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Hi, everyone. We're just gonna make a start. Um Can everyone hear me? Ok, lovely, thank you. So, in today's session, this is actually our final session of this revision series. So thank you for joining us for the ride. And hopefully it's been really helpful um In today's session, we're gonna be covering postpartum hemorrhage and antenatal hemorrhage as well. So just like the other sessions, here's just a disclaimer. So our session slides are meant to be used as a supplementary resource. They haven't been checked by anyone. Um It's just so that you can kind of test your own understanding. Um And that's about it, but we will have the recording of the presentation and the slides uploaded at the very end. So you guys can refer back to it if you want. Um But yeah, just wanted to put disclaimer out there first. Ok. So in today's session, we are going to be following three patients. We've got Kaya Jenny and Lila. So Kaya is a G two P, 128 year old woman who's just given birth to a baby boy on the labor ward by spontaneous vaginal delivery. However, she continues to bleed after complete delivery of the placenta, she's lost 700 mL of blood. Can people write in the chat? What are some causes of postpartum hemorrhage? Ok. So we've got some really good ideas coming in. So we can think of it as the forties. So we've got to. So uterine A which is the most common cause of postpartum hemorrhage trauma. So for example, perineal tear can cause postpartum hemorrhage, um retained placenta and also clotting and bleeding disorders as well. So, can people write in the chart, what are some risk factors for developing postpartum hemorrhage? Ok. So, thank you for those answers. Um Here are just a couple of other risk factors. So we've got previous PPH preeclampsia, increased maternal age, instrumental delivery um because that can lead to trauma and like perineal tears, which is another risk factor, multiple pregnancy and also general anesthesia. So, here is just a bit of background about postpartum hemorrhage. You've got primary PPH um which is bleeding within 24 hours of birth if there's bleeding after vaginal delivery, um it should be greater than 500 mL to be considered postpartum hemorrhage. Um If they've had ac section, it should be more than 1 L for it to be considered a postpartum hemorrhage. Now, you've also got secondary PPH and that's bleeding from 24 hours after delivery to 12 weeks after birth. So, can anyone write any suggestions for what could commonly cause a secondary postpartum hemorrhage? Well, then guys, those are both correct. So, infections such as endometritis and retained products um can commonly cause secondary postpartum hemorrhage. So, to investigate those you'd be doing a transvaginal or um transabdominal ultrasound, um especially to check for retained products of conception. If you're suspecting infection, then you would do an endocervical or high vaginal swab. Um and then the management would be cause dependent. So we've done an abdominal examination and that revealed a soft boggy, relaxed uterus, which of the following methods is the most appropriate initial management of PPH. In this patient, is it im Oxytocin im ergometrine into U balloon, tamponade alos maneuver or you try massage. Ok. Very well. Um that uterine massage is the correct answer. So, in this patient, the soft boggy relax uterus is essentially uterine atony. Um When you do a uterine massage, this promotes contraction of the uterus. And this should be tried before any pharmacological or surgical intervention. Um And we can also use a foley catheter to drain the bladder because if the bladder is full, that's going to prevent uterine contraction. So, following mechanical management, pharmacological managements are further indicated and initiated. So that was Im Oxytocin and Im ergometrine to stimulate uterine contraction, but Kaya continues to bleed. So, a decision was made to bring her into theater for surgical intervention, which of the following initial surgical interventions is most appropriate. Is it one uterine artery embolism, two hysterectomy, three intrauterine balloon tamponade, four B linked suture or five uterine artery ligation we in everyone. So the answer is three intrauterine balloon tamponade. So essentially what happens is you put a deflated balloon and that's inserted into the uterine cavity and it's inflated using saline. So it can be left in the uterine cavity for up to 24 to 36 hours after the bleeding has stopped or until uterine contractions occur. So that's first line, second line would be a B linn suture and that's essentially a suture around the uterus to compress it. Third line would be uterine artery ligation and obviously, hysterectomy would be last line and that would be the last resort. So later, Kai presents to her GP as she has not had a period since she gave birth six months ago, a urinary pregnancy test was negative and she has not been breastfeeding or taking um taking any contraception. She is otherwise fit and well and not taking any other regular medications. What could be the cause of her secondary amenorrhea? Is it one Turner syndrome? Two imperfect Hymen, three Asherman syndrome, four Sheehan syndrome or five Polycystic Ovarian Syndrome, well