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MRCOG PART 2 SBAs and EMQs

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ESSAY 274 - APH

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		Posted by hoping .. Tue Aug 5, 2008 11:24 pm
A healthy 30 year old primigravida presents at 32 weeks gestation with a 3 hour history of abdominal pain and vaginal bleeding. (a) Justify your initial clinical assessment [7 marks]. Patient should be quickly assesed to determine amount of bleeding or any haemodynamic compromise.Whilst antepartum haemorrhage is common , severe bleeding is less common and is Obstetric emergency. If patient appears well, amount of bleeding should be asked as significant bleeding is more likely of placental origin where as smear of blood may be due to vaginal or cervical cause and mucusy blood may sugest threatned preterm labour. If abdominal pain is constant and severe abruption is major concern, intermittent pain may suggest contractions or irritable uterus. If patient is unwell then priority is to secure her airway and support ciculation with intravenous fluids. Information can be gathered from accompanying friend or relative. Her mid trimester scan report should be checked to check placental site. Her pulse and blood pressure should be monitored. Her skin and eyes should be checked for pallor. Abdomen examined for uterine tenderness. Woody hard and tender uterus suggests severe abruption. Palpable contractions raise possibility of preterm labour. Lower genital tract should be examined, visible blood at introitus or running down legs indicate severe bleeding. Vagina should be examined using speculum to look for any visible vaginal or cervical cause or blood seen coming through cervical os. This also facilitates rule out heavy blood stained liquor and obtain high vaginal swabs. Digital examintation should be deffered until low lying placenta has been ruled out unless indicated to rule out cord prolapse or advanced labour. Patient should be positioned left lateral and fetal heart rate assesd using CTG when maternal condition permits. Intravenous acess should be obtained and bloods sent for full blood count to determine haemoglobin and platelet count. Group and save requested as she may need transfusion or anti-D.If rhesus negative kleihauer should be sent to determine dose of anti-D. If major antepartum haemorhage is suspected blood should be crossmatched for atleast 4 units and clotting profile checked. (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. Ultrasound scanning is easily accesible investigation in most maternity units. Its main use is its high sensitivity for placental site localisation. Placenta praevia with any amount of bleeding needs close surveillance for remainder of pregnancy. Placental abruption is other serious diffrential but ultrasound is poor in confirming small retroplacental bleeds. It may show large bleed which would have been very likely picked up clinicaly and usualy indicates early intervention rather than further investigation to confirm. Ultrasound is not helpful in ruling out vasa praevia bleeding.Ultrasound is must investigation if fetal heart is inaudible with doppler to locate fetal heart or sadly to confirm fetal demise. Lower genital tract pathology is also difficult to diagnose on ultrasound . (c) The CTG shows late decelerations. Justify your management [8 marks Late decelerations are associated with increased risk of fetal hypoxia and acidosis. Late decelerations on there own categorise it as pathological CTG even if other variables are in normal range, however overall assesment of fetal heart adds more information to probailty of fetal distress. Shallow deceleration or deep and long lasting decelerations are more sinister. If maternal bleeding is controlled conservative measures with left lateral positioning and intravenous fluids may improve uteroplacental perfusion and imrove feal heart. If these fail to improve CTG over next 20 minutes or pattern deteriorates or mother continues to bleed preparations for delivery made. This should be conducted by senior most onsite Obstetrician and anaethetist. For severe bleeding or placenta praevia, consultant Obstetrician and anaesthist should attend as soon as possible. Haematologist should be informed of situation and cross match of minimum 6 units should be requested. Neonatal unit should be alerted and experienced paediatrician should attend delivery as baby will very likely require resusitation measures. Regional anaesthesia may be appropriate if platelets above 70 and normal coagulation parameters.Delivery would be by Caesarean section with patient\'s informed consent as is quickest method and preterm gestation. Unless patient is in advanced labour with lowlying placenta ruled out, then amniotomy may be appropriate. This may improve CTG and shorten duration of labour. Caesarean section should be done if early delivery unlikely with sucpicion of fetal distress as fetal blood sampling is not an option in view of prematurity. Postnatal oxytocin infusion should be commenced in view of increased risk of postpartum haemorrhage. If patient has had severe blood loss antepartum and during delivery she should be monitored in High dependancy unit postpartum until stable.Patient and birth partner should be debriefed of events at earliest possible opportunity and again before discharge. This imroves patient satisfaction and allows them to express feelings and seek answers. If mother wishes to breast feed baby she should be encouraged and supported for breastmilk expression to feed baby.
