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MRCOG Intrapartum/Management of labour/Postpartum Part 2 Revision - Hay > APH/PPH > Flashcards

APH/PPH Flashcards

1
Q

What % of pregnancies are effected by APH?

A

3-5%

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2
Q

Definition minor APH

A

<50mls settled

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3
Q

Definition Major APH

A

50-1000mls, no signs of shock

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4
Q

Definition Massive APH

A

> 1000mls and or signs of shock

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5
Q

Risk factor abruption after 1 abruption?

A

4.4%

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6
Q

Risk factor abruption after 2 abruption?

A

20-25%

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7
Q

Other RF for placental abruption?

A

PET, FGR, Non-vertex presentation, polyhydramnios, advanced mat age, multiparity, PROM, abdominal trauma, smoking/drug misuse, 1st trimester bleeding, intrauterine haematoma, maternal thrombophilia.

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8
Q

What % of placental abruption in low risk pregnancy?

A

70%

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9
Q

What preventative measure for APH can be suggested?

A

Stop smoking & drugs use (cocaine, amphetamines)
If placenta praevia, avoid vaginal and rectal examinations.

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10
Q

Specific Qs to ask APH

A

Pain ?continous
FM
Recent SI
Previous trauma to abdomen
Previous cerival smear
Rh status

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11
Q

How to approach examination of patient with significant APH?

A

A-E approach
Abdo palpation - woody/tense
Speculum Dilation/cause of APH
Assess fetus - CTG or USS

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12
Q

Initial Ix for APH

A

IV access x 2 - Hb, coag, U+E, LFT, G+S, cross match 4 units, VBG
Kleihauer test if Rh -ve
USS - placenta position
Assess foetus - CTG if mother stable

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13
Q

Where to care for women
1) Spotting, placenta high, no active bleeding
2) Ongoing bleeding/heavier than spotting

A

1) discharge
2) Admit until bleeding stops

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14
Q

What % of placental abruption will have abnormal CTG?

A

69%

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15
Q

When to consider steroids

A

If risk of preterm labour 24-34+6

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16
Q

Should you give tocolysis if contracting?

A

Not in major APH, contraindicated in abruption

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17
Q

How should AN care be changed after unexplained APH/APH from abruption?

A

High risk
Review cons ANC and serial growth USS

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18
Q

If fetal death confirmed what MOD?

A

Vaginal delivery

CS if foetus compromised but discuss with Cons

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19
Q

If >37 weeks with minor or major APH but patient/baby stable when should delivery be recommended?

A

IOL from presentation, to avoid adverse outcomes associated with APH

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20
Q

When should continuous CTG be considered?

A

Active APH
Previous major APH
Recurrent minor APH

If 1 episode minor APH, intermittent is appropriate

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21
Q

What delivery complication should you expect in someone with APH? How to minimise this?

A

PPH, active 3rd stage

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22
Q

If APH immediately after ARM, which cause of APH? How to manage?

A

Vasa praevia
Cat 1 EMCS, clamp cord immediately after delivery and leave the long part attached to neonate

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23
Q

If recurrent APH how often should Anti-D be given if required?

A

> 20 weeks 6 weekly

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24
Q

If APH what should be arranged post partum?

A

Assess VTE
Debrief
Incident report
Consider FU with Obstetric Cons within 4-6 weeks
If fetal demise consider informing GP