done everyone. So the answer is she has a syndrome. So this is a condition where there is pituitary infarction following postpartum hemorrhage and that can lead to pituitary necrosis. So, because LH and FSH are produced by the anterior pituitary gland, um there is a decrease in these hormone levels which can then lead to secondary amenorrhea. Yes. So the the session is being recorded and it will be uploaded afterwards. OK. So we're on to our next patient. This is Jenny A G one P zero woman currently at 27 weeks and she presents to ma as she's experiencing bleeding and is really worried about it. She does not complain of any abdominal pain or contractions. So what's some differentials for antenatal bleeding? Those are all some really good answers. I've just got a few um on my slide. So we've got placenta abruption, placenta, previa, phaa, pre and uterine rupture. But all of the suggestions that you've given are correct. So, placenta previa is often picked up on a route 20 week. Um Transabdominal ultrasound, you should probably should not be um performing a digital vaginal examination and that is just, there is a risk of provoking a severe hemorrhage. Um So on the picture, we can see that there is a normal placenta at the top on the left hand side. Um Then we have a low lying placenta where it's coming closer to um the opening to the cervix. And then we've got placenta Previa where the placenta lies um above that opening. So with placenta Previa and um women who have that, they normally have their delivery planned um for 36 to 37 weeks, gestation just to reduce the risk of spontaneous labor and bleeding. So, what are some risk factors for placenta Praevia? Ok. Thank you. Those are all really good suggestions. So we've got previous C sections. Um And that's because you can have scar tissue from those previous C sections. Previous placenta previa, old, maternal age, maternal smoking, also structural uterine abnormalities such as fibroids and assisted reproduction. Um I'm sure multiple pregnancy can also cause placenta Praevia as well. So why are corticosteroids given to Jenny between 34 and 35 plus six weeks gestation? Yeah, that's correct. So it's to mature the fetal lungs as there's an increased risk of preterm delivery. So, um like I mentioned before, with placenta previa, um you would consider delivery of the baby around about this time. So uh from 36 to 37 weeks just because there is that risk um that they could hemorrhage. So that's why we want to give the mom some corticosteroids just to make sure that the baby's lungs are maturing. Ok. So now we're on to our third patient. So later on that day, Lila presents to M AU at 36 weeks gestation where you're working as an F one. The F two sees Lila and tells you that she's got placental abruption and that you need to notify the registrar. So how might have Lila presented clinically? Thank you everyone. Those look like some really good exam. Um answers. So Lila could have presented with sudden and severe abdominal pain, contractions, hypovolemic shock, potentially vaginal bleeding, which could range from spotting to major hemorrhage. Um And this might be disproportionate um to the hypovolemic shock. And she might have also, she might have also had an abnormal CG and reduced fetal movements as well. So, can anyone try explaining what placental abruption is? And what is a concealed abruption? Lovely. You guys have pretty much got it. So, placental abduction is basically premature separation of the placenta from the uterine wall during pregnancy, which you can see in the picture. Um So the site of attachment can bleed extensively after the placenta separates and a concealed abruption. Like you all mentioned is when the cervical os remains closed. So any bleeding that occurs will remain within the uterine cavity. So, a patient may show a disproportionate signs of hypovolemic shock to bleeding. So in lila's notes, it says that she is r negative. What test does she require and what will it help determine well done guys. So it would be the test which you all got. And that's to help determine how much fetal blood has mixed with the maternal blood. And it can also help determine the dose of anti D that's required um which would be given to any woman who bleeds um if she's negative. But that is actually the end of all the case studies just because we had um an emergency session last week. So these are just sort of the other high yield topics that we wanted to cover. But thank you so much for joining us for this session. Um Please take literally 30 seconds to fill out this feedback form. It'd be really appreciated. I'm just gonna pop a link in the chat as well. But thank you so much. So for the management of placental abruption. If there's fetal distress, then you would have to immediately do cesarean section. Um But if there's no fetal distress, you could just observe closely depending on the number of weeks gestation, you might need to give the mom some steroids. Um And then if you can wait out um to deliver the baby at a later date, do that. But otherwise you will, I guess it, it's very situation dependent on how many weeks gestation the mom is at. So it's usually any time between uh before 35 weeks even because after that, then the lungs are almost mature.