		Posted by rasiah B. Wed Aug 6, 2008 09:58 am
A healthy 30 year old primigravida presents at 32 weeks gestation with a 3 hour history of abdominal pain and vaginal bleeding. (a) Justify your initial clinical assessment [7 marks]. I would make sure she is alert and orientated, checking airway, breathing and circulation. I would take a history to localise the site, severity and nature of the pain, together with the amount of bleeding and duration. I would check that fetal movements had been present, exclude a history of intercourse and trauma and find out whether this patient had any medical problems. I would check if she is on any medications, if she has any affiliated urinary or bowel problems or if she has ruptured her membranes. I would find out her resus status, last haemoglobin level and placental localisation. I would check her blood pressure, heart rate and temperature and obtain iv access with a large bore cannula, obtaining blood for FBC, clotting, Group and save (crossmatch four units if obvious and active bleeding on pad), U&Es and LFTs. I would palpate her abdomen, checking to see if the abdomen felt rigid, tender and appropriate for dates. I would assess vaginally to see if the patient was in pre-term labour, or had broken her waters. I would obtain a CTG, to check fetal heart, liase with the senior midwife and anaesthetist and alert the neonatologist. I would consider the administration of antenatal corticosteroids in order to reduce the risk of respiratory distress syndrome (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. Ultrasound is easy to perform, cheap with few known contraindications. However, it requires a trained facilitator and adequate expertise together with familiarity with the equipment if available. It may not detect all pathology, and cannot be used to exclude an abruption. However, it can be used to localise the placentta and can identify obvious large abruptions. It can reassure the patient quickly that the fetus is viable, and quantify the fetal heart, showing the patient an active baby, if present, and also confirms presentation. (c) The CTG shows late decelerations. Justify your management [8 marks]. This patient warrents delivery. However, the mode of delivery is dependent on whether the patient is in pre-term labour, fetal presenation and dilatation. Abdominal palpation, vaginal examination and ultrasound is required to confirm the position, station and presentation of the fetus. CTG should be kept on throughout. If fully dilated with cephalic presentation, this patient may be suitable for a forceps delivery (not ventouse as under 37 weeks), with maternal effort. This may be done in the delivery suite room or in theatre. Fetal blood sampling is contraindicated in pre-term labour. If this patient is not fully dilated, she will warrent delivery by Caesaren section, which should be done through the lower segment. Blood should be crossmatched. Adequate analgesia is required-pudendal block is warrented for forceps and spinal anaesthesia for Caesarean section. Cord gases should be taken at the time of the delivery The neonatologists should be informed and present at the time of delivery, and the patietn should be debriefed after delivery. Breast milk should be expressed and the patient should be counselled on the risk of recurrence in the next pregnancy.
		Posted by Srivas P. Wed Aug 6, 2008 10:18 am
a) I would ask her about regularity of pains—whether intermittent or continuous, and if she had any leaking P/V prior to this, any prior episodes of bleeding. History of fall or direct hit to abdomen should be taken. Possibility of domestic violence should be kept in mind and history elicited judiciously and sensitively. Drug history especially Cocaine use can cause abruptio placenta. They may also be associated with preterm labor. I would check her antenatal record to see any prior USG has been done to localize placenta. I will take her pulse, B.P; Look for any external signs of injury. P/A will be done to see whether uterus soft or tense to look for signs of abruption. I will see if she has any palpable uterine contractions-its regularity, frequency and whether uterus relaxes in between. Tense, tender overdistended uterus with fundal height more than period of amenorrhea suggests a possible Abruptio placenta. Regularly contracting uterus with good relaxations may suggest a preterm labor with excessive show. Presenting part when well down into maternal pelvis suggests preterm labor while free floating or abnormal presentations suggests a placenta previa. CTG should be done to see if FHS is normal. Abnormalities in CTG are more often seen with abruptio placenta. I will do her P/S examination to see amount of bleeding and see if there are other lesions which could have caused bleeding including carcinoma cervix. I would do her P/V examination only after Placenta previa has been ruled out. (b) About 25-60% placenta praevias diagnosed by TA USG are reclassified by TV USG which is more accurate. Hence TV USG is advocated and is also safe to do with 88 % sensitivity in detecting suspected placenta previa. USG can also be useful to assess fetal well being, presentation and lie of the fetus. Abnormal CTG can give indirect evidence of abruption placenta though it lacks sensitivity in ruling out abruptio placenta though it may detect large retroplacental clots, but cannot be relied upon either to assess diagnosis or assess severity of abruption. USG may be useful to detect some lesions on cervix like carcinoma though it needs to be combined with direct P/S examination and biopsy to confirm diagnosis. (c) The presence of late decelerations signifies the fetus is in jeopardy and needs a quick delivery to save the fetus. Whether to deliver her vaginally or by C.S, depends on clinical assessments, cause of bleeding, if she is in labor and at what stage and whether she is likely to deliver quickly. Senior obstetrician should be involved in decision making and patient’s wishes should be taken and she should also be explained about risk of prematurity. If the USG shows a major degree of placenta previa, she should have C.S, as the fetus is in jeopardy even if she is not having significant bleeding. Such CTG decelerations could be due to bleeding from a vasa praevia. C.S is best done by a consultant after making arrangements for 4 units of blood by cross matching. If clinical examination suggests either threatened preterm labor or an abruptio placenta, P/V examination should be done. If cervix is fully dilated and presenting part well down and there is a possibility of hastening the vaginal delivery by Forceps, then it may be attempted. Vacuum delivery should be avoided in this preterm baby. If delivery does not seem possible within 30 mins, she should have C.S for fetal sake if mother is not collapsed and is fit for CS. When FHS is present she is unlikely to be major abruptio placenta with coagulopathy. Neonatlogists should be informed to make arrangements for managing the baby in the unit. If facilities don’t exist he should make arrangements for ex-utero transfer to units with facility to manage this premature and possibly a compromised baby after initial resuscitation and stabilization of the baby.
