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MRCOG PART 2 SBAs and EMQs

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eSSAY 322 - Placenta previa

Posted by Sarika N.
A healthy 30 year old woman is known to have a placenta encroaching on the internal os on ultrasound scan at 20 weeks. She presents at 28 weeks with heavy painless vaginal bleeding. (a) Discuss your initial management [9 marks].
Initial management will involve urgent assessment of maternal condition as can be associated with severe maternal morbidity and mortality. If unstable check airway, breathing, give high flow oxygen, circulation by checking pulse, BP. Insert two large bore cannulas and take urgent blood for FBC to assess anaemia, platelet count, clotting, Gr &save , X- match four units. Call for help if unstable : seniour obstetrician, anaesthetist, involve haematologists, porters. Start IV fluids or 0-neg blood if compromised. Insert the catheter to monitor for oliguria in severe compromised patient. Cointinious monitoring using MEWS chart should be started. Events should be documented. Decision for delivery should be made urgently as a life saving procedure.
If stable assessment of fetal condition should be made by CTG if any signs of compromise decision for delivery with neonatologist involvement should be made.
If stable and bleeding settled admit for observation, ps, BP, RR, saturation should be monitored for the first 24 hours on Labour ward with continious CTG. If no plans for urgent delivery steroids should be given to prevent neonatal respiratory distress syndrome, neonatal morbidity. Inform SCBU and neonatologist regarding the possible plans of delivery.
Anti -D should be given in Rh negative woman.
(b) Discuss the factors that will influence your decision on the timing of delivery [5 marks].
Maternal stability is the most important factor to influence the timing of delivery. The fetal condition should be assessed and if compromised delivery by Caesarean section is required.
If mother and baby are stable continious monitoring and delay to give steroids to reduce neonatal morbidity should be anticipated.
The timing of emergency surgery will be influenced by individual circumstances, but where possible should be deferred to 38 weels to minimise neonatal morbidity.
Plans should be discussed with the patient and documented in the notes.
(c) Discuss the additional steps that you will take to minimise peri-operative morbidity from haemorrhage in a woman undergoing elective caesarean section for major placenta previa [6 marks].
History of previous Caesarean section in association with anterior placenta previa should be an indication for colour flow Doppler USS to exclude placenta accreta.
Proir to operation patient should have an antenatal discussion regarding delivery, haemorrhage, possible blood transfusion and major surgical intervention, such as hysterectomy, any queries should be dealt effectively.
At least 4 Units of blood should be X-matched prior to surgery, cell savage may be considered in cases at high risk of massive haemorrhage.
The operation should be performed by the most expirienced obstetrician and anasthesiologist. Consultant should be present within the delivery suite. If previous caesarean section should be performed by consultant obstetrician.
Uteritonics after delivery of the baby should be given, in absecence of contraindications Ergometrine and Oxytocinon infusion should be started.. In cases of severe bleeding bi-manual compression, baloon catheterisation, compression sutures, uterine artery embolisation, internal iliac artery ligation can be attempted. All staff should be trained in managing massive obstetric haemorrhage, hysterectomy should not be delayed as a life saving procedure.
Postnatally patient should be counselled regarding the operation, assessed for thromboprophylaxis. Debrief in case of massive haemorrhage.
Posted by anupama S.
initial management is to assess the patient and to stabilise her as she is bleeding heavily.Assess her PR, BP, oxygen saturation,general condition. help should be called for from the consultant obstetrician , anesthetistand the senior midwife. haematologist informed regarding the need for blood, porters called for. 2 large bore iv cannulas are inserted and blood taken for FBC, coagulation profile, grouping and cross matching,urea electolytes, iv crystalloids started, 4 units of blood to be crossmatched.
examination of the patient assessing the uterine size , look for tenderness to rule out abruption. confirm the vaginal bleeding and assess whether the bleeding is decreasing. fetal condition to be checked by CTG.
ultrasound confirmation of the placental site and if possible doppler screening to look for adherent palcenta must be done
Admit the woman ,if bleeding is continuing or fetal condition is deteriorating, immediate delivery is planned
antenatal corticosteroids for fetal lung amturity can be considered if patient is stable.
inform the patient about the situvation and plan of action.documentation of the examination and treatment given must be done

B Maternal haemodynamic status and fetal viability are the factors which influnce the timing of delivery. If the bleeding is controlled prolonging the pregnancy upto 38 weeks can be considered. prophylactic steroids for fetal lung maturiy must be given
If the women is continiung to bleed emrgency measures for delivery needs to be taken.
If the fetus is compromised due to the bleeding, then delivery needs to be considered

