Obstetric Emergencies

Question 1

Define Antepartum Haemorrhage

Answer 1

Bleeding from the genital tract after 24 weeks. (Before 24 weeks is termed threaten miscarriage).

Question 2

Define a primary post partum haemorrhage

Answer 2

Bleeding of more than 500mls from the genital tract in the first 24 hours after delivery.

Question 3

Define a secondary post partum haemorrhage

Answer 3

Excessive bleeding from the genital tract between 24hours and 6 weeks post partum.

Question 4

Causes of antepartum haemorrhage

Answer 4

Placenta praevia
Placental abruption
local causes in genital tract (cervical ectropian, cervical polyp, trauma)
Unexplained

Question 5

Causes of post partum haemorrhage

Answer 5

Tone - atonic uterus
Trauma - to genital tract
Tissue - retained products
Thromin - abnormal clotting

Question 6

What other symptom may indicate placental abruption?

Answer 6

Continuous pain. (If intermittent consider labour)

Question 7

How can you roughly divide the causes of placental abruption vs praevia?

Answer 7

Abruption: Causes during pregnancy (PET, fetal growth restriction, polyhydriamnios, intrauterine infection, PROM, abdominal trauma, advance ages, assisted concenption, smoking/drug

Praevia: Causes before pregnancy (previous CS, prv termination, advance mat age, multiparty, smoking, deficient endometrium e.g. endometriosis, sub mucous fibroid, assisted conception.

Question 8

If placental praevia is a possible diagnosis what should you not do.

Answer 8

PV examination. Need USS to exclude low lying placenta.

Question 9

What is the Kleihauer test?

Answer 9

Is a blood test to measure the amount of fetal haemoglobin transferred from fotus to a mother blood stream. It is to determine if rhesus negative women need anti-D immunoglobulin (anti-D Ig) to stop prevention of antibodies that prevent Rh disease is future rhesus negative children.

Question 10

How can you diagnose placental abruption?

Answer 10

Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available. Ultrasound has limited sensitivity in the identification of retroplacental haemorrhage.

Question 11

What is vasa praevia

Answer 11

Vasa praevia is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

Question 12

Should corticosteroids be administered to women who present with APH before term?

Answer 12

offer a single course of antenatal corticosteroids to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth.

In women presenting with spotting, where the most likely cause is lower genital tract bleeding, where imminent delivery is unlikely, corticosteroids are unlikely to be of benefit, but could still be considered.

Question 13

What are tocolytics?

Answer 13

Medications used to suppress preterm labour, allows time to administer steroids to mature foetal lungs e.e terbutaline

Question 14

What are the main maternal side effects of tocolytics?

Answer 14

Cardiovascular e.g. arrythmias, PE, MI, hypotension

Question 15

It is recommended if Hx of APH, an active 3rd stage of labour should be performed. What does this mean?

Answer 15

Active management of the third stage involves a package of care comprising the following components:

routine use of uterotonic drugs
deferred clamping and cutting of the cord
controlled cord traction after signs of separation of the placenta.

Question 16

What is a physiological 3rd stage of labour?

Answer 16

Physiological management of the third stage involves a package of care that includes the following components:
no routine use of uterotonic drugs
no clamping of the cord until pulsation has stopped
delivery of the placenta by maternal effort

Question 17

Should women presenting with APH who are RhD-negative be given anti-D Ig?

Answer 17

Anti-D Ig should be given to all non-sensitised RhD-negative women after any presentation with APH, independent of whether routine antenatal prophylactic anti-D has been administered.
In the non-sensitised RhD-negative woman in the event of recurrent vaginal bleeding after 20+0 weeks of gestation, anti-D Ig should be given at a minimum of 6-weekly intervals.

In the non-sensitised RhD-negative woman for all events after 20+0 weeks of gestation, at least 500 iu anti-D Ig should be given followed by a test to identify FMH greater than 4 ml red blood cells; additional anti-D Ig should be given as required.

Question 18

What is the uterotonic of choice in the 3rd stage of labour for woman without risk factors for PPH delivering vaginally?