		Posted by Shachi M. Wed Aug 6, 2008 07:26 pm
A healthy 30 year old primigravida presents at 32 weeks gestation with a 3 hour history of abdominal pain and vaginal bleeding. (a) Justify your initial clinical assessment [7 marks]. (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. (c) The CTG shows late decelerations. Justify your management [8 marks]. (a) Justify your initial clinical assessment [7 marks]. The purpose of the initial assessment is to find if the patient needs resuscitation, to check fetal well being (once mum is stable) and to plan delivery if needed. After assessing consciousness, the patient’s pulse and blood pressure should be checked. Tachycardia with or without hypotension is an indicator of haemodynamic compromise. A brief history of the events in the current pregnancy should be taken. Once should ask if the patient is known to have any bleeding disorders and if she is on any anticoagulants which could be the cause of bleeding. It is important to know of she had placenta praevia (which could be the source of bleeding) on previous ultrasound scan. A history of cervical smears should be taken. Once the patient is stable, she should have abdominal examination to check if the uterus is soft or hard and to elicit tenderness if any. A woody hard tender uterus is seen in abruption. The baby’s lie and presentation should be checked to be able to plan mode of delivery if needed. A cardiotocograph (CTG) should be performed to assess fetal well being. After excluding placenta previa (high placenta on 20 week ultrasound scan or portable ultrasound on labour ward) a sterile speculum examination should be performed to assess the amount of bleeding, visualise the cervix (to rule out rare cervical cancer and to assess dilataion) and if possible visualise the site of bleeding (cervical lesion, vaginal laceration). If the cervix appears to be dilated a vaginal assessment should be performed to see if the patient is in labour. A full blood count (for haemoglobin and platelets) and clotting screen should be performed as disseminated intravascular coagulation (known complication of abruption and major haemorrhage) will result in deranged clotting screen. A group and save and kliehaur test should be performed to assess the need for anti-D administration in rhesus negative women. (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. An ultrasound is useful in diagnosing placenta praevia in a patient with antepartum haemorrhage. A transvaginal ultrasound is more accurate for this purpose. Placental abruption is suspected in this patient and ultrasound (USS) has limited role for diagnosing abruption. Blood may show up as hyper/iso/hypo echogenic areas depending on the age of bleed. It might not always be possible to visualise abruption on USS. Even if abruption is visualised on USS, it will not affect the management of patient which is guided by her haemodynamic state, tests of fetal well being and her gestational age. USS is of value in checking growth and liquor volume in patients with recurrent antepartum haemorrhage , to check placental position where it is not known and lie and presentation of baby. Justify your management [8 marks]. A pathological CTG (late decelerations) should prompt urgent delivery of the baby as there is risk of fetal hypoxia, long term morbidity and perinnatal mortality. The neonatologist should be present at delivery. Mum’s condition should be stabilised first by giving her fluids and if needed blood (O-negative if cross matched blood not available). A multidisciplinary team of senior obstetrician, anesthetist, labour ward co-ordinator and senior midwife should be involved in resuscitation. If the patient is fully dilated a vaginal instrumental delivery should be performed (after obtaining mum’s consent), the choice of instrument depending upon baby’s position and skills of the operator.If the delivery is not imminent the patient should be delivered by emergency caesarean section. The procedure should be explained to her and written consent obtained. Cross matched blood should be available at caesarean section. If the patient is still actively bleeding and platelet and clotting results are not available she should have general anaesthesia as opposed to regional anaesthesia for caesarean section. Cord blood gases should be performed after delivery of the baby. This patient is at a high risk of having postpartum haemorrhage and preventative measures (intravenous oxytocin bolus, oxytocin infusion, ergometrine) should be employed in line with local protocols. The patient and her partner should be debriefed after delivery of the baby. All the events should be accurately documented. Heparin thrombo-prophylaxis may be started postnatally for at least 5 days in high risk patients (major haemorrhage combined with emergency caesarean section, obesity). TED stockings, adequate hydration and early mobilisation may suffice in low risk cases.
