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MRCOG PART 2 SBAs and EMQs

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notes334
EMQ1478
SBA2084
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for marking please Posted by narmin B.
Evaluate the methods of controlling severe postpartum haemorrhage at caesarean section for placenta previa.



Post partum haemorrhage is one of the main causes of maternal mortality and morbidity. In the case of placenta previa massive bleeding can occur after removing of the placenta from the lower segment of the uterus. However there are various methods for controlling of this bleeding and each method has its own values.


One of the methods is the use of uterotonic agents. For instance intravenous syntocinone, ergometrine and intramyometrial haemabate can be used for this purpose. Since the main effect of these agents is on the smooth muscles of the uterus, they are not very effective in controlling the bleeding from the lower segment which contains small amount of smooth muscle. However these agents reduce bleeding from the upper parts of the uterus.

Another way for reducing blood loss is suturing the placental bed. As the haemorrhage is usually from the large vessels of the lower segment, a running suture for occluding these vessels may be helpful. But in practice it is not possible to stitch every bleeding vessel, and in the case of failure other methods should be considered.

Uterine artery embolisation is an effective method of controlling the haemorrhage. As a radiologist with an expertise in this technique is required; it is not practical in all circumstances. Also transferring of the patient can be difficult and time consuming. Compared with hysterectomy this procedure is less invasive and also the uterus can be preserved. Moreover, further pregnancies after this technique have been reported.

Another method which can be used effectively is bilateral hypogastric ligation. However many obstetricians are not familiar with this technique and a vascular surgeon may be needed to attend. Successful pregnancies have been seen after this operation. Yet the procedure can be difficult technically and cause complications such as bleeding and uretral damage.

Finally, hysterectomy is the last resort of controlling the haemorrhage. The decision for proceeding to this method should not be delayed as the patient may lose considerable amount of blood within a short period of time. Although it is highly effective but may have considerable psychological consequences. Also it can be associated with physical complications like damage to ureters and bladder.

Although there are different ways of controlling the bleeding at caesarean section for placenta previa but the choice of technique will depend on the surgeon?s skills, available facilities and also patient?s condition.