C A consultant obstetrician and a senior anesthetist must do the caesarean section. arrange for group specific cross mathced blood and for cell salvage if possible. If placenta accreta is suspected (previous Cs and an anterior placenta) or confirmed by doppler, if facilities are available, uterine artery catheterisation can be done so that embolisation can be done in case of severe bleeding.
after the delivery of the baby prophylactic oxytocin or prostaglandins can be given, If bleeding is continuing intrauterine balon therapy, B Lynch suturing, internal ilicac artery or uterine artery ligation must be tried witjhout delay. a decision for hysterectomt must be made if bleeding is not controlled.
Posted by Lilantha W.
(a) I call for help to manage this obstetric emergency which is associated with higher risk of maternal and neonatal morbidity and mortality, if not treated well. Anaesthetist, senior midwives, junior obstetrician, blood porters are called immediately, and consultant obstetrician and the theatre is alerted according to the management protocol. I would initiate monitoring her condition and resuscitation at the same time. Ensure patient’s airway is patent and she is breathing normal. Provide 10-15L/min oxygen via face mask attached to a reservoir bag. Two gray 16G (or 14G) cannule are inserted and bloods taken for FBC, group and cross match 6 units of red cells, coagulation screening and U&E. 2L of Hartmann’s solution is given rapidly through both cannule followed by 1L of colloids. Attempt is made to give warm IV fluids all the time. Red cells are given If the bleeding continues and the estimated loss is heavier, eg. >2L, group specific red cells will be transfused through a blood warmer. Otherwise, cross matched blood will be transfused. 4 units of FFP is given with each 6 units of red cells transfused. Senior haematologist’s opinion is sought at this stage to consider cryoprecipitate and platelet transfusion. Interventional radiologist is called, if possible, according to the local policy. Automated monitoring of blood pressure is done every 10 minutes. Continuous automated monitoring of pulse, O2 saturations is done. Temperature and urine output is checked hourly. Foetal heart is auscultated and CTG may be considered. Patient is reasured appropriately.

(b) Severity of maternal haemorrhage is the main factor which influences the timing of delivery. If the bleeding is uncontrollable with impending maternal shock, immediate delivery is indicated. If the bleeding is moderate and is settling with no contractions/pains, time can be bought until reasonable fetal maturity is acquired (eg. 34 weeks) or until effects of steroids on fetal lungs have been attained (eg. 48h after administration of Betamethasone 12 mg 24h apart). When it comes to a bleeding that has settled; local availability of neonatal cots and interventional radiology influence timing of delivery. Similarly, if there is no threat of either maternal or fetal compromise, delivery can be deferred until relevant expertise become available eg. obstetric consultant, senior anaesthetist, interventional radiologist, haematologist; and also until the blood is cross matched. Patient may be fasted for 4-6h, if she has eaten recently. If she has taken any LMWH, waiting is required until its therapeutic effects diminish. However, if there is an acute fetal compromise as a result of bleeding vasa praevia, abruption or other condition, immediate delivery is indicated.

(c) Antenatal recognition of anaemia and prompt treatment with systemic/oral iron, B12, folate supplementation, recombinant erythropoietin, as appropriate, will reduce risk of haemorrhage and requirement of blood transfusion. Diagnosing the condition accurately and excluding possibility of placenta accreta in high risk cases with MRI scan will reduce morbidity. Recognition of co-morbid factors such as coagulation disorder (thrombocytopenia, vWD, LMWH therapy), atypical antibodies and taking appropriate steps to rectify them (if possible) will reduce the morbidity. Use of cross matched blood rather than group specific or O Rh negative blood is such an example. Ideally, interventional radiology inputs should be sought. Referral to relevant centre may be required in -special circumstances eg. Jehovah’s Witness or restrictive cardiomyopathy(HOCM). If a patient refuses blood product/s it is important to counsel her and explore to what extent she does it as some may accept cryoprecipitate, platelets and the majority will accept their own red cells through an intraoperative cell salvage system. Use of cell salvage system effectively by trained operators will result in higher post operative haemoglobin levels than those without and hence, minimise morbidity in massive haemorrhages. Seeking haematological advice and presence of haematologist at the time of caesarean section will aid prompt assessment of the ongoing situation and its management.

The caesarean section should be carried out by the most experienced surgeon with appropriate assistance to minimise operative time, complications and hence, morbidity. Prompt administration of uterotonics (eg. Ergometrine IM, Carboprost IM, Syntocinon IV), intra- and peri-operatively will result activation of physiological ligature mechanism in the myometrium with consequent reduced blood loss. Quick and accurate intraoperative decisions regarding the use of brace sutures, arterial ligation, tamponade balloons and hysterectomy will reduce massive haemorrhages, requirement of massive transfusions and consequent morbidity.
Posted by R S.
a. Rapid clinical assessment is essential including assessment of consciousness and vital signs. Two large pore cannulas are inserted and 10 cc blood is obtained and send for FBC, blood grouping and cross match of 4-6 units of blood. Intravenous fluid (crystalloid) is infused. If bleeding is heavy and continuous; RH O D negative is infused till cross- matched blood is prepared. Meanwhile we try to assess fundal level and see whether the uterus id soft or not. If fundal level is larger than date and the uterus is tense, there might be accompanying placental separation (Abruption). Foleys catheter is fixed and early warning chart is started. Extra help is summoned and the patient is monitored in HDU. Abdominal US can be helpful in confirming placental site and detecting fetal viability, however, fetal compromise can rapidly progress so fetal CTG is recommended. Special care baby unit is notifies. Multidisplinary team is involved in the management including senior obstetrician, anaesthetist, pediatrician and heamatologist. The patient is closely monitored with accurate estimation of blood loss per vaginum. Her antenatal notes are reviewed including history of uterine scar.
b. Heavy and continuous bleeding will demand immediate delivery, usually by emergency CS, this will be life saving. Also if the patient develops uterine contraction as this mean more bleeding is anticipated. If bleeding settled and the mother and fetus is in good condition; delivery can be delay to achieve fetal lung maturity. The aim to reach 37 weeks of gestation unless further bleeding attack will occur.
Presence of other medical or obstetric problem may require early delivery like hypertension or multiple pregnancy.
If there is no available bed at SCBU or advanced neonatal resuscitation facilities and the mother is in a stable condition, delivery is also delayed to allow in utero transfer.