		Posted by g.b. D. Thu Aug 7, 2008 12:00 am
GB. a) I will take the pulse, blood pressure and respiratory rate. I will look at the pad, and check the amount of blood loss. I will start oxygen by mask, make the bed flat to maintain circulation to vital organs. If the blood loss is heavy or patient is in shock, I will ask for help from senior midwife, obstetrician and anesthetist. I will pass two wide bore cannulas (18G) and collect blood for CBC, blood group and crossmatch 4 units, renal and liver func tests and coagulation profile. I will start infusion of crystalloids at 100 to 120 ml per hour with normal saline or Hartman’s solution. If she is bleeding continuously, then I will alert blood bank about the urgent need of blood. I will collect urine for proteins. High blood pressure, proteinuria indicate preeclampsia. I will check the antenatal record to see for any high risk factors like pregnancy-induced hypertension, the location of placenta and blood group and Rh status. I will palpate the abdomen to check for symphysio- fundal height and will check if the uterus is tense and tender. If there is relaxation in between the contractions with moderate bleeding, it may be due to preterm labour with excessive show. If the uterus is tense and tender, it points towards abruption. I will assess the fetal heart with sonic aids and start a continuous CTG. I will do a per speculum examination to check the amount of bleeding and status of cervix. I will perform a gentle PV to assess the bishop’s score. b) Ultrasound will be helpful to locate the placenta and rule out placenta previa. In case of abruption, the sensitivity of ultrasound to diagnose the retro placental clots or placental separation is very low and cannot rule out abruption. It can evaluate the fetal heart, weight and lie. It can be helpful to reassure the mother if the baby is active. c) If the maternal condition is critical (hypotensive/ shock), I will resuscitate her with blood transfusions. Life of mother has priority over fetus. If the mother is stable, I will check fetal presentation and Bishops score. If the patient has been in preterm labour, and she is fully dilated, with cephalic presentation, I will try for normal delivery. If normal delivery is not imminent, she will need delivery by caesarean section. Also if the fetus is in breech presentation, or if the cervix is undilated, which is quite likely at this gestation age in primigravida, she will need caesarean section. Patient should be informed about fetal condition and need for urgent delivery. Written informed consent should be taken. The OT team should be alerted, patient should be given sodium citrate orally, injection metoclopramide and ranitidine IV given before shifting to the operation theater. This is to reduce the risk of mendelson syndrome as she is most likely to receive GA. Neonatologist has to present at the time of delivery. After delivery, maternal debriefing of all the sequence of events should be done and documented clearly.
		Posted by Farina A. Thu Aug 7, 2008 01:28 am
a) Initially I would like to assess her vital signs (pulse, blood pressure, temperature, respiratory rate) her conscious level and the severity of pain she is having. It is important to know the type of pain weather constant or intermittent as constant pain is a sign of abruption. I would like to know about the amount of bleeding, and weather recurrent, and associated with a cause like a fall down, trauma or coitus. As recurrent, causeless and painless bleeding is usually a sign of placenta previa however placenta previa may bleed with contractions. While the bleeding associated with pain, fall down or trauma is usually associated with abruption. On examination a tense tender uterus with a state of shock and absent fetal heart sounds are a sign of abruption. While a relaxed uterus with high presenting part is usually a sign of placenta previa. A post coital episode may reveal a local cause at speculum examination. b) Ultrasound scanning is regarded as the main stay of diagnosis as it can readily differentiate between a normally sited placenta and placenta previa. Transvaginal US can reclassify about 20-30% of the low lying placetae and is safe with placenta previa. It is important to differentiate between the types of placentae as type 1 and type 2 can allow vaginal delivery. Grey scale US has limited role in the diagnosis of abruptio placentae however colour Doppler can increase the sensitivity. The diagnosis of abruption placentae is usually clinically correlated. c) Late decelerations are a sign of fetal distress urgent delivery is indicated. Once placenta previa is excluded vaginal examination can reveal the state of cervical os and the estimated time required for a vaginal delivery. If delivery is expected to be delayed and fetal scalp blood sampling is acidotic a category II CS is indicated. Informed consent should be taken. CS should be done by a senior obstetrician with a senior anaesthetist in the presence of fresh frozen plasma and whole blood. A regular estimate of clotting profile is indicated. Amount of retroplacental clots should be noted down carefully. Post operatively pt should be monitored carefully for signs of DIC and renal failure. If delivery can be expected to be soon and fetal PH is reassuring a trial of vaginal delivery can be considered. A consultant opinion should be taken before embarking upon the delivery. Pediatrician should be informed well before delivery, about the prematurity, the diagnosis and the fetal distress. Pt should be informed about the events as soon as possible.
