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Flashcards in RANZCOG Q Deck (16)
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1

A healthy 34 year old at 35 weeks gestation reports 2 hours of back pain followed by heavy vaginal bleeding.

On examination she is pale, distressed and in pain. Pulse 130bpm, BP 70/40, the uterus is tender, the fundal height is 39cm above the symphysis pubis, longitudinal lie, cephalic presentation mobile at the pelvic brim. No fetal heart can be heard on auscultation, an ultrasound shows no activity of the fetal heart. The cervix is felt to be long and closed. Your provisional diagnosis is a placental abruption.

a. List in order of priority how you manage the initial presentation and subsequent delivery (5 marks)

- Arrange help – call emergency code for senior obstetrics/anaesthetics/midwifery +/- blood bank/haematology/OT/ICU
- Maternal ABC
- A and B – ensure airway patent and spont breathing especially if losing consciousness, consider high flow O2 and intubation/ventilation as appropriate
- C – IVL x2 large, take blood for FBC, G&S, X-match, Kleihauer, coag
- Rapid infusion with fluids e.g. crystalloid up to 3.5L
- Blood transfusion once available if still unstable after above, ideally matched but O neg if delayed
- If heavy bleeding/still unstable – will need delivery via hysterotomy, prepare for MTP/coagulopathy and PPH – needs specialist obstetrician and anaethetist
- If stabilises – confirm IUFD with formal USS, arrange IOL at a time to suit woman if stable (unlikely given the above)
- Anti D if Rh negative
- High dependency unit - ?need for ICU
- Document
- Debrief

2

After delivery the couple asks if you can determine why this occurred. What possible causes should be considered? (3 marks)
(abruption q)

- Maternal
Medical conditions – HTN, thrombophilia, APLS/SLE
Smoking/cocaine use
Previous abruption
Mulitparity
ART
Idiopathic

- Fetal/obstetric
PPROM
Infection
Polyhydramnios
IUGR/PET
Fall/DV/other trauma
Others not relevant to her: multiple preg, malpresentation

3

What investigations would you organize? (3 marks)

Kleihauer
PET screen – FBC, U&E, LFT, urate, urine PCR
ANA, ESR, LAC, ACL, thrombophilia screen
Fetal – postmortem and placental histology

Other IUFD bloods – HbA1c, TORCH screen, karyotype

4

Justify the management options and advice you would consider for her next pregnancy (4 marks)

- Increased risk of recurrence but absolute risk still small (approx 4%)
- Cessation of smoking/drug use pre-pregnancy – reduce risk recurrence
- Early booking with LMC and obstetric input – early planning of co-ordinated care
- Consider aspirin and heparin In early pregnancy if APLS/SLE – reduced chance of IUGR/abruption/PET, miscarriage
- Routine care – folate/iodine, USS for dating/morphology, 1st trimester anuepolidy screeing and DM screening
- PET vigilance – check BP and urine – early identification to treat BP/timely delivery/reduce complications
- Monthly growth USS – IUGR is a RF for abruption
- Present early if any pain/bleeding – early identification to reduce complications
- Delivery – reasonable to offer at 38-39/40 – no evidence to back, but considerate of feelings if anxious. Mode dependent on previous delivery/maternal preference.

5

a. List four (4) serious adverse outcomes that are more commonly associated with placental abruption than with placenta praevia. (2 marks)

Maternal
Coagulopathy- 10%
Acute renal failure, acute tubular necrosis
Stroke

Fetal
Feto-maternal haemorrhage
Anaemia
Coagulopathy
Stillbirth
NICU admission
Fetal growth restriction

6

A 36 year old primigravid patient at 34 weeks gestation presents to the Delivery Ward with sudden onset of fresh vaginal bleeding (100 mL) and abdominal pain. On admission she is distressed, pulse rate 130 bpm, blood pressure 80/50 mmHg. Her uterus is tender, hard and difficult to palpate. The fetal heart beat cannot be heard. A bedside ultrasound scan confirms the absence of fetal heart activity and a cephalic presentation. Her cervix is tightly closed.

b. Outline step-by-step (giving at least 16 steps) your protocol for management of this woman. (8 marks)