c. Anemia should be corrected vigorously before the operation. Investigation like MRI is requested to exclude placenta accrete/ increta particularly if the patient has previous uterine scar. If this is the case, liaison with interventional radiologist to do UAE just before the operation. Adequate crossed matched blood is prepared and the blood bank staff is notified about possibility of massive obstetric hemorrhage. Multidisplinary team will be required including general surgeon, vascular surgeon and consultant obstetrician. Different techniques can be applied if bleeding occurs like suturing placental bed, uterine packing, internal iliac ligation or B-lynch sutures. Decision of hysterectomy should not be delayed provided that the patient gave an informed consent. Uterotonic agent is used and patient monitored in HDU.
Posted by Mark C.
a) This is an emergency which needs immediate action to decrease maternal and fetal morbidity and mortality. First assess for ABC and start resus as needed. If profuse bleeding call for help (obstetric consultant, anaesthtist, SHO, senior MW, inform haematology of urgency) Start high flow oxygen via face mask (10-15L/min), two wide bore cannula and start volume replacement from one and take FBC, Group, XM 6 units, clotting screen including fibrinogen level, LFT/U&E/Cr which are sent urgently. Start MEWS chart and catheter for urine output. If there is no improvement may need crash section.
If the [patient is well she needs to be admitted. Blood investigations as above (without XM). Give steroids as possible prematue delivery. Review notes to assess degree of placenta praevia and whether there was a previous LSCS. Site of placenta (anterior vs posterior would be very important). Give 500IU anti D and send Kleihauer if RH negative.
Once stable will need repeat abdominal US to confirm diagnosis and to assess fetal well being. If confirmed TVUS as this is more specific in identifying degree of placenta praevia especially if posterior. Doppler to assess for the risk of placenta accreta or increta, or even MRI.

b) Bleeding is an important factor. If this is continuing profusely then urgent section is indicated. Also fetal well being. WIth any evidence of fetal distress early LSCS indicated. If both stable can wait until viability. Mode of delivery depends on the grade. Grade I-II can attempt vaginal delivery. Grade III-IV need LSCS. Aim for LSCS at 36-37/40 unless indicated earlier. Maternal wishes should always be kept in mind when deciding such issues.

c) Delivery in a consultant based clinic with consultant obstetrician and consultant anaesthetist present. Ideally done as an elective. If interventional radiology is available then consider preparation for uterine artery embolisation. Ensure that 6 units of cross matched blood is in theatre. Cell saver present if available. If bleeding heavily, early hysterectomy would be recommended.
Posted by Green K.
A healthy 30 year old woman is known to have a placenta encroaching on the internal os on ultrasound scan at 20 weeks. She presents at 28 weeks with heavy painless vaginal bleeding. (a) Discuss your initial management [9 marks]. (b) Discuss the factors that will influence your decision on the timing of delivery [5 marks]. (c) Discuss the additional steps that you will take to minimise peri-operative morbidity from haemorrhage in a woman undergoing elective caesarean section for major placenta previa [6 marks].

Green:

a) Severity of bleeding would be gauged by the number of pads used or presence of large amount of clots. Precipitating factors such as preceding history of sexual intercourse may suggest bleeding from placenta praevia, local trauma to genital tract or cervical polyp. Preceding history of trauma to abdomen would suggest placenta abruptio. History of previous bleeding and previous administration of steroids. Previous mode of delivery as previous history of caesarean section would increase the risk of placenta accretion this pregnancy.
Blood pressure, pulse rate and oxygen saturation would be obtained. A tachycardia with low BP would indicate significant bleeding and hypovolemic shock. Her nail beds, conjunctiva and tongue will be examined for pallor. Abdominal palpation to determine presence of tenderness and uterine size in relation to gestation. A uterine size larger than dates with woody hard consistency and irritability may suggest abruption. Fetal heart will be checked using daptone. Speculum examination done to gauge ongoing pv bleeding and to look for local cause of bleeding for the cervix ,vagina and vulva.
Blood would be sent for full blood count to check hemoglobin and platlet levels. Blood sent for PT and APTT to check clotting profile. Blood sent for group and save in case of need for transfusion. Blood sent for urea and electrolytes as baseline in case of need for anesthesia.
The consultant obstetrician, consultant anesthetist, hematologist, blood bank and lead midwife and porters would be informed. Special care baby unit would be informed in case an early delivery is needed. Patient would be cannulated with at least 2 large bore branulas (size 14g or 16G). If bleeding is significant and ongoing, she would be resuscitated with warm crystalloid Hartmann\'s solution up to 3.5 litres followed by colloids up to 2 litres while awaiting crossmatched blood. Uncrossed group specific or group O rhesus negative blood may be given crossed matched blood not available. Delivery would need to be considered in significant ongoing bleeding. Patient would be kept up to date regarding her clinical condition and plan of management.