		Posted by A P. Thu Aug 7, 2008 01:50 am
a.The history is consistent with antepartum haemorrhage –likely placental abruption with potential fetal-maternal morbidity and mortality if mismanaged. Initial assessment commences with a history of the onset, location and type of pain. Generalised, constant abdominal pain suggests abruption. Intermittent pain may also suggest preterm labour which occurs in 10% of abruptions.The quantity of vaginal bleeding is misleading as 20-35% of abruptions are concealed. Any previous admissions for vaginal bleeding are noted. Review of antenatal scans may reveal a low lying placenta, which is co-incident in 10% of the above presentation, or multiple pregnancy and may alter management. Examination of the abdomen may reveal a tense tender uterus or palpable contractions and difficulty in assessment of the lie/presentation of the fetus. A speculum examination is not usually performed if placenta praevia is suspected. Investigation includes a pulse and blood pressure to assess haemodynamic stability and may reveal hypertension. Once intravenous access is secured a full blood count, clotting and group and cross match is taken and sent to haematology. Rhesus status will determine need for anti-D. A kleihauer may be useful to assess fetomaternal haemorrhage but may be normal in the acute situation. A cardiotcograph is performed to assess fetal well-being and detect compromise. B Transabdominal scanning is of value if there is difficulty in assessing fetal viability and presentation in the presence of uterine hypertonicity. It may be uncomfortable for the patient. It may not reveal an abruption. Transvaginally it can assist in the safe and more accurate diagnosis of placenta praevia or cervical dilatation if already in labour. However, its use requires a trained operator. C.This constitutes fetal compromise and delivery must be expedited as there is an increased risk of fetal-maternal morbidity and mortality. Multidisciplinary approach requires consultant obstetric, anaesthetic, midwifery, haematology and neonatalology input. Special care baby unit is informed. Delivery is likely by caesarean section. The situation is explained to the patient and informed consent obtained outlining the benefits and risks of the procedure including blood transfusion and hysterectomy in the event of massive blood loss. Any objections to additional procedures are documented. The route of anesthesia is determined by the anaesthetist. Continuous fetal heart rate monitoring is employed. The neonatologist is present at delivery. Appropriate management of intra-operative bleeding is via fluid replacement, uterotonics, bimanual compression, packing of the uterus, B-lynch suture, internal iliac artery ligation or hysterectomy. Red cell salvage or recombinant activated factor 7a may be used in massive haemorrhage if available according to local protocol. Postpartum thromboprophylaxis is assessed. The events are explained to the patient and partner postoperatively. Postnatal review should be arranged with the consultant prior to discharge.
		Posted by Sam M. Thu Aug 7, 2008 04:14 am
Part a. Initial clinical assesment is based on history and examination .History of onset of pain, its nature ,localization ,radiation ,its aggravating and relieving factors will be asked.she will be asked whether she is having regular uterine contractions or having a constant abdominal pain signicant for placental abruption.History of onset and amount of blood loss will be taken.She will be asked that whether this bleeding was provoked because of a physical activity or not because pain less unprovoked bleeding are important for diagnosis placenta praevia. I will ask her about fetal movements as placental abruption and vasapraevia can cause fetal demise significantly .History of abdominal trauma will be taken.History of previous antepartum haemorrhages , investigations and treatment is importanat .She will be asked about raised blood pressure and /or protein uria in current pregnancy and treatment taken for that .History of dating scan and low lying placenta diagnosed on a scan done at at 18 to 20 gestation is important .Blood pressure ,pulse ,temperature and chest examination will be done to asses if she is haemodynamically stable or not .Resuscitation by securing 2 intravenous lines with wide bore cannula and haemaccel infusion should be started if unstable .Abdomen will be examined for tense tender or soft abdomen .Fundal height (which may be increased with placental abruption ),lie presentation and palpable uterine contractions will be assessed. I will do a cardiotocography for a fetal surveillance.After ruling out placenta previa on ultrasound Vaginal examination will only be done and Speculum examination for local pathology can also be done. Part b.Ultrasound will be done for fetal well being and placental localization. This will help in deciding mod of delivery as caesarean section for major degree placenta previa.But ultrasound is not reliable for diagnosis of placental abruption. Abdominal pain could be because of a degenerating fibroid, or ovarian cyst(previously asymptomatic) torsion or renal tract pathology and ultrasound can help in their diagnosis. Part c.A multidisciplinary approach is required involving anaesthetis,senior obstetrician,haematologist and neonatalogist. I will send FBC,blood group and Rh factor(if she is Rh D negative then she will be needed a anti D prophylaxis) cross match,clotting profile ,renal function test and urine for microscopy.Her intravenous line will be accessed (if not done previously) and intravenous fluids will be started.Haematologist will be informed and arrangements for blood transfusion will be done. It will be safe to have group specific ,cross matched blood but for obstetric emergency blood group rh D negative blood can be used if cross matched blood is not available.If diagnosis is placenta previa major degree then emergency caesarean section will be the choice .Informed consent will be taken from mother.For placental abrution ,I will do a vaginal examination to see whether vaginal delivery is imminent or not.If operative delivery is required for fetal distress then I will do a forcep delivery as vaccume delivery is contraindicated for premature fetuses. Otherwise emergency caesarean section for fetal distress will be done. And type of anesthesia will be discussed with anesthetist .If patient is haemodynamically stable and there is no coaggulopathy then regional anaesthesia is not contraindicated. Neonatologist will be requested to attend delivery as baby will be premature and also distressed.At this gestation lower segment will not be formed so a classical uterine incision might be required.Active management at the delivery of shoulders will reduce risk of PPH. Consent for hysterectomy because of placenta accrete or ,postpartum haemorrhages because of atonic uterus following abrution will also be taken.Regarding blood transfusion,there is no role of autologous blood transfusion but role of cell salvage therapy is there.All the events will be documented with time date and signature.
