Obstetric haemorrhage (FRANZCOG lecture 22)

Question 1

Incidence of APH in pregnancy?

Answer 1

3-5%

Question 2

Proportion of preterm birth associated with APH?

Answer 2

1/5th of preterm babies born in association with APH

Question 3

Risk factors for placental abruption

Answer 3

previous abruption (1)
PET, FGR
IVF
non-vertex presentations
Infection, trauma, PROM, first trimester bleeding

multip, AMA, low BMI, thrombophilia

Question 4

Primary PPH incidence

Answer 4

1-5% of birth
1/4 of deaths globally
leading cause of maternal death developing countries
Australia 18% of maternal deaths.

Question 5

Benefits of carbetocin

Answer 5

long acting oxytocin receptor agonist
at least equivalent to oxytocin bolus
not contraindicated with HTN

Question 6

At what level should fibrinogen be replaced and maintained?

Answer 6

Replace if <1.5-2g, and maintain >2g with cryoprecipitate.

Question 7

Triggers for FFP administration with PPH?

Answer 7

PT or APTT are prolonged
haemorrhage ongoing
after 4 units RBC

Question 8

Suture for uterine artery ligation?

Answer 8

blunt needle
0 or 1 absorbable

in myometrium 2-3cm medial/inferior to uterines
out broad ligament superior/lateral to vessels
tied

Question 9

If performing internal iliac ligation, what trunk would you want to ligate?

Answer 9

anterior trunk of internal iliac artery

open anterior leaf of broad
identify external at medial margin of psoas. Follow proximally to common iliac artery bifurcation. Identify internal iliac.
Can be difficult to find anterior trunk, so can ligate entire iliac artery at its origin.
use 1-silk non-absorbable synthetic suture around the artery from lateral to medial.

Question 10

Symptoms of external iliac artery ligation

Answer 10

lower limb pulse of ipsilateral leg absent

should check intraoperatively.

Question 11

Define minor placenta praevia

Answer 11

inside lower uterine segment +/- edge reaching the internal os

Question 12

Define major placenta praevia

Answer 12

placenta partially or completely covers the cervix

Question 13

Risk factors placenta praevia? Risk factors for placenta not migrating?

Answer 13

1 CS = 1%
previous TOP
multiparity
AMA
Multiple pregnancy
Smoking
history of: SM fibroid, uterine scar, endometritis, MROP, curettage
Assisted conception

Previous CS or posterior.

Question 14

Timing of delivery for placenta praevia with history of APH?

Answer 14

34- 36+6

Question 15

Asymptomatic placenta praevia delivery timing?

Answer 15

36-37+0

Question 16

Surgical considerations placenta praevia

Answer 16

vertical skin +/- uterine incision if transverse or <28/40
pre operative USS
immediate clamping if placenta transected
planning of medical, surgical, radiological management options for bleeding
early recourse to hysterectomy

Question 17

Risk of placenta accreta with number of CS?

Answer 17

1 = 0.42%
2= 0.9%
3 = 2.4%
4 = 3.4%
5 = 9%

Question 18

Ultrasound findings of placenta accreta

Answer 18

multiple placental lacunae
disruption of the bladder line
myometrial thinning
abnormal vascularity
abnormal uterine contour or placental bulge
exophytic mass

Question 19

Consent for delivery with placenta accreta should include?

Answer 19

massive haemorrhage
hysterectomy
urinary tract damage

Question 20

Incidence placental abruption

Answer 20

1%

Question 21

Risk of abruption after one previous?

Answer 21

4.4%