Immediate management
Airway, breathing and circulation assessment- results as above
Give supplemental O2
Place in L lateral tilt to allow better venous return
Call an obstetric code: SMO, help from senior midwives, anaesthetists, theatre on standby
IV access: 2x 14-16 gauge IV lines each arm
Send as urgent:
Full blood count
Urea, electrolytes, creatinine
Liver functions
Coagulation screen: APTT, PR, fibrinogen
Kleihauer: quantify the amount of anti-D needed if Rh negative
Blood group and hold
Call blood bank- cross match 4 units urgently, advise further requests may come
Resuscitate: warmed IV fluids 2L (blood loss from an abruption with a fetal demise usually >1.5L)
Continuous monitoring of maternal HR and SaO2
Q15 minute BPs until rising, then Q30 minutes
Empiric management with massive ongoing haemorrahage: 1 unit colloid, 4 FFP, 10 cryoprecipitate, O- blood
Correct:
Anaemia- packed RBCs
Coagulopathy- fibrinogen, FFP, platelets
Activate massive transfusion protocol with severe anaemia and coagulopathy
Early involvement of haematologist in administration of products
Insert IDC
Carefully monitor output given risk of acute renal failure and ATN

Concurrently:
Explain to the mother what is happening and offer condolences
Offer support and counselling
Offer to call family and friends to be with her

Planning for delivery
Once the mother stable- confirm fetal demise with formal USS
Advise regarding mode of delivery- vaginal delivery preferred with fetal demise if mother stable
IOL with misoprostol protocol recommended by NICE guidelines for fetal demise
High risk of spontaneous labour with abruption
Close monitoring during labour- ideally labour in an obstetric HDU, may need an ART line for continuous monitoring
If mother remains unstable then CS indicated on maternal grounds, but this would be high risk with coagulopathy, blood loss, and potential for emergency hysterectomy
GA needed with coagulopathy/unstable mother
If transfer to another unit for management necessary, ensure that mother stabilised before this
Anticipate PPH and have a plan in place for steps to proceed:
Active 3rd stage management with syntocinon
Stepwise administration of further ecbolics
Bakri balloon
Consider IR for uterine artery embolisation
Laparotomy last resort

Post-partum
Placenta + cord for histology, discuss PM
Admit to HDU post-operatively if unstable
Hourly obs and urine output
Debrief
Give anti-D after Kleihauer back if Rh negative mother

7

Discuss five (5) risk factors which are associated with recurrence of placental abruption in this patient’s next pregnancy. Where appropriate, include how each risk factor may be managed or modified to try to avoid placental abruption. (5 marks)

Previous abruption: Biggest risk factor and not modifiable

Smoking: Smoking cessation
Cocaine and amphetamine use: Cessation
Pre-eclampsia: Aspirin and calcium in the next pregnancy
Hypertension : Anti-hypertensives, weight loss, smoking cessation
Low BMI: Weight gain to a healthy BMI

8

A Rhesus (D) negative woman has a Rhesus (D) positive baby.

a. Describe the immune process, circumstances and requirements that:

Lead to Haemolytic Disease of the Newborn (HDN). (3 marks)

Mother is Rh sensitized – either from incompatible blood transfusion, previous delivery/TOP/miscarriage of Rh positive fetus, or fetomaternal haemorrhage earlier in this pregnancy

Maternal IgG antibodies to Rhesus D red cell antigen develop and persist in maternal circulation
These IgG antibodies can cross the placenta and cause autolysis of fetal cells, leading to fetal/neonatal anaemia and neonatal jaundice

9

Describe the immune process, circumstances and requirements that:

b. Prevent HDN occurring by the use of Rh immunoglobulin (anti D). (3 marks)

Anti-D attaches to Rh pos antigen on the surface of fetal RBC present in the maternal circulation and destroy the cell before the maternal immune system can recognize it and mount an antibody response.

