APH (Previa/PAD/VP)

Question 1

APH mx

Scenario 1 - 26/40, 250ml, rural, breech, BMI35

Scenario 2 - 24/40, major bleed, previous CS, known PP

Scenario 3 - 28/40, rural, previous CS, LLP/short cervix, PPROM+chorio

Scenario 4 - 34yo, ~28/40, p/w APH in labor -> presumed abruption -> emCS, rural setting

Scenario 5 - 39yo, x3 CS, MPP 34/40 p/w APH in rural hospital

Answer 1

DDx
- uterus - rupture
- placenta - previa, abruption, VP
- others - polyps, ectropion, ca, vagina

Hx
- provoked (trauma, ECV) vs unprovoked
- quantity/pain/contractions/liquor/FM
- urinary/bowel sx
- ANHx - RFs for abruption/LLP
- OGHx - EDD, G&P, CST, perfs/CS
- PHx…RFs for abruption

Exam
- vitals, appearance
- uterine tender/irritability/present/lie
- speculum - ?active bleeding/plac/clots

Ix
- FBE/UEC (abruption/tubular nec)
- G&S/Kleihauer/Coag (DIC)
- MCS - urine, HVS
- RTS (FHR/FM/presentation) +/- CTG
- Obs USS - wellbeing/plac/exclude VP

Immediate mx
- obs emergency
- MDI…inform senior obs con
- resus/stabilization/ix simultaneously
- maternal HDS vs not
- admit +/- deliver vs transfer
- mat = IVC/IVT/G&S/X-match +/- anti-D
- fetal = RTS - FHR/steroid loading
- once stable
1. HDU level care
2. formal USS +/- MRI - growth & PAS
3. consent classical, discuss hysterectomy
4. paeds rv

• if rural, stable -> Piper
• +/-steroid load +/- MgSo4 (gestation)
• if rural, unstable - deliver & Piper out

Emergency response in setting of previa with massive APH
- GA/+/- midline +/- classical
- +/- aortic compression
- +/-MTP of O-‘ve blood
- +/- cell-save

Question 2

Abruption mx

Scenario 1 - emCS for placental abruption c/b atony + DIC

Scenario 2 - emCS for concealed abruption in setting of PPROM 28/40

Answer 2

• Activate hospital emergency response
• MDI - Obs/MW/Paeds/Anaesthetic
• Simultaneous resus + transf OT

Resus
- O2 hudson mask
- x2 wide bore IVC + warm crystalloid
- IDC insertion
- FBE/UEC/LFT/Coag/G&S
- X-match PRBC
- +/- MTP with O -‘ve blood
- CTG to establish fetal wellbeing
- Left lateral
- Avoid terbutaline

Intra-op
- GA/Trendlenburg +/- Lithotomy
- Pfannenstiel or Midline
- +/- Classical incision
- Immediate cord clamping
- Paeds in room
- Cord gases
- Ax - blood in uterus/retroplacental clot
- Uterotonics + Txa
- +/- Bakri insertion

Post-op
- HDU
- Debrief team/pt
- MH support
- LMWH APP
- Optimize anemia
- Perinatal M&M - ?preventable RFs
- Postpartum F/U

Question 3

AN mx (hx of multiple cs)

Answer 3

• counsel re: risk of Previa/PAD
• need for tertiary morph
• subsequent USS+/-MRI if LLP to exclude PAS

Question 4

LLP advice

Answer 4

• M risk - APH/Abruption/Admission (3 As)
• F risk - IUGR/PTL/PTB/SB
• Monitor sx - PROM/PVB/pain
• GS - LLP resolution 80% by 32/40, wellbeing
• avoid - long distance travel, intercourse
• optimize - haematinics

Question 5

LLP/VP preg mx

Scenario 1 - preterm/rural

Answer 5

• VP -> sig risk to foetus -> PROM/PTL -> bleed -> rapid exsanguination
• pt education -> sx monitoring (PVB/SROM) = emergency
• TF care to tertiary center with adequate neonatal facilities
• assoc LLP/velamentous cord -> IUGR -> serial scans (fortnightly)
• repeat scan ? spont resolution 20% of cases
• consider elective admission from 30-32/40 - steroid loading, paeds rv/counsel
• I/P mx = CTG, G/S, G&S, consent, emergency plan
• I/P emerg response - PVB + NRCTG -> emCS (don’t delay to confirm dx)
• consider del 34-36/40 by CS (birth before labour), pre-op mapping of vessel

Question 6

LLP/VP preg advice

Scenario 1 - preterm/rural, don’t want to remain I/P

Answer 6

• pros - home/support/psych
• cons - PTB ->CS/Neo resus N/A
• risk mitigating options
  near hospital accom w supp person
  FFN, cervical length
  map vessel location (VP)

Question 7

Plan CS for MPP

Scenario 1 - 39yo x3 previous CS, known MPP, rural hospital

Answer 7

• MPP pose sig M&M for baby/mother
• Facility - MTP/rapid transfus/cell save
• Refer care to tertiary center
• MDI - Obs/Ano/Paeds/Urology/Rad

Pre-op
- Tertiary scan +/- MRI to exclude PAD
- MDT for pre-operative planning
- Optimize hematinics
- Elective admit if recurrent APH
- Consent - CS/Hysterectomy/Transfus
- Serial G/S
- Aim elCS - complex CS list 38/40
- +/- steroid loading pre-op

Intra-op
- x2 Wide Bore IVC
- PRBC matched/Cell saver
- Consultant led
- Pfannenstiel incision
- Delivery of below edge or through
- Immediate cord clamping
- Neonatal team in room
- Uterotonics + Txa on standby
- Avoid using uterine relaxants

Postpartum
- HDU support for care
- Routine…

Note - if PAD
- urology if bladder involved
- need interventional rad

Question 8

Plan for PAD (e.g. percreta)

Answer 8

Essentially the same as above but more involved from both personnel & resource POV

Key points
- adequate consent
esp - risk of hysterectomy

• other team on standby
  GONC for suppor
  Urology for stenting
• blood products ready
  4-6units matched

Alternative uterine sparing placental mx
- placenta left in-situ - MTX rx
- UAE following delivery