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Obs and Gynae in the spotlight Session 8: Emergencies pt.2 By Sahana Muthuswamy Session outline Post-partum haemorrhage Antenatal haemorrhage DISCLAIMER Thank you for joining for the last session of the Obs and Gynae in the spotlight series. We’re thrilled that you’re here with us & hope that you find the session useful. We will email out the slides after the session. Before you use our resources, kindly take note of the following: •Content in this presentation has been designed by our committee members, who are medical students like yourselves! Therefore, the questions may not be representative of what comes out in your exams and there may be errors in the questions. •Do NOT rely solely upon these resources for your medical practice and exam revision. Please refer to your local guidelines and/or supervising clinician if you need any clarification. •We would be grateful if you could take the time at the send of the session to fill out feedback form. Thank you.Kaia Jenny Lyla A G2 P1 28 year old woman who has just given birth to a baby boy on the labour ward by spontaneous vaginal delivery. However she continues to bleed after complete delivery of the placenta. 700ml of blood has been lost. What are the causes of post partum haemorrhage? Kaia A G2 P1 28 year old woman who has just given birth to a baby boy on the labour ward by spontaneous vaginal delivery. However she continues to bleed after complete delivery of the placenta. 700ml of blood has been lost. What are the causes of post partum haemorrhage? 4T’s Kaia Tone (uterine atony-most common) Trauma (eg. perineal tear) Tissue (retained placenta) Thrombin (eg. clotting/bleeding disorder) A G2 P1 28 year old woman who has just given birth to a baby boy on the labour ward by spontaneous vaginal delivery. However she continues to bleed after complete delivery of the placenta. 700ml of blood has been lost. What are some risk factors of developing PPH? Kaia A G2 P1 28 year old woman who has just given birth to a baby boy on the labour ward by spontaneous vaginal delivery. However she continues to bleed after complete delivery of the placenta. 700ml of blood has been lost. What are some risk factors of developing PPH? previous PPH Kaia pre-eclampsia increased maternal age instrumental delivery general anaesthesia perinear tears multiple pregnancy Primary PPH Secondary PPH bleeding within 24 hours of birth bleeding from 24hrs to 12 weeks after birth >500ml after a vaginal delivery What can commonly cause this? >1000ml after a c-section Primary PPH Secondary PPH bleeding within 24 hours of birth bleeding from 24hrs to 12 weeks after birth >500ml after a vaginal delivery What can commonly cause this? >1000ml after a c-section Endometritis Retained products eg.placenta Abdominal examination reveals a soft, boggy, relaxed uterus. Which of the following methods is the most appropriate initial management of PPH in the patient? 1) IM oxytocin 2) IM ergometrine 3) intrauterine balloon tamponade 4) McRoberts manouevere 5) Uterine massage Abdominal examination reveals a soft, boggy, relaxed uterus. Which of the following methods is the most appropriate initial management of PPH in the patient? 1) IM oxytocin 2) IM ergometrine 3) intrauterine balloon tamponade 4) McRoberts manouevere 5) Uterine massageFollowing mechanical management, pharmacological managements are further initiated such as IM oxytocin and IM ergometrine to stimulate uterine contraction, but Kaia continues to bleed. A decision was made to bring her into theatre for surgical intervention. Which of the following initial surgical intervention is most appropriate? 1) uterine artery embolism 2) hysterectomy 3) intrauterine balloon tamponade 4) B-lynch suture 5)uterine artery ligationFollowing mechanical management, pharmacological managements are further initiated such as IM oxytocin and IM ergometrine to stimulate uterine contraction, but Kaia continues to bleed. A decision was made to bring her into theatre for surgical intervention. Which of the following initial surgical intervention is most appropriate? 1) uterine artery embolism 2) hysterectomy 3) intrauterine balloon tamponade 4) B-lynch suture 5)uterine artery ligationLater Kaia presents to her GP as she has not had a period since she gave birth 6 months ago. A urinary pregnancy test was negative and she is not breast feeding or taking any contraception. She is otherwise fit and well and not taking any regular medications. What is the cause of her secondary amenorrhoea? 1) Turner’s syndrome 2) Imperforate hymen 3) Asherman’s syndrome 4) Sheehan’s syndrome 5) Polycystic ovary syndromeLater Kaia presents to her GP as she has not had a period since she gave birth 6 months ago. A urinary pregnancy test was negative and she is not breast feeding or taking any contraception. She is otherwise fit and well and not taking any regular medications. What is the cause of her secondary amenorrhoea? 1) Turner’s syndrome 2) Imperforate hymen 3) Asherman’s syndrome 4) Sheehan’s syndrome 5) Polycystic ovary syndrome A G1 P0 woman currently at 27 weeks presents to MAU as she has experienced some bleeding and is really worried about it. She does not complain of any abdominal pain or contractions. What are some differentials for antenatal bleeding? Jenny A G1 P0 woman currently at 27 weeks presents to MAU as she has experienced some bleeding and is really worried about it. She does not complain of any abdominal pain or contractions. What are some differentials for antenatal bleeding? placental abruption Jenny placental praevia vasa praevia uterine rupture• placenta praevia is often picked up on routine 20 week TA USS • digital vaginal examination should not be performed before an ultrasound as it may provoke severe haemorrhage • planned delivery is considered between 36 and 37 weeks gestation to reduce risk of spontaneous labour and bleeding What are some risk factors for placenta praevia? Jenny What are some risk factors for placenta praevia? previous c-sections previous placenta praevia older maternal age Jenny maternal smoking structural uterine abnormalities eg. fibroids assisted reproduction eg. IVF Why are corticosteroids given to Jenny between 34 and 35+6 weeks gestation? Jenny Why are corticosteroids given to Jenny between 34 and 35+6 weeks gestation? to mature the fetal lungs as there is an increased risk of Jenny preterm deliveryLater on that day Lyla presents to MAU at 36 weeks gestation where you’re working as an F1. The F2 sees Lyla and tells you she’s got placental abruption and that you need to notify the registrar. How might’ve Lyla presented clinically? LylaLater on that day Lyla presents to MAU at 36 weeks gestation where you’re working as an F1. The F2 sees Lyla and tells you she’s got placental abruption and that you need to notify the registrar. How might’ve Lyla presented clinically? • sudden and severe abdominal pain • contractions Lyla • hypovolaemic shock • vaginal bleeding (ranges from spotting to major haemorrhage- may even be disproportionate to the hypovolaemic shock) • abnormal CTG and reduced fetal movements What is placental abruption? And what is a concealed abruption? What is placental abruption? Premature separation of the placenta from the uterine wall during pregnancy. The site of attachment can bleed extensively after the placenta separates. And what is a concealed abruption? The cervical os remains closed so any bleeding that occurs remains within the uterine cavity, hence the patient may be showing disproportionate signs of hypovolemic shock to bleeding In Lyla’s notes it say that she is Rhesus-D negative What test does she require and what will it help determine? Lyla In Lyla’s notes it say that she is Rhesus-D negative What test does she require and what will it help determine? Kleihauer test will help determine how much fetal blood has mixed with the maternal blood Lyla And also help determine the dose of anti-D that is required (anti-D prophylaxis is required when bleeding occurs) THANK YOU! Please take a minute to fill out this feedback form for us: