Haemorrhage

Question 1

Main causes of APH

Answer 1

Placental abruption
Placenta praevia
Vasa praevia
Uterine rupture

Question 2

Describe types of placental abruption

Answer 2

Revealed - edge of placenta separates from uterine wall resulting in PV bleeding

Concealed - centre of placenta separates from uterine wall. Can cause DIC

Question 3

Clinical features of placental abruption

Answer 3

Tense or tender abdomen
Tachycardia
+/- PV bleeding
CTG heart rate abnormality

Question 4

Grades of placenta praevia

Answer 4

1: <3cm from os (<5cm on US)
2: touching the os
3. Covering half the os
4. Covering the entire os

Question 5

Diagnosis of placenta praevia

Answer 5

USS

Question 6

What is vasa praevia

Answer 6

Cord branches before entering placenta

Blood vessels may be close to os and can be damaged in examination

Question 7

What is placenta accreta

Answer 7

Placenta invades myometrium (can invade further)

Often through a C section scar

Question 8

Management of APH due to placental abruption

Answer 8

A-E assessment
Stabilise mother
Blood test: cross match 4-6 units, coag screen, Hb and platelets
Continuous CTG monitoring
Deliver asap:
- If fully dilated, vaginal delivery may be faster
- Otherwise a C section

Question 9

Management of PPH

Answer 9

A-E assessment 
Lie patient flat
Bimanual fundal massage
Fluid resuscitate in meantime but transfuse asap 
Blood test: Hb, coag screen, cross match 4-6 units
Catheterise 
Drugs
If drugs fail, theatre

Question 10

Drug management of PPH

Answer 10

1. IV syntocinon
2. Ergometrin
3. Haemibate 250mg IM (a PG)

Question 11

Surgical management of PPH

Answer 11

1. Bakri balloon insertion
2. B lynch suture
3. Uterine artery ligation
4. Hysterectomy

Question 12

Causes of PPH

Answer 12

Atonic uterus e.g prolonged labour
Retained placenta/accreta 
Trauma
DIC 
APH

Question 13

Weeks of APH and PPH

Answer 13

APH from week 24 to 2nd stage of labour

PPH from 2nd stage of labour onwards

Question 14

Risk factors for placental abruption

Answer 14

Multiple pregnancy
Previous history
Polyhydramnios
ECV
Preeclampsia
Previous C/S
>41 weeks
Cocaine

Question 15

Risk factors for placenta praevia

Answer 15

Previous history
Previous C/S
Multiparous 
Previous miscarriage
IVF

Question 16

Management of placenta praevia

Answer 16

US at 32 weeks
Plan C/S if placental edge <2cm from os
Admit from week 34 (risk of cord prolapse and abruption)
Monitor blood loss (may need transfusion)
Avoid intercourse if grade 2-4

Question 17

Management of placenta accreta

Answer 17

C/S to delivery baby followed by total hysterectomy

May need urology, bowel and vascular surgeons present

Question 18

Management of vasa praevia

Answer 18

Emergency C/S asap if presenting with APH with rupture of membranes
If detected antenally prepare for elective C/S and avoid vaginal examinations

Question 19

Risk factors for vasa praevia

Answer 19

IVF
Placenta praevia
Multiple pregnancy

Question 20

Primary vs secondary PPH

Answer 20

Primary within 24 hours of delivery

Secondary 24 hours after delivery to 6 weeks postpartum

Question 21

Minor vs major PPH

Answer 21

Minor 500-1000ml

Major >1000ml

Question 22

Risk factors for PPH

Answer 22

APH in current pregnancy 
Prolonged labour
Multiple pregnancy
Preeclampsia 
Maternal obesity
Multiparous
Previous history
Maternal age >40
Maternal obesity

Question 23

What’s the most common cause of post partum haemorrhage

Answer 23

Uterine atony

Question 24

Describe Sheehans syndrome

Answer 24

Complication of major PPH where there is pituitary ischaemia
Cause of secondary amenorrhoea and infertility

Question 25

What is an episiotomy

Answer 25

Mediolateral incision from the vagina to increase the opening for the fetal head to be delivered
Prevents posterior tearing = faecal incontinence and fistula formation

Question 26

Grades of perineal tears

Answer 26

1- mucosa
2- perineal muscles
3- anal sphincter muscles
4- extends to anus (anal epithelium breached)

Question 27

Management of grade 3-4 perineal tear

Answer 27

Suture under LA
Analgesic suppository
Stool softeners
Pelvic floor exercises