		Posted by Ephia Y. Thu Aug 7, 2008 01:28 pm
A healthy 30 year old primigravida presents at 32 weeks gestation with a 3 hour history of abdominal pain and vaginal bleeding. (a) Justify your initial clinical assessment [7 marks]. Airway, breathing and circulation will be assessed first and amount of bleeding assessed. All bleeding may not be revealed. General condition of the patient is noted. Blood pressure, pulse and oxygen saturations are checked. Amount of blood loss checked from pads patient is wearing and any active loss is noted. If patient is stable, history is taken about the onset of bleeding amount lost, any previous episodes of bleeding and any injury or trauma. History is taken about headache, visual disturbances like flashing lights, nausea, epigastric pain as placental abruption can occur in pre eclampsia. History of smoking and use of any drugs such as cocaine is taken and notes are checked for records and previous scans for placental localisation. Further examination is performed to look at fundal height which may be large for date in placental abruption. Tone and tenderness of the uterus is checked. The uterus may be hard and tender in case of abruption. Lie and presentation are checked but may be difficult if uterus is tonically contracted. A speculum examination is performed to look at the cervix, bleeding suggestive of heavy show, or ruptured membranes, presence of dilatation and any local source of bleeding such as from vagina or cervix. If placenta praevia is suspected, digital examination is avoided but in case of abruption, internal examination is performed to look for cervical dilatation. Fetal heart is auscultated and CTG commenced. If fetal heart not picked up ultrasound is used. (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. The role of ultrasound is limited in case of placental abruption which seems most likely from her symptoms. Most cases are missed in ultrasound. Clots resemble placenta and any active bleeding is assessed clinically with no added advantage of ultrasound. The only role of ultrasound in this case would be if the fetal heart cannot be heard or to confirm presentation. If the bleeding settles and there is no fetal compromise detected in CTG ultrasound has a role in further evaluation of fetal growth and wellbeing. Ultrasound is very useful in diagnosis of placenta praevia with very good sensitivity and specificity and low false negatives of about 2%. Transvaginal sonography is superior to abdominal scan and is safe in the presence of placenta praevia. Ultrasound also will not pick up vasa praevia or causes from lower genital tract. (c) The CTG shows late decelerations. Justify your management [8 marks]. Persistent late decelerations in CTG are a sign of fetal hypoxia. Significant bleeding would have occurred if there are signs of fetal hypoxia. Cause of APH is most likely to be placental abruption. Arrangements should be made for delivery. IV access is secured and she may need infusion of fluids if bleeding heavily. Blood is sent for grouping and cross matching and rhesus status if not known. Full blood count for haemoglobin, platelet count, coagulation profile and FDP due to risk of coagulopathy and DIC are performed urgently. Urea and electrolytes and liver function tests are performed. The consultant obstetrician, anesthetist, paediatrician, senior midwife are informed. The haematologist may need to be involved in case of heavy bleeding or coagulopathy. Availability of bed in special care baby unit checked and if unavailable, ex-utero transfer will be required. The risks to fetus, need for delivery and risks of prematurity are explained to the patient. There would be no time for steroids to enhance lung maturity. If the cervix is not fully dilated, caesarean section would be indicated. Patient is consented, risk of PPH and possibility of requiring hysterectomy if all other measured for controlling PPH fails are discussed. At 32 weeks the lower segment may not be well formed and may need extension of incision to the upper segment. If the patient’s condition is not stable general anaesthetic will be required. If stable, no prolonged fetal bradycardia and in the absence of coagulopathy, regional anaesthesia is not contra indicated. A lateral tilt is ensured to improve circulation and preloading in case of regional anesthesia. If cervix is fully dilated, vaginal delivery can be allowed. Ventouse is not preferred due to prematurity