b) Presence of significant continuous bleeding would required immediate delivery after stabilization of patient. If bleeding has subsided and no fetal compromise, delivery may be delayed till after completion of Bethametasone. If bleeding has stopped and no fetal compromise, Bethametasone would be given and patient kept in ward for monitoring for a few days. A repeat trasvaginal scan would be done at 32 weeks and readmitted if still praevia till delivery which would be at 38 weeks by elective Caesarean section if no further bleed.


c) Ensure involvement of consultant obstetrician, consultant anesthetist, blood bank, consultant hematologist. Blood would be crossed matched and at least 4-6 units made available. Patient cannulated with at least 2 large bore branulas (size 14G or 16G). It would be a planned procedure done in the day where full support from staff at all levels are available. Caesarean section done by the most experienced consultant obstetrician or by trainee under direct supervision. Consultant obstetrician and consultant anesthetist must be in theatre. Use of cell savage would be considered if available. Mechanism for rapid transfusion of warm blood would be made available.
Posted by K I.
A healthy 30 year old woman is known to have a placenta encroaching on the internal os on ultrasound scan at 20 weeks. She presents at 28 weeks with heavy painless vaginal bleeding.

(a) Discuss your initial management [9 marks].
THe patient needs to resuscitated appropriately including making sure her airways is intact, and she is breathing. intravenous cannulae inserted and iv fluids commenced. Bloods should be taken for full blood count and blood crossmatched for 4 units. This is necessary to avoid hypovolemic shock.
When the patient is stabilise, history should be taken including when the bleeding started and if there is any provoking factors prior to the blleding,e.g. trauma to abdomen or intercourse. The abdomen should be palpated for any tenderness and hardening of uterus for signs of abruption and to feel for fetal position and presentation.
Fetal monitoring should be commenced using cardiotocogram to assess fetal weelbeing.
Ultrasound scan should be done to lacote pacental localisation as her previous scan was done 8 weeks previously and as the lower uterine segment formed, the location could have me=oved.
Speculum examination should be done to assess the bleeding, to look at the cervix fro any pathology or dilatation, and to look at local causes of bleeding such as from the vaginal wall. Steroid injection of bethamethsone should be given for fetal lung maturation.

(b) Discuss the factors that will influence your decision on the timing of delivery [5 marks].
Factors will include maternal and fetal. If the patient continous to bleed heavily and signs of shock, the fetus needs to be delivered as soon as possible. She is at risk of DIC if she continous to bleed. Fetal monitoring usin the CTG will detect fetal compromise which will also prompt delivery. If both maternal and fetal conditoin is stable, delivery can be postponed until the steroids is effective.

(c) Discuss the additional steps that you will take to minimise peri-operative morbidity from haemorrhage in a woman undergoing elective caesarean section for major placenta previa [6 marks].
The delivery should be done early during the day with senior obstetrician and senior anaesthetist available. Haematologist should be informed and advice sought if needed. Two large bore ivcannulae inserted with bloods available in theatre. Exact location of the placenta should be known and if possible to void the incision at that location, which could mean a need for classical incision. As soon as the baby and placenta are delivered, a bolus dose of oxytocin and oxytocin infusion should be started by the anaesthetist. Uterine wound should be sutured promptly and any bleeding points detected and sutured as necessary.Surgical drain should be inserted for post-operative monitoring of any internal bleeding.
Posted by R J.
RJ] Assess the general condition of the woman as she has come with heavy vaginal bleeding.assess the vitals like pulse , bp ,respiratory rate and amount of blood loss to know if she is in shock.Simultaneously a short history to know about the onset and duration of bleeding.any antenatal complications and her obstetric history to know about her previous delivery whether by vaginal route or cs .Perabdomen examination to see whether uterus relaxed or tense and tender or having uterine contractions.a tense and tender uterus suggests abruptio placenta while a relaxed uterus with painless bleeding suggests placenta previa.uterine size to see for gestational age.fetal heart rate to confirm fetal viability.local examination to see the amount and colour of bleeding as it will guide us regarding blood loss.
As the woman is bleeding and usg at 20 weeks showed placenta in lower uterine segment chances of bleeding is suspected to be due to placenta previa.ultrasound transabdominally is to be done to localise the placenta whether low lying or has migrated upwards.if low lying then whether it is minor or major placenta previa as it will affect decisions and management . In cases of haemorrhage communication,evaluation,resuscitation and monitoring should be simultaneously done.call for help from midwife ,anaesthetist and consultant on call if bleeding heavy .iv access by wide bore canula and take blood for fbc, urea and electrolytes ,coagulation screen and group and save.alert the blood bank for need of blood and blood products.alert the neonatologist for need of nicu bed as fetus is of 28 weeks.intravenous cystalloidsshould be started.if bleeding stops or not much bleeding then conservative approach with corticosteroids and in patient management can be tried in view of fetal prematurity.if heavy vaginal bleeding then the woman and her partner need to be informed of urgent operative delivery to reduce maternal and perinatal morbidity and mortality .
b] if heavy vaginal bleeding then there is risk of hypovolaemic shock and increased maternal mortality and morbidityand fetal hypoxia and death and so urgent caesarean section is indicated.another factor is fetal well being ,if fetal compromise then also early delivery irrespective of gestational age.third factor is whether bleeding has stopped or is less then we can have expectant management with administration of corticosteroids for fetal lung maturation and inpatient management .if vaginal bleeding recurs and is heavy then there is need for caesarean section at that time.
c]informed written consent from the woman and her partner and also high risk consent for haemorrhage ,need for blood transfusion,additional procedures that may be needed to arrest bleeding eg,hysterectomyshould be taken .adequate blood should be crossmatched and kept as there is risk of massive haemorrhage.caesarean section should be done by the consultant or atleast under the observation of consulatant.senior anaesthetic consultant should be present.In any case of placenta previa and history of previous cs and anterior placenta ,adherent placenta should be ruled out in antenatal period with the help of color doppler and if needed with mri as morbidly adherent placena is associated with massive haemorrhage and needs consulatant led multidisciplinary care.As placenta previa is associated with PPH,active managemnt of third stage of labour should be done.use of uterotonic agents like syntocinon and ergometrine, carboprost is to be done liberally to prevent and minimise blood loss.resort to surgical methods to mange major pph should be done like balloon tamponade ,brace sutures,uterine artery ligation and int illiac artery ligation .hysterectomy if needed should be done sooner rather than later to reduce maternal morbidity and mortality.interventional radiological method like uterine artery embolisation can be done where facilities and expertise is available.In some tertiary centres ,in morbid adherent placenta intraarterial catheters can be kept before going to operataion theatre so that embolistaion can be done when required.
Posted by Bee N.
(Bee)

