Antepartum + Postpartum Haemorrhage

Question 1

Dose of oxytocin post vaginal delivery

Answer 1

10iu intrasmuscularly

Question 2

Dose of oxytocin after cesarean section

Answer 2

5iu intravenous slow push

Question 3

What is the definition of minor PPH

Answer 3

EBL 500- 1000L without clinical shock

Question 4

Management of minor PPH (5)

Answer 4

• one 14G iva
• 20ml blood for cbc, gxm, coagulation, fibrinogen
• vitals every 15minutes
• warmed crystalloids
• uterotonics

Question 5

Definition of major PPH

Answer 5

• EBL >1L
• ongoing bleeding
• or clinical shock

Question 6

Management of Major PPH (10)

Answer 6

• HELP
• ABC
• 2 large bore iva - cbc,u+e,pt/ptt,fibrinogen,gxm
• Temperature q 15mins, continuous pulse,resp,bp monitoring charted on MEOWS
• Foley catheter for I/O
• Flat position
• Warm
• Transfuse ASAP(clinically determined)
• rapid 3.5L warmes clear fluids until blood available
• HDU level care

Question 7

When and how is FFP administered

Answer 7

-If no coagulation panel available
- after each 4 units of blood

Rate: 12-15ml/kg until results available

Question 8

Target fibrinogen level

Answer 8

> 2g/l

Question 9

What should be used to replace fibrinogen?
Cryoprecipitate or FFP

Answer 9

Cryoprecipitate

Question 10

What value of platelets require transfusion

Answer 10

<75 × 10e9/l

Question 11

Definition of secondary PPH

Answer 11

Significant uterine bleeding between 24hrs and 12 weeks postpartum.

Question 12

Initial evaluation of secondary PPH

Answer 12

• HVS and endocervical swab
• Ultrasound if patient haemodynamicallt stable

Question 13

What is the further classification of Major PPH

Answer 13

Moderate 1001- 2000ml
Severe >2000ml

Question 14

Therapeutic target in PPH (4)

Answer 14

• Hb >8g/l
• Platelet >50 x 10e9
• PT/PTT less than 1.5 times normal
• Fibrinogen >2g/l

Question 15

Obstetric shock index

Answer 15

Tool used to clinically asses patients with obstetric hemorrhage and the risk of adverse outcomes

HR/SBP

score >/=1 associated with adverse outcomes

Question 16

What is the rule of 30 (6)

Answer 16

Clinical red flag signs associated with severe hemorrhage

• respiratory rate >30
• pulse rate increase by 30bpm
• fall in systolic bp of 30mmhg
• hct fall >30%
• urine output <30ml/hr
• EBl 30% blood volume

Question 17

Mechanical measures for management of PPH (2)

Answer 17

• fundal massage
• Foley catheter

Question 18

Pharmacological management of initial pph (5)

Answer 18

• 5uiv slow push oxytocin
• ergometrine 5iu slow iv/I’m (htn)
• oxytocin infusion 40iu in 500ml at 125ml/hr
• carboprost 0.25mg I’m q 15mins max 8 doses (asthma)
• misoprostol 800mcg sublingual

Question 19

Surgical interventions for pph
- first line

Answer 19

Intrauterine balloon

Question 20

What surgical measures to attempt post Balloon failure (5)

Answer 20

Laparotomy
Brace sutures- b lynch
Uterine artery ligation
Internal Iliac ligation
Hysterectomy

Question 21

Failure rate of BLYnch

Answer 21

25%

Question 22

Risk factors for B Lynch failure (3)

Answer 22

• increased maternal age
• vaginal delivery
• delay if 2-6hrs between delivery and placement

Question 23

How many pregnancies are complicated by APH

Answer 23

3-5%

Question 24

Most predictive risk factor for placental abruption

Answer 24

Previous abruption

Question 25

What is the recurrence rate of placental abruption

Answer 25

4% after 1 abruption 25% after 2 previous abruptions

Question 26

What are other risk factors for placental abruption (maternal) (6)

Answer 26

- pre eclampsia - AMA - multiparity - ART - low bmi - smoking and cocaine - domestic abuse and trauma

Question 27

What are fetal causes of abruption(3)

Answer 27

- malpresentation - polyhydramnios - FGR

Question 28

What are other risk factors beside maternal and fetal for placental abruption (2)

Answer 28

- PPROM - intrauterine infection

Question 29

Risk factors for placental praevia (10)

Answer 29

- previous placenta previa - previous cesarean section - previous top - uterine surgery - endometritis - AMA >40 yrs - ART - multiple pregnancy - smoking - multiparty

Question 30

Management of suspected DIC(pending coagulation screen)

Answer 30

- up to 4units/1L FFP - up to 10 units/2 packs cryoprecipitate

Question 31

What is the odds ratio of recurrent placenta praevia

Answer 31

9.7

Question 32

Incidence of placenta praevia at term

Answer 32

1:200

Question 33

What is the rank of antepartum hemorrhage interms of direct maternal death

Answer 33

Sixth

Question 34

Diagnosis of vasa praevia

Answer 34

- combination transabdominal and transvaginal colour doppler has best diagnostic accuracy - done at time of anomaly scan - may be diagnosed in labour after arom

Question 35

At what gestational age should patients with vasa praevia ve delivered

Answer 35

- planned csection at 34-36 weeks I'd asymptomatic Admit for corticosteroids at 32 weeks

Question 36

How is vasa praevia classified

Answer 36

Type 1 - velamentous attachment Type 2- succenturiate or accessory lobe attachment

Question 37

What is the fetal mortality rate with ruptured vasa praevia

Answer 37

60%

Question 38

What is the survival rate of vasa praevia with antenatal diagnosis

Answer 38

95%

Question 39

What is the reported prevalence of vasa praevia

Answer 39

1: 1200 to 1: 5000

Question 40

What is the prevalence of vasa praevia following ivf

Answer 40

1:300

Question 41

What is the fetal blood volume at term

Answer 41

80 -100ml/kg

Question 42

Can vasa praevia resolve pre delivery?

Answer 42

Yes 20% of 2nd trimester vasa praevia resolve by t3 hence repeat ultrasound d at 32 weeks recommended

Question 43

What is the risk of placenta praevia after ... 1 section 2 sections 3 sections 4 sections

Answer 43

1- 1:160 0.6% RR(nice) 4.5 2- 1:60 1.6% 7.4 3- 1:30 3.3% 6.5 4- 1:10 10% 44.9