, 2A1V, completeness of placenta & chorion & amnion
   b. send for swab / histology if necessary

Question 2

Management of uterine atony in labour ward

Answer 2

1. Uterine massage
2. Bimanual compression of uterus (after bladder emptying)
3. Strong uterotonic agents (IM Carbopost)
4. Intrauterine balloon tamponade (Bakri balloon)

Question 3

Surgical intervention of uterine atony

Answer 3

[If haemodynamically stable] Image-guided UAE
[If haemodynamically unstable]
* Uterine compression suture
* Bilateral arterial ligation
* Hysterectomy (last resort)

Question 4

4 Common DDx of PPH

Answer 4

• Tone: uterine atony
• Trauma: lower genital tract injury
• Tissue: PP, retained placenta, PAS
• Thrombin: coagulopathy

Question 5

What should be done to systematically check for causes of PPH?

Answer 5

• Tone: palpate uterus for size & tone
• Trauma: speculum for lower genital tract injury
• Tissue: inspect placenta for missing cotyledon / broken vessels
• Thrombin: inspect blood for “thin” blood

Question 6

Management for haemodynamically unstable PPH patients

Answer 6

1. Call for help: Inform senior
2. Resuscitation
   
   • Replace circulating volume: large bore (16G) IV cannula *2 -> NS +/- gelofusine
   • Transfusion
   • Treat coagulopathy: Transamin, Platelet concentrates, Clotting factors
   • Repeat uterotonics PRN
   • Patient in head-down position
3. Investigations
   
   • CBC for IDA
   • Clotting profile for DIC
   • Cross match for transfusion
   • ABG for acidosis
   • LRFT
4. Systematically check for causes for PPH
   
   • Palpate uterus for size & tone
   • Speculum for lower genital tract injury
   • Inspect placenta for any missing cotyledons / broken vessels
   • Inspect blood for “thin” blood
5. Treat the cause accordingly
   
   • Tone: uterine massage -> bimanual compression of uterus -> strong uterotonic agents -> Bakri balloon -> surgical intervention
   • Trauma: surgical repair
   • Tissue: manual removal of placenta (MROP)
   • Thrombin: replace clotting factors, treat underlying factors

Question 7

Causes of 2nd PPH

Answer 7

• Retained placenta
• Endometritis
• Uterine AV malformation
• Coagulation disorders
• Wound dehiscence

Question 8

Management of 2nd PPH

Answer 8

1. Admission, NPO
2. Resuscitation
   
   • Replace circulating volume (large-bore 16G IV cannula *2 for NS +/- gelofusine)
   • Transfusion
   • Treat coagulopathy (Transamin, Platelet concentrates, Clotting factors)
   • Patient in head-down position
3. Investigations
   
   • CBC for IDA
   • Clotting profile for DIC
   • Cross match for transfusion
   • ABG for acidosis
   • LRFT
4. Systemically check for causes
   
   • PE: abdominal exam for any uterine contraction, tenderness, enlargement
   • Infection workup: endocervical swab, MSU for C/ST, blood culture
   • USG (TAS + TVS) for any retained products of gestation, evidence for endometritis (e.g. abscess)
     
     • Doppler for any AVM
5. Treat accordingly
   
   • RPOG: D&C
   • Endometritis: broad spectrum antibiotics

Question 9

Complications of manual removal of placenta

Answer 9

• Endometritis
• PPH due to uterine atony / PAS
• Uterine perforation
• Broad ligament tear with haematoma

Question 10

Light menstrual pain and cyclical pain 6w after D&C. Likely diagnosis?

Answer 10

Uterine scarring / Asherman syndrome

Question 11

How to confirm the diagnosis of uterine scarring?

Answer 11

Hysteroscopy seeing scarred endometrium

Question 12

How to management uterine perforation during MROP?

Answer 12

1. Stop MROP and call seniors for help
2. Admit for 1 night for any S/S of bowel perforation
3. Monitor vitals, resuscitate when necessary
4. Prophylactic Abx + Pain relief
5. (perforated hole will repair on its own) +/- Diagnostic & Therapeutic laparoscopy
6. Abstrain from sex & vigorous exercise

Question 13

Possible obstetrics complications of placenta accreta spectrum

Answer 13

• PPH
• Uterine inversion
• Uterine perforation

Question 14

Standard management of PAS for mothers with no fertility wish

Answer 14

CS at 37-38w + intrapartum hysterectomy

Question 15

Pregnancy-specific diseases, other than massive haemorrhage, that cause coagulopathy

Answer 15

• Placenta abruptio
• Amniotic fluid embolism
• HELLP syndrome
• Acute fatty liver of pregnancy