If there are no antibodies in the maternal circulation, then there is no autolysis of RBC in fetal circulation

Requires appropriate dose, with measures of fetal blood in maternal circulation eg by Kleihauer

Reduces risk of alloimmunisation from 16% to <1%

10

List the TWO most important red cell antibodies (in an Australian-New Zealand population), other than anti-D, that may be responsible for a hydropic fetal death. (2 marks)

Anti-Kell
Anti-c

11

You are seeing a woman in her 3rd ongoing pregnancy at 20 weeks gestation with anti-D antibodies detected on booking bloods done at 16 weeks gestation. She has not had any anti-D injections in this pregnancy. She has no history of anti-D antibodies or affected pregnancies.

c. List the 2 investigations you will arrange now. (2 marks)

Antibody titre (or quantification)

Paternal blood type and genotype for homozygosity/heterozygosity

12

Discuss the implication(s) of each investigation with respect to the risks of this pregnancy being affected by these antibodies. (3 marks)

Antibody titre or quantification- gives indication of whether neonatal anaemia is likely to have occurred – if titre < 1:16, this is very unlikely and do not need MCA PSV and referral to fetal medicine team yet, however to need to do so if titre >1:16

If partner is also Rh pos homozygous, the fetus has 100% chance of being at risk. If heterozygous 50%, and if Rh negative then this fetus will not be at risk (this also suggests that previous children were fathered by different father, or that the antibodies were produced following blood transfusion). Alternatively, NIPT can be used from maternal serum to detect fetal rhesus status if paternity uncertain

13

What parameters are used in current practice in Australia and New Zealand to determine the need for fetal blood sampling in a Rhesus isoimmunised pregnancy at 28 weeks gestation? (The fetus is known to be D-positive.) (2 marks)

MCA-PSV above 1.5 MOMs
Evidence of fetal hydrops

Note: Albumin titre of 1:16 or higher determines need for MCA-PSV to detect fetal anaemia if first affected pregnancy, or any titre if previous pregnancy was affected

14

A woman is referred to you in her 3rd ongoing pregnancy at 20 weeks gestation with anti D antibodies on her recent booking bloods. She has not had any anti-D injections in this pregnancy.

a. Outline the key points in the history you will take. (4 marks)

Past obstetric history
Mode of delivery
Sensitizing events in previous pregnancies e.g. APH, trauma, miscarriage
Whether anti-D given after event or after deliveries
Were other pregnancies affected by Rh isoimmunisation, fetal anaemia, hydrops or neonatal jaundice?
Past gynae history
TOPs, miscarriages, ectopics
Whether anti-D given
This pregnancy
Antibodies at booking
Sensitising events – bleeding, falls etc
General – usual antenatal investigations
PMHx, meds.
Previous blood transfusion
Social history
JW?
Paternity of this pregnancies and whether partner’s blood group known
Previous drug use

15

List the investigations you will arrange at this visit and discuss the reason for each. (2 marks)

Antibody titre
If this is first affected pregnancy, then critical titre for further investigation is 1:16 – 1:32
If not first affected pregnancy then pt should be immediately referred for ongoing assessment with MFM team
Partner’s blood type and genotype
- If Rh neg, fetus not affected. If Rh pos heterozygote – 50% chance fetus is at risk, and if Rh pos homozygote – 100% chance fetus is at risk.

16

Outline the management plan of the pregnancy from now in regards to the rhesus iso- immunisation. (9 marks)

If father Rh neg – normal antenatal care.
If father pos - counselling – explain problem and potential outcomes
Check titre and continue to monitor monthly
If critical titre – 1:16 – 1:32, or if previously affected pregnancy at any titre – refer MFM service
MDT input – MFM, midwife, counselor, family, neonatalogist, blood bank if considering IUT
USS for growth, liquor, MCA-PSV, hydrops
Perform USS for MCA-PSV every 1-2 weeks from 18/40
If MCA-PSV above 1.5 MOMs – suggests fetal anaemia
If fetal anaemia – guarded prognosis, although depends on gestation and presence of hydrops– discuss options – TOP, FBS/transfusion/deliver
If FBS shows Hb >2 SD below mean, discuss benefits and risks of intrauterine transfusion +/- perform IUT
Ongoing monitoring as above and deliver approx 37/40.
Neonatal concerns – paeds at delivery. Complex resus if hydrops. Cord blood at delivery – Hb and blood group, direct Coombs, bilirubin level.
Baby may need – blood transfusion, phototherapy, exchange transfusion, and followup.
Discuss care for next pregnancy – consider sperm donor or surrogate. If same parents – early specialist involvement and frequent MCA Doppler regardless of anti-D titre.