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25
What 3 things to consider when estimating blood loss
- Measured blood loss - Signs/symptoms of shock - Patients weight
26
What utertonic to use - Low risk - High risk no BP concerns - High risk BP concern
- Oxytocin - Syntometrine - Oxytocin Oxytocin can be given 5IU or 10IU
27
When should oxytocin be given?
After delivery of the anterior shoulder/baby before cord is clamped
28
If blood loss 1000-1500mls, what could you see on the observations?
Tachycardia, Tachyponea, Fall in SBP
29
If blood loss >1500mls, what could you see on the observations?
SBP <80, worsening Tachycardia/Tachyponea, altered mental state
30
Who should be called if blood loss 500-1000mls + no sign of shock
- 1st Line obstetric + anaesthetic Dr
31
Who should be called if >1000mls or signs of shock or ongoing bleeding
Experienced MW + MW in charge Obs middle grade Anaesthetic middle grade On call haematologist Porters Inform Obs/anaesthetic cons Inform Blood lab
32
When should the consultants attended?
>1500mls patient unstable
33
Management of minor PPH 500-1000ml
- IV access x 1 14-guage - Urgent bloods – FBC, G+S, Coag including fibrinogen - Obs every 15mins (HR, RR, BP) - Commence warm crystalloid IV
34
What will happen if insufficient FFP and platelets are given?
Dilutional coagulopathy
35
Major PPH >1000mls, ongoing bleeding, shock
- ABC - Position patient flat, keep woman warm - Transfuse blood, until blood available infuse up to 3.5 L warmed clear fluids, initially 2 L warmed isotonic crystalloid, then isotonic crystalloid colloid - Bloods X-Match 4 units, FBC, Coag including fibrinogen, U+E, LFT - Continous BP, HR, RR - Temp every 15mins - Give high flow oxygen - Foley catheter to monitor UO - 2 x 14 gauge cannula - MOEWs chart - Document fluid balance, blood, blood products and procedures - Consider: Arterial line, ITU once bleeding controlled
36
What pharmacological methods can be given to control PPH?
Rub fundus Empty bladder Oxytocin 5IU IV - can repeat Erymetrine 0.5mg IV (caution HTN) Oxytocin infusion 40 IU in 500mls saline (unless fluid restriction) Carboprost 0.25mg IM every 15 mins, max 8 dosa (caution asthma) Misoprostol 800mcg (1-2.5hrs)
37
What is the maximum amount of fluid that can be given before RBCs?
Max 3.5 litres clear fluids (2L warmed isotonic crystalloid, 1.5 warmed colloid)
38
What can hypothermia (from cold fluids) do?
Exacerbate acidosis
39
When transfusing what are we aiming for: Hb
>80
40
When transfusing what are we aiming for: Platelets
- Platelet > 50 x 10-9
41
When transfusing what are we aiming for: PT
- PT < 1.5 x normal
42
When transfusing what are we aiming for: APTT
- APTT < 1.5 normal
43
When transfusing what are we aiming for: Fibrinogen
- Fibrinogen > 2g/l
44
Which blood should be given in an emergency setting?
Start with O -ve, K-ve blood Switch to 'Group specific blood' as soon as possible CMV negative if AN
45
How much does intra-operative cell salvage reduce risk of blood transfusion?
38→21%
46
How regularly should bloods be sent in uncontrolled MOH, to asses blood products?
Every 30 mins
47
What blood often becomes abnormal first in MOH?
Fibrinogen
48
If no blood results when should FFP be given? At what rate?
After 4 units RBCs 15ml/kg/hr Consider earlier if suspected coagulopathy Given in ration 6:4 Order ASAP as need to be thawed
49
If PPH stopped, do you need to give FFP? (if not suspecting coagulopathy)
No
50
If ongoing bleeding, PT/APTT < 1.5 greater than normal
Give FFP 12-15 ml/kg aiming to maintain <1.5 PT/APTT
51
If ongoing bleeding, PT/APTT >1.5 normal
Higher dose FFP, increased risk TACO
52
Would you give FFP if ongoing bleeding and PT/APTT normal?
No, ongoing testing
53
If no blood results, when should Cryopreciptates and platelets be given? How much?
If > 8 units 2 pools cryoprecipitate 1 pool platelets
54
At which blood level should fibrinogen be given?
If falls <2 2 pools will increase by 1
55
At which blood level should platelets be given?
If <75
56
If using 1st line surgical - uterine balloon tamponade, how long should it be left in for? What is the maximum amount of saline needed?
4-6 hours, remove in daylight hours Mx 500mls
57
What are contraindications to uterine balloon tamponade?
Uterine malformations Uterine rupture Placenta retention Endometrial infection
58
Which haemostatic suture required a hysterotomy?
B-Lynch
59
What % of haemostatic sutras will require hysterectomy? What is the biggest RF?
25% will require hysterectomy Biggest RF is prolonged delay between delivery and uterine compression
60
Describe stepwise uterine devascularisation
Succssive ligation of 1) 1 uterine artery 2) both uterine arteries 3) Low uterine arteries 4) 1 ovarian artery 5) Both ovarian artiees 6) Internal iliac (vascular surgeon must be present)
61
How successful is selective arterial occlusion/embolisation by IR at controlling bleeding?
86.5% success
62
In which cases should hysterectomy be considered sooner?
Bleeding associated with placenta accreta/uterine rupture Decision by experienced Cons
63
Which patients should be considered for ITU
>2500mls > 5units transfused Tx coagulopathy
64
How to assess 2nd PPH
Vaginal swab (HVS and endocervical) Abx for endometritis Pelvic USS ?RPOC
65

MRCOG Intrapartum/Management of labour/Postpartum Part 2 Revision - Hay (32 decks)

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