Answer 18

oxytocin (10 iu by intramuscularinjection)

Question 19

What is the uterotonic of choice in the 3rd stage of labour for woman delivering by C/S

Answer 19

oxytocin (5 iu by slow intravenous injection)

Question 20

What additional uterotonic may be used in women at risk of PPH. What contraindications does it have?

Answer 20

Ergometrine.

Contraindicated in hypertension

Question 21

Rhesusiatation in Minor PPH (500-1000mls) without clinical shock

Answer 21

intravenous access (one 14-gauge cannula) urgent venepuncture (20 ml) for:– group and screen– full blood count– coagulation screen, including brinogen pulse, respiratory rate and blood pressure recording every 15 minutes commence warmed crystalloid infusion

Question 22

Full rhesus protocol for major PPH (blood loss greater than 1000 ml) and continuing to bleed orclinical shock

Answer 22

A and B – assess airway and breathing C – evaluate circulation position the patient at keep the woman warm using appropriate available measures transfuse blood as soon as possible, if clinically required until blood is available, infuse up to 3.5 l of warmed clear uids, initially 2 l of warmedisotonic crystalloid. Further uid resuscitation can continue with additional isotoniccrystalloid or colloid (succinylated gelatin). Hydroxyethyl starch should not be used. the best equipment available should be used to achieve rapid warmed infusion of uids special blood lters should not be used, as they slow infusions.

Question 23

What are options for blood transfusion

Answer 23

o-negative, rhesus negative (should be supply onward) & switch to group-specific blood as soon as possible

If intrapoperative consider cell salvage

Question 24

After 4 until of blood what other blood products, continuing bleeding and unknown haemostat results what should be considered?

Answer 24

FFP (Fresh Frozen Plasma) should be infused at a dose of 12–15 ml/kg until haemostatic test results are known.

Question 25

When are volumes of FFP in excess of 15 ml/kg likely to be needed to correct coagulopathy?

Answer 25

prothrombin time/activated partial thromboplastin time is more than 1.5 times normal andhaemorrhage is ongoing.

Question 26

What level should plasma fibrinogen be above? How is it replaced?

Answer 26

Above 2 g/l

Cryoprecipitate

Question 27

When should platelets be transfused

Answer 27

If below 75

Question 28

Full protocol for major PPH with ongoing bleeding and/or clinical shock

Answer 28

immediate venepuncture (20 ml) for:
– cross-match (4 units minimum)
– full blood count
– coagulation screen, including fbrinogen
– renal and liver function for baseline
- monitor temperature every 15 minutes
- continuous pulse, blood pressure recording and respiratory rate (using oximeter,electrocardiogram and automated blood pressure recording)
- Foley catheter to monitor urine output
- two peripheral cannulae, 14 gauge, consider arterial line monitoring (once appropriately experienced staff available for insertion)
- consider transfer to intensive therapy unit once the bleeding is controlled or monitoring athigh dependency unit on delivery suite, if appropriate
- recording of parameters on a modifed early obstetric warning score (MEOWS) chart + acting and escalating promptly when abnormal scores from a MEOWS chart are observed
- documentation of fluid balance, blood, blood products and procedures.

Question 29

Options to stop bleeding

Answer 29

Medical
Utertonics: Oxytocin, ergometrine (not if HTN), haemobate (not if asthma), misoprostol
Tranexamic acid

Mechanical

• Uterine pressure with swab
• Empty and clots or products
• Bakri balloon

Surgical

• Suture any perineal tears
• Consider move to theatre for EUA
• Lapartomy +/- hysterectomy

Question 30

Management of secondary PPH

Answer 30

Assess vaginal microbiology - swabs of high vaginal and endocervical
Start approptiate Abx
USS to exclude retained products +/- surgical evacuation

Question 31

Risk factors PPH

Answer 31

Tone:
Multiple pregnancy, previous PPH, Fetal macrosomia, failure to progress in 2nd stage, prolonged 3rd stage of labour, general anaesthesia

Tissue:
retained placenta, placenta accreta

Trauma:
Episiotomy

Thrombin:
PET