A healthy 30 year old woman is known to have a placenta encroaching on the internal os on ultrasound scan at 20 weeks. She presents at 28 weeks with heavy painless vaginal bleeding. (a) Discuss your initial management [9 marks]. (b) Discuss the factors that will influence your decision on the timing of delivery [5 marks]. (c) Discuss the additional steps that you will take to minimise peri-operative morbidity from haemorrhage in a woman undergoing elective caesarean section for major placenta previa [6 marks].

A) I take a quick history of onset of bleeding and if provoked by anything.I will ask for any other episode of PV bleeding in pregnancy and how often she has been bleeding.I will ask about her smear history and if she has had any odd PV discharge including liqour prior to PV bleeding. I will ask for history of presence of contractions.
I will check her blood pressure, pulse and oxygen sats continuously. I will examine her abdomen for tenderness, fundal height and presentation.I will commence 15L oxygen administeration , place on the left lateral position while asking a colleague to inform the anesthetist, the consultant obstetrician, the labour ward mid wives and theatre nurses as well as heamatologist and blood bank. I will send her bloods for FBC and coagulation screen as well as cross match 4 to 6 units of blood. I will insert 2 intravenous cannula with wide bore and commence administration of infusion of colloid fluid.I will insert a urinary catheter to monitor fluid input and output. I will then commence CTG monitoring and tranfer to labour ward HDU as soon as poosible. I will then arrange for a pelvic scan as soon as possible for placental site location. I will administer 4mg IM dexamethasone which may be useful in lung maturation especially in bleeding settles and a second dose given 24hrs later. I will keep patient nil per oral until stable. Speculum examination will be attempted after scan has shown absence of placenta previa.

B)Factors that will influence timing of delivery will include severity and persistence of bleeding. If bleeding settles or is very minimal, inpatient observation is acceptable to allow as much fetal maturity as possible. Other factors will include gestation of pregnancy. In a pregnancy at term, delivery in indicated. Maternal wish will also be considered after adequate information has been given to the benefits and possible losses of delivery at any stage of pregnancy. If there is sign of fetal distress, immediate delivery is indicated. Finally I will aim to deliver the patient in the presence of experienced staff and when a well equiped neonatal unit can accommodate the baby after delivery especially if ceasarean section is needed. I will abide by unit protocol at all times and always keep patient informed.

