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Obstetric Haemorrhage Dr Michael WilkinsonYour Learning Outcomes • Recognise how to provide immediate care in maternal emergencies including basic and advanced life support • Demonstrate an understanding of the causes and clinical implications of postpartum haemorrhage • Demonstrate an understanding of the causes of pain and bleeding in the second trimester of pregnancy • Demonstrate an understanding the clinical problems associated with abnormal placentation • Apply knowledge of placental pathophysiology in a normal pregnancy to explain how this contributes to maternal and fetal morbidity and mortality Join at vevox.app Or search Vevox in the app store ID: 146-948-046 Join: vevox.app ID: 146-948-046 and Press Is there anything in particular you'd like to Send cover in today's session? Join: vevox.app ID: 146-948EntVote Trigger Outline 1. Disorders of Placentation 2. Antepartum Haemorrhage • Causes • Immediate investigation and management 3. Postpartum Haemorrhage • Causes • Emergency management 4. Quiz 5. Q&A Disorders of Placentation Position Invasion Separation • Placenta praevia • Placenta accreta • Placental abruption spectrum • Retained products of conceptionAntepartum Haemorrhage •Bleeding from or into the genital tract, after 24+0 weeks and prior to birth of the baby •Affects 3-5% of pregnancies •Associated with preterm birth and cerebral palsyCauses of APH •Placenta praevia • Can be sudden and severe bleeding •Placental abruption • Often concealed – may be no PV bleeding, or only a small amount •‘Bloody show’ •Vasa praevia •Cervical/vaginal bleeding • Cervical cancer • Ectropion • VaginitisVasa Praevia •Fetal vessels run in the membranes (outside placenta/cord) below presenting part •1:2500 pregnancies •APH after rupture of membranes •Fetal distress •Fetal mortality 33-100% What is your first priority when managing APH? 1. Assessing for fetal compromise 21.21% 2. Investigating for cervical cancer 0% 3. Giving anti-D immunoglobulin 9.09% ✔ 4. Assessing for maternal compromise 66.67% 5. Reassuring the patient 3.03% Join: vevox.app ID: 14Vote TriggerLL OPENAssessment of APH •Is there maternal compromise? – Check MEOWS •History • How much bleeding? Is it ongoing? • Any precipitating factors (post-coital?) • Pain? – praevia vs. abruption • Fetal movements? •Examination • Abdomen – tender? Contractions? Woody uterus? • Speculum – is the cervix normal? • Fetal heart rate +/- antenatal CTG +/- USSInitial management of APH •A-E assessment •IV access •Bloods – FBC, clotting, cross-match, Kleihauer test (if rhesus –ve) •Fluid/blood product resuscitation if required •Admission if mori than spoheing •D• Emergency CS if maternal or fetal compromise •Give Anti-D if rhesus negativePostpartum Haemorrhage •Primary PPH – loss of >500ml blood from genital tract within 24h of birth •Secondary PPH – loss of >500ml blood between 24h – 12 weeks after birth •Affects 2-11% of pregnancies in the UK •Uterine blood flow is around 700ml/min at term, so can bleed to death in around 10 minutes! What is the most common cause of postpartum haemorrhage? 