PPH, Rh isoimmunisation, DVT

Question 1

Primary and secondary PPH

Answer 1

primary- <24hrs post partum
500ml-1000ml
mcc- uterine atony

secondary- >24hrs to 6 wks post partum
mcc-
poor epithelisation of placental bed retained products
`r/o endometritis

Question 2

**Mx of primary PPH

Answer 2

●1st - palpate uterus - lax/soft - atony
Start fundal massage

●Oxytoxic agents
IV Syntocinon 10 IU (direct infusion) f/b
IV syntocinon 40 IU in Hartman solution

(Can try uterotonic agents:
1. intra-myometrial prostaglandin-F2 alpha- CARBOPROST injection
2. GEMEPROST pessary )

PPH still +
Ergometrine 0.25mg IV

PPH still +
Misoprostol 1mg (5 tabs) per-rectum

PPH still +
Bimanual compression for 3 mins

Bakri balloon for tamponade, Ilial artery ligation, hysterectomy if needed

●Remove retained fragments

●Resuscitate pt- O2 mask, fluids

Check placenta - laceration
Check genital tract - bleed
Catheterise bladder

Question 3

Mx of secondary PPH

Answer 3

Inv:
USG - retained products/clots
Cervical swab - smear, culture

Rx:
1. Oxytocin 10IU + 40 IU in hartmans sol
Ergometrine 0.5mg IM
Misoprostol per rectum
-then do USG
2. Antibiotics- PV bleed + discharge, fever (endometritis)
IV Amoxicillin+ metronidazole + Gentamycin
3. Curettage - only if clots

Question 4

Rh isoimmunisation

Answer 4

1. 2nd pregnancy of Rh- mom with Rh+ baby - antibodies - attack fetal blood
2. Newborn - Anaemia, fever, jaundice, hepatospleenomegaly, Hemolytic disease of newborn
   Hydrops fetalis, death

Question 5

Screening of Rh antibodies

Answer 5

At
1. Presentation
2. 28wks
3. 34-36wks

*no need of screening if Anti D given

Anti D given at 28 and 34wks in Rh-mom

Question 6

When do you give Rh isoimunisation

Answer 6

Anti D in Rh- moms, no prior anti D
1. at 28 and 34wks in Rh-mom
2. Post Rh+ baby delivery
3. Spontaneous abortion/terminated preg
4. Ectopic pregnancy
5. After events - transplacental haemorrage
-Amniocentesis
-Chorionic villous sampling
-APH
-External cephalic version

Question 7

*Kleihaur test

Answer 7

1. Amount of feto-maternal blood mixed
2. Dose of Anti-D is concluded with this test

Question 8

Mx In a preg with Anti D positive d/t previous preg

Answer 8

1. Check for hydrops fetalis and anaemia of baby
   -MCA peak systolic velocity
   -Serial amniocentesis
2. Monitor Rh antibody titre

3 . If anaemia +
Blood transfusion before 34wks and at birth

Question 9

how do you monitor anti-D antibody titre

Answer 9

if <1:32 in T1
check monthly till 28wks
Check fortnightlt till birth

If stays < 1:32 = term NVD
If >1:32 = fetomaternal team

If increases 2 fold i.e., from 1:2 to 1:4 to 1:8 = feto maternal team

Question 10

Risk of DVT in preg

Answer 10

1. In T2
2. Enoxaparin (LMWH) until 6wks post partum
3. Switch to unfractionated heparin (UFH) only during delivery

Warfarin, apixaban are C/I

Question 11

Smoking during preg s/e

Answer 11

1. Placental abruption
2. Preterm delivery&raquo_space;
3. IUGR