C) I will ensure that aneamia is well treated before labour. I will arrange to perform MRI/USS to identify morbidly adherent placenta as this may pose more challenge in theatre. I will ask for assistance of an experienced surgeon in dealing with placen previa. I will make sure she has 6 units of blood cross matched for the procedure.I will employ multidisciplinary approach to her care, involving hematologist and interventional radiologist in her care. I may decide to leave the placenta insitu if very morbidly adherent rather that attempt to extracta little which may cause heavy bleeding. I will leave a pelvic drain insitu to monitor continuing blood loss.I will actively manage third stage of labour. I will encourage breast feeding and manage post operative in HDU with continuous monitoring. I will ensure bladder is catheterised to ensure always empty. I will follow unit protocol in management.
Posted by Chitra.s M.
Initial management invovles stabilising the maternal condition as it could be associated with maternal mortality and morbidity.Maternal ressuucitation should be started immmediately if unstable .Simultaneously it requires a multidisiplinary approach if unstable involving the senior obstetrician, anaesthetist senior midwife, theatre to be alerted, hametologist to be involved and also the porter.Oxygen 0f 10-15 liters by mask has to started .2 large IV cannulas ( no 14) has to placed for rapid iv infusion to maintaiin circulation if blood presssure is low.Blood to be drawn simultaneously for FBC, blood grouping and typing and to cross match 6unitsof blood.Crystalloids to be started initially for iv infusion . If condition demands blood , O negative blood can be started initially. Once she stabilises fetal condition to assessed with symphysio fundal height. CTG. Corticosteroids to be administered . Repeat scan has be arranged to reconfim placental positon ,the fetal presentation and fetal wellbeing.Needs in patient care until delivery by LSCS by 38wks if stabilised.
If condition detiroates she needs emergency LSCS to save her life . Relatives should be explained about fetal and maternal risks in such situiation,SUBU has be informed with involvement of the neonatologist.
Maternal condition is single most factor which decide the timing of delivery initialy.
If unstable needs immediate delivery. If stable and if no further episodes of bleeding and if still persistent major degree placenta previa will need delivery by LSCS at 38 wks gestation.
Fetal condition takes next priority. If unstable needs delivery by LSCS immediately after disscusion with the couple.If later detected to have IUGR needs to be delivered by 34 wks.
Additional steps pre operatively are to maintain optimum hameoglobin level ,ruling out placenta accreta by colour doppler USG in case of anterior placenta and previous LSCS . Includes arrangement of 6 units of crossmatched blood as PPH will be an expected situiation, involvement of senior anaesthetist and experienced obsterician for the surgery. During surgery oxytocics to be used judiciously to reduce PPH.
Step wise devascularisation sutures to be placed initiaaly to manage PPH like uterine artery ligation,B Lynch sutures . Chow stich for lower segment. If still uncontrolled to proceed wit h hysterectomy to save life.
Post operatively to be managed in HDU with one to one care. Thromboprophylaxis to be considered. managedin
Posted by Preethi A.
aflntepartum heamorrahge is associated with increased morbidity and mortality
Call for help for senior obstetrician, aneasthetist,midwife and assess airway, breathing and circulation
2 largebore IV cannuala inserted bloods for heamoglobin,platelet count,coagulation screening baseline hepatic and renal function to be assessed
imediate rapid fluid replacement with crystalloids
/colloids or transfuse o negative red cells in case of life threatening bleeding
monitor bp,pulse.and urinary out put by inserting indewlling urinary catheter.
abominal examination to look for others causes of bleeding like abruptio placenta if associated with tenderness and fetal heart abnormalities a
speculum examination to assess severity of bleeding, cervical dilation any vaginal or cervical cause of bleeding.
expectant and conservative managment if heamodynamically stable and no fetal compromise
admission on to labour ward for close monitoring ctg monitoring
steroids to enhance fetal lung maturation to be administered as there advantages are well estasblised
surgical intervention is needed if mothers life is in endanger needing emergency cesaerean section to deliver the fetus and women risk of PPH from dilatd sinusof placental bed
Decision to deliver depends on degree of heamorrahage and fetal maturity
elective surgery to be deffered up untill 38 weeks if possible to avoid neonaal morbidity
blood should made available for peripartum period as increased risk bleeding
if atypical antibodies are present direct communication with blood bank to enable specific plans
placental site imaging to be performed if anterior placenta previa and previous cesearean section to appropriatetly plam further management
preoperative counselling regarding massive blood loss need for blood transfusion risk of thrombosis and hysterectomy to be couselled.
senior obstetrician to do the cesearean section anticipating complication and excess bleeding from sinus oof placental bed and extention of uterine incision.
MDT approche involving urologist, interventional radiologist and heamatogist vascular surgeon gynaecologist if morbid adherent placenta is diagnosed

Posted by Dr Dyslexia V.
X

a) I will take a quick history of precipitating factors such as any abdominal trauma or any recent coitus. History of association with abdominal tightening such as contraction and the presence of fetal movement is also taken. Examination should include her general state if she is comfortable or in shock. Her pulse rate, blood pressure, temperature should be assessed. Her conjunctiva and tongue assessed for pallor. The fetal heart rate is also noted and if tachycardic I would proceed for a CTG. 2 large bore intravenous line are inserted and blood taken for group and cross match for 4 units of pack cells, and base line investigation for coagulation profile and renal profile. A speculum examination is done to note the severity of bleeding and the point of bleeding as it could be from local course or from the external os. A quick ultrasound is done to determine the position of the placenta and possibilities of an accreta in a previous LSCS scar patient. The patient should be given intramuscular betamethasone for fetal lung maturation. A ventilator for fetus should also be booked if anticipating delivery. If she is rhesus group negative than anti-D should be given. The patient and the partner should be informed of the current event and possibility for a cesarean section and its associated morbidity. There is a role for tocolysis for selected cases in a tertiary center setting.

b) During the monitoring of this patient if noted there is increasing in per vaginal bleeding with evidence of increasing usage of sanitary pads or ongoing fresh bleeding, then decision should be made for prompt delivery. Presence of regular contraction or labor should also prompt for immediate delivery. Presence of abdominal pain which could indicate co-existing abruption should also require immediate delivery. Other parameters such as, unresolving and increasing maternal tachycardia or abnormal CTG or presence of fetal compromise should prompt for early delivery. If there is no presence of ongoing bleeding or fetal compromise then she should be delivered at about 37 to 38 weeks to reduce perinatal morbidity.