but forceps may be used if needed and criteria fulfilled. Paediatrician is present during delivery. Ante partum haemorrhage due to abruption carries risk of post partum haemorrhage and DIC . Uterine contraction is ensured with oxytocin, ergometrine if not contraindicated (pre eclampsia), carboprost and misoprostol. Blood transfusion , FFP, cryoprecipitate may be required. After delivery, the patient is monitored in the high dependency unit in labour ward post delivery. Risk factors for thromboprophylaxis checked. Detailed documentation carried out and the patient is debriefed. Risk of recurrence in a subsequent pregnancy is discussed if a cause is identified such as drug use and pre eclampsia. However most cases of abruption have no identifiable cause
		Posted by Hadia K. Thu Aug 7, 2008 03:00 pm
A- Rapid history is taken to assess amount of blood loss. We enquire from the patient whether she is hypertensive and if she had any medical problem during her antenatal period like the presence of low lying placenta or the need for Thromboprophylaxis. General examination is done to assess level of consciousness and degree of pallor. The patient may be normotensive despite losing significant amount of blood because she may be hypertensive originally but the presence of tachycardia and low volume pulse can be correlated with degree of hypovoleamia. Abdominal examination is done to see the fundal level, if it is more than 32 weeks gestation, it can reflect significant retroplacental heamorrhage. We also look for other signs of abruption like presence of tense uterus with difficulty in feeling fetal part or presentation. Fetal heart may be negative but if positive we try to do CTG to assess fetal wellbeing. Pelvic speculum examination is done to assess amount of blood coming per viginum , also to confirm that blood is coming out from the uterus and not from cervical lesions or vaginal tears. Cervical dilatation and effacement can be assessed also. Digital examination is done if placenta previa is excluded to assess the presenting part and its station. B- Ultrasound is helpful in determining placental site, it can exclude low lying placenta or placenta previa in its different grades. However, it has low sensitivity and specificity in detecting placental separation or retroplacental heamorrhage unless it is very significant. It can determine also fetal viability, lie and presenting part to help making a plan of delivery. Doppler US of umbilical blood vessels can reflect fetal well being. Presence of reversed end diastolic flow or high resistance index can reflect impending fetal demise. C- Late deceleration is a sign of fetal distress. Management includes maternal resuscitation with arrangement for prompt delivery. We call for help of Multidisplinary team including senior obstetrician, senior anaesthetist , pediatrician and expert midwife, also we inform SCBU and blood bank staff about this emergency situation. We send for FBC, coagulation profile and serum fibrinogen. We prepare cross matched blood meanwhile insert wide pore iv cannulae and start iv fluid; crystalloid infusion . If bleeding is significant , we can transfuse ORH-ve blood till her cross matched blood is available. If there is cervical dilatation and presenting part is feasible, we can do FBS to confirm fetal hypoxia and acidosis. If cervix is fully dilated with the fetus is cephalic presentation and vaginal delivery is imminent, we allow for her to proceed for vaginal delivery. Forceps can be used to accelerated second stage of labour and protect fetal head from sudden decompression while passing through birth canal, but if vaginal delivery is not imminent, we arrange for emergency C/S after taking informed consent from the patient and her family and notify theatre staff. Regional anesthesia is not contraindicated as far as adequate preloading is done unless there is evidence of DIC, regional anaesthesia can cause epidural heamatoma. Cord blood sample is taken for blood gas analysis and PH measurement. Meticulous haemostasis is done and patient kept on oxytocin infusion as there is increased risk of developing postpartum heamorrhage particularly if the patient has covellaire\' uterus. Syntometrin is given if the patient is not hypertensive. Clear documentation of sequence of events, time of occurrence and name of personnel who take part in the management is done carefully. Debriefing and psychological support is offered later on.