1. Retained placenta 20% 2. Vaginal tears 11.11% 3. Sepsis 2.22% ✔ 4. Uterine atony 64.44% 5. Coagulation disorders 2.22% Join: vevox.app ID: 14Vote TriggerLL OPENCauses – 4 T s •Tone • Commonly exacerbated by prolonged labour, grand multiparity, infection, macrosomia/multiple pregnancy •Tissue • Retained placenta, placenta accreta spectrum •Trauma • Tears, episiotomy, cervical laceration •Thrombin • Severe preeclampsia, sepsis, placental abruptionManagementManagementManagement •If uterus still not contracted after 30 minutes, consider transfer to theatre for EUA •If medical therapy fails, can consider things like intrauterine balloon, brace sutures, uterine artery embolization, and hysterectomyPPH Summary •PPH is common and can be life threatening •Early recognition and early involvement of MDT is crucial •Get good IV access and start resuscitation •Simple things first! •Oxytocin 10 → TXA → Oxytocin 40 → Carboprost → Misoprostol Join at vevox.app Or search Vevox in the app store ID: 146-948-046 Join: vevox.app ID: 146-948-046 A 37 year-old G2P1 presents to maternity triage at 36 weeks with abdominal pain and a small amount of PV bleeding. She smokes 10 cigarettes a day. On examination her MEOWS score is 0, and she has abdominal tenderness with a woody uterus. What is the most likely cause of her presentation? 1. Spontaneous labour 0% 2. Placenta praevia 4.76% 3. Pelvic inflammatory disease 0% 4. Acute appendicitis 0% ✔ 5. Placental abruption 95.24% Join: vevox.app ID: 146-94Vote TriggerPEN The same patient has ongoing vaginal bleeding. Her heart rate is 120bpm and BP 90/60, and you auscultate the fetal heart beat at 80bpm. What would be your next step? 1. Induction of labour 2.08% ✔ 2. IV access and fluid resuscitation 68.75% 3. Emergency caesarean section 25% 4. Reassure and discharge 0% 5. Ultrasound scan 4.17% Join: vevox.app ID: 146-Vote Trigger OPEN How should a patient with known placenta praevia deliver their baby? 1. Induction of labour at 36 weeks 0% ✔ 2. Await spontaneous vaginal delivery 2.08% 3. Elective caesarean section 93.75% 4. Emergency caesarean section 4.17% Join: vevox.app ID: 14Vote TriggerLL OPEN A G1P0 at 39 weeks presents to maternity triage with vaginal bleeding. She noticed a small amount of blood stained mucus on her pad. Examination is normal and an antenatal CTG is normal. What is the most likely cause of her bleeding? 1. Placental abruption 0% ✔ 2. Bloody show 86.05% 3. Cervical ectropion 13.95% 4. Vasa praevia 0% 5. Cervical cancer 0% Join: vevox.app ID: 146-94Vote TriggerPEN A patient who has just delivered her baby vaginally has an estimated blood loss of 1000ml, and is still bleeding. What should you do first? 1. Count the baby's toes 0% 2. Obtain IV access 17.02% ✔ 3. Put out a major obstetric haemorrhage call 82.98% 4. Give IV tranexamic acid 0% 5. Insert a catheter 0% Join: vevox.app ID: 146-Vote Trigger OPEN You are managing a PPH and have given 10 units of oxytocin and 1g of TXA. The uterus feels boggy. What would be the next step in medical management? 1. Hysterectomy 0% 2. Sublingual misoprostol 0% 3. Intrauterine balloon 6.67% 4. Intramuscular carboprost 13.33% ✔ 5. 40 units oxytocin infusion 80% Join: vevox.app ID: 146-Vote Trigger OPEN An emergency caesarean section is performed for chorioamnionitis with fetal distress. The EBL is 1200ml with ongoing bleeding, but the placenta is complete and the uterus feels well contracted. The patient's platelet count is 276, and her INR is 2.1. Which of the following will aid haemostasis? 1. IV 0.9% saline 16.28% ✔ 2. Fresh frozen plasma 44.19% 3. Platelets 27.91% 4. Unfractionated heparin 9.3% 5. IV Gelofusine 2.33% Join: vevox.app ID: 146-948-04Vote Trigger A 27 year-old lady has a successful VBAC with a PPH of 2.1L. She has had oxytocin, TXA, and carboprost. The placenta cannot be delivered after 40 minutes. What is the likely cause of her bleeding? 1. Uterine atony 34.09% 2. Placenta praevia 0% ✔ 3. Placenta accreta 56.82% 4. Uterine rupture 9.09% 5. Cervical ectropion 0% Join: vevox.app ID: 146-94Vote TriggerPENAny questions?