c) Her state of anemia if present should be optimized by hematinics or blood transfusion for prior surgery is important. The operation should be carried out by a senior consultant who’s experienced in handling these cases. Patient who has a previous LSCS scar should undergo Doppler investigation to rule out any presence of a plasent accreta. The blood bank and hematologist should be alerted and ready for usage of massive amount of blood products in the event of severe hemorrhage. Other team such as the surgeons and the urologists should be informed if plasenta, percreta is suspected which could be invading adjacent structures. The use of uterine artery canalization with baloon and subsequently embolization should be done if placenta accreta is suspected. Delivery of the placenta intraop should be done gently with control cord traction and manual removal should be avoided. The use of uterotonics such as syntometrin or oxcytocin and carboprost should be used without hesitation. Placental bed should be sutured and hemostasis secured before closing uterine incision in a placenta previa. Post operatively patient should be observed closely for evidence of any hemorrhage and prompt decision made for return to theater and need for hysterectomy. The usage of cell salvage for anticipated massive hemorrhage could be done in centres with its availabilty
Posted by Seham S.
SE-SA

(a) Initial managment unclude resuscitation measures,maintain airway,facial O2.Insertion of 2 wide bore canula and start I.V fluid till blood is ready. Transfusion of O - ve blood could be done till cross matching is completed.I.V fluid could be crystalloid or colloid. B.P, pulse and CVP is inserted to control transfused fluid in case of sever haemorrhage. Catheter should be inserted to calculate urin output. Blood sample for FBC,U&E,coagulation profile and liver function tests. Assessment of fetal condition should be done when patient general condition permit.CTG and U/S could be done. Consultant obstetrician ,anaesthetist, neonatologist and haematologist should be included. Condition should be explained to the woman and the need for emergency C/S.Complications that may occur during operation as the need for blood transfusion and hysterectomy should also be explained and consent should be signed and counselling to woman is documented.

(b) Bleeding severity and mother general condition are important factors in infuencing timing of delivery to safe life of mother and baby. Presence of fetal distress as seen on CTG and the need to safe baby is another factor . If mother condition is good,bleeding decreased and CTG is normal so, there is chance to give corticosteroids and postpone delivery as far as possiple for benefit of baby.This should be done in hospital under close observation and facilities for emergency C/S. Another factor is availability of neonatal cots . if bleeding decreased or stopped ,preparation to transfer baby in utero to another center is considered.

(c) Operation should be done by cosultant obstetrician or trainee under direct supervision of the cosultant. Risk assessment of DVT should be done . Laision with haematologist to ensure availability of blood (4-6 units) and blood products as fresh frozen plasma. Early intervention in sever bleeding to safe mother life and prevent against DIC. During operation if placenta accreta is diagnosed ,managment include ligation of uterin arteries or internal iliac artery.B-lynch suture could be also tried.placenta could be left in situ and injection of methotrexate at bed of placenta.Hysterectomy should not be delayed if bleeding did not decreased. No evidence to support use of autologous blood transfusion during operation as patient need more blood. Cell salvage could be considered in woman with high risk of sever bleeding. Post operative use of uterotonic agents,blood transfusion could be continued.Patient should be managed in high dependency unit.
Posted by Ida I.
I.

a)
A quick history of ascertain the amount of bleeding and the duration of the bleed. A history of sexual intercourse may suggest a bleeding placenta praevia, whereas a history of trauma may suggest a placental abruption. A previous history of caesarean section would give rise to a suspicion of adherent placenta. Any antenatal records should be made available where possible.
A general assessment of the patient is vital, and this should include her blood pressure and pulse rate. The presence of hypotension and tachycardia would indicate significant bleeding. Signs of anaemia is sought by examination of her nails, conjunctivae and tongue. Her abdomen palpated for any tenderness and uterine size. Fetal heart is detected by daptone, and a cardiotocograph can be done if fetal heart is present. Speculum examination is done to exclude any bleeding from the vagina or the cervix.
She needs at least 2 large bore branulas, size 14G or 16G, with fluid resuscitation with colloids and crystalloids. Blood for full blood count is sent to look at the hemoglobin level and platlet count. A PT and APTT sent to look at her coagulation profile. Blood sent for group and save in case she needs a transfusion or operative intervention. A baseline renal profile is sent in case she needs anaesthesia. Any significant blood loss can be transfused with unmatched O negative blood as a life saving procedure.
The consultant obstetrician, anaesthetist, midwife, hematologist and blood bank needs to be notified. The neonatologist and special care nursery also needs to be notified for possible neonatal resuscitation. Antenatal corticosteroids can be given in case of an early delivery.

b)
Timing of delivery would depend on the severity of the bleeding, as well as the maternal and fetal condition and wellbeing. She would need prompt delivery if the bleeding is severe with signs of hypovolemic shock. Any signs of fetal compromise would also require a prompt delivery. If her bleeding has subsided, and there is no evidence of fetal compromise, and antenatal corticosteroids completed, her delivery via elective caesarean section can be delayed to 38 weeks to reduce perinatal morbidity.

c)
A multidisciplinary team of senior obstetrician, anaesthetist, midwife and hematologist, including the local blood bank should be involved in the management of this patient. Her anaemia has to be corrected before her operation. if she has a previous caesarean section, she requries a colour Doppler ultrasound to assess the presence of an adherent placenta. If she is suspected to have an adherent placenta, liaison with the surgeon or the radiologist may be required. Her blood needs to be grouped and saved in the blood bank. Any rhesus negative woman with abnormal antibodies need liaison with the hematologist and the blood bank. Any risks of thromboembolism due to prolonged bed rest in the ward needs to be dealt with. The operation has to be done by an experienced obstetrician. Uterotonics has to be made available during the surgery. Placenta has to be delivered via controlled cord traction, not by manual removal of the placenta. Cell salvage can be considered if massive hemorrhage is anticipated. Surgical manouvers such as balloon tamponade, B lynch suturing, internal iliac artery ligation or hysterectomy can be applied intraoperatively to reduce the amount of blood loss. The couple needs to be carefully counselled on the risk of postpartum hemnorrhage and hysterectomy before the operation, and patient information leaflets made available for them.
Posted by Ulduz A.
a)Initial assesment will start by resusitation of the patient.Airway secured and o2 given by face musk at the rate of 15 ml/hrs.2 large-borne cannulas inserted and blood sent for FBC,group and x-matching of at least 4 units of blood,coagulation screen.Fluid resusitation with cristalloids and colloids began.Monitoring of BP,P,RR and SO2 done continuously.Foley\'s catheter inserted and urine output monitored.At the same time call for help performed.Senior obstetrician,senior anaestetist,haematologist,neonatologist,ICU physician alerted.
When mother stabilised fetal condition should be assisted by CTG.Any abnormalities need prompt delivery.
If the mother is stable and fetal condition is reassuring,antenatal steroids given and expectant inpatient management followed.
Anti D given to all Rh negative non-sensitised women.
b)Fetal compromise is an important factor which can necessitate urgent delivery.If maternal and fetal conditions are stable,antenatal steroids are given and expectant inpatient management done.Any further bleeding is an indication for delivery.Plan regarding delivery should be discussed with the patient and fixed in the notes.
c)With expectant management patient needs heamatinics to keep her Hb on the upper limit of normal.6 units of blood should be x-matched.Vascular surgeon and radiologist informed when patient is in OR if internal iliac ligation or uterine artery embolisation needed.Consent should be taken for possible hysterectomy and blood transfusion.Senior obstetrician and anaestetist should be in the theatre during operation.Hysterectomy should not be delayed as a life-saving procedure.Intraopertively uterotonics should be given.Postoperatively patient should be debriefed about the procedures done and all questions answered. Need for thromboprophylaxis assesed.
Posted by Bgk H.
a. Patient is currently having an antepartum haemorrhage. She needs prompt assessment and timely management to reduce maternal and fetal mortality and morbidity. I will assess her airway, breathing and her hemodynamic stability. I will call for help including midwives, senior obstetricians, SHO and porter. I will also alert anaesthetic team and inform SCBU regarding the patient. I will prop her up and put her on O2 via face mask. Two large bore canula need to be fixed and blood withdrawn for blood cross match, coagulation profile, full blood count. If she in haemodynamically unstable blood transfusion need to be initiated with O negative blood.
If patient stable, I will obtain history from her and review her antenatal record. I will ask about symptoms of labour including contraction pain and leaking liquor. Any aggravating factor such as abdominal trauma or sexual intercourse should be asked. Her past obstetrics history such as previous placenta praevia or caesarean delivery should be asked as this may suggest recurrence and the latter may have risk of placenta acreta.
I will then perform a perineal inspection and assess her bleeding. Amount of blood loss need to be estimated. Bleeding per rectum and urethral need to be excluded. I will perform pelvic scan to locate the placenta location for the diagnosis of the placenta praevia. Fetal presentation and weight estimation need to be done. Fetal well being need to be monitored using continuous CTG. If placenta praevia excluded, vaginal speculum examination need to be done to rule out any local cause such as cervica polyps or ectropian.
I will then administer antenatal steroids to prevent reduce the incidence of respiratory distress syndrome, NEC. I will also arrange for her to be seen and counselled by the neonatologist regarding her fetal outcome.

b. Factors include the severity of the bleeding. If patient is bleeding heavily and not appear to stop and maternal condition is not stable, emergency delivery should be done. I will also deliver her if there are signs of fetal distress. But if bleeding has stopped, I will treat her conservatively and repeat her ultrasound at 32 weeks if placenta praevia major and deliver her at 37 weeks if remain asymptomatic. I will consider delivering her if she has persistent bleeding and signs of fetal compromise.

c. I will optimise her haemoglobin level before the procedure until at least more than 11g/dl. I will also make an early anaesthetic referral for risk assessment. Uterine artery embolisation prior to the procedure need to be considered. Procedure preferably done as elective case and perform by consultant obstetricians or trainee under supervision. Placenta mapping preprocedure can be useful to have an idea while performing the caesarean. Intraoperatively, early seek of help needed if uncontrollable bleeding. After delivery of placenta, careful inspection of the placenta bed needed to identify bleeding and multiple suture can be applied to secure the bleeding. If placenta is adherent, there is option to leave the placenta insitu and need further follow up and Methotrexate terapy. Neonatologist back up should be available. Post operatively, thromboprophylaxis need to be given.
Posted by drvimaladkm@yah K.
Dear Dr.Paul,
What exactly u mean by obstetric early warning chart?

Is it vitals & fresh bleeding per vaginum ?

Please reply,

Thanks,
VDKM
query Posted by sushma S.

 do we need to add  investigation in clinical assessment?