		Posted by J P. Thu Aug 7, 2008 06:59 pm
A. This is the case of antepartum haemorrhage which is an important cause of maternal and fetal morbidity and mortality if not treated urgently. If the patient is clinically stable I will enquire about duration ,amount of bleeding [spotting or passing clots],any previous history of bleeding after 28 weeks to suggest of placenta previa and if any present review of previous records including ultrasound pelvis for localization of placenta.History of nature of pain whether constant or intermittent will be elicited.I will ask for any history of trauma preceeding bleeding and medicl history like PIH in this pregnancy which may predispose to abruptio placenta.Perception of fetal movements by mother will also be enquired for fetal well being though it has a low sensitivity to detect it. I will carefully assess her airway , breathing circulation and provide facial oxygen.Her vitals like pulse ,BP will be recorded to look for any signs of shock.BP may be also raised in cases of abruption with PIH.Venous access will be obtained by two 14 gauge needles and blood will be sent for full blood count, clotting profile,group and save serum for the need of transfusion,urea and electrolytes and liver function test for base line assessment. Obstetric examination would include assessment of gestational age and consistency of uterus.A woody hard uterus with tense and tenderness will suggest abruption.FH will be localized by Doppler since localization of FH by fetoscope may be difficult. Gentle speculum examination will be done to note the amount of bleeding and any local causes of genital tract..If placenta previa is ruled out by ultrasound pervaginal examination will be done to note the nature of the cervix,bishop’s score to decide on the mode of the delivery.Any bleeding from the venepuncture sides will also be noted for the possibility of DIC.CTG will be done for fetal assessment. B.Ultrasound abdomen is reliable detecting placenta previa by eight months of gestation. TVS has a better sensitivity than TAS in detection of placenta previa.Ultrasound is essential in placenta previa in deciding the mode of delivery.If placenta is seen within two centimeters of internal os,it is major placenta previa and caesarean section will be decided.Vaginal delivery can be allowed if placental margin is more than three centimeters from internal os.Abruptio placenta cannot be excluded by ultrasound.Abruptio and placenta previa can co-exist in ten percent of cases. Ultrasound is also needed for assessment of FH, liquor volume and major congenital anomalies to decide on the nature of the delivery. C.Late fetal decelerations which are persistent is a indication of delivery.Fetal blood sampling will be done if the patient is an active phase of labour and if thePH is less than 7.2 is a definite indication for delivery.The mode of delivery depends on the cause of APH and the nature of cervix.Aiming delivery with simultaneous resuscitation is the goal.In case of abruption placenta,vaginal delivery will be aimed if eminent delivery is possible.Forceps delivery may be attempted.Cessarian section will be the option if cervix is not favourable.Neonatologist will be informed and also the SCBU.If facilities are not available for neonatal management ex-utero transfer will be arranged.Anaesthesia will be discussed with anaesthetist in case of DIC.If major placenta previa is detected,caessarian section is the mode of delivery.In minor cases if delivery is emminent,forceps delivery can be attempted.There is a risk of Post Partum Haemorhage hence 4 to 6 units of blood to be cross matched and discussed with the hematologist and lab in case of DIC.Need for thrombo prophylaxis to be assessed.Anti-D to be given in case of RH negative mother.Attenders and the patient will be debriefed of the events.Incident form will be filled.
		Posted by H P. Thu Aug 7, 2008 07:59 pm
(a)I will assess her pulse, blood pressure, degree of pallor and check her pads/ clothes for amount of bleeding. If there is tachycardia or hypotension with pallor I would immediately call for help and start resuscitation. If she is haemodynamically stable, I will take history regarding the onset and amount of bleeding. Prior history of similar episodes may suggest placenta previa (PP) or local causes. Profuse bleeding may occur as a first episode in PP or in abruption. Although PP is usually present with painless bleeding, preterm labour may occur. Spotting may be due to local causes or following coitus. A history of trauma to the abdomen may suggest abruption. I will ask her if she experienced any leaking as abruption may follow rupture of membranes (ROM) or it may be a cause for preterm labour. I would ask her whether pain is constant or intermittent. I would do a per abdomen examination to palpate for uterine size, fetal presentation and contractions. I would check fetal heart as fetal distress can follow abruption or vasa previa. A woody hard, tender and non relaxing uterus points to abruption while regular contractions with intermittent relaxation suggest preterm labour. High presenting part may be due to low lying placenta. Symphysiofundal height may be less than gestation if she has gestational hypertension which is likely to be associated with abruption though BP may be normal. Pedal edema is checked. After explaining her, I would do per speculum examination to rule out any local cause. It will also reveal the amount of bleeding, leaking if present and presenting part, if low down. After confirming fundal placenta from labour notes or portable ultrasound, I will do a vaginal examination to rule out active labour in case of abruption or preterm labour or cord prolapse following ROM. If delivery is imminent or bleeding uncontrolled, neonatologist and NICU need to be informed. (b) In view of her symptoms of antepartum haemorrhage, ultrasound helps to rule out placenta previa. USG has very high sensitivity for placental localization especially by transvaginal route. USG has very low sensitivity for detecting small retroplacental bleeds or early abruption as concealed blood may be iso-echogenic in immediate period. It can detect abruption when more than 50% of placental surface area is separated. However, clinical signs of fetal distress/demise with maternal shock are more helpful. If the cause is local, it has very low sensitivity. Also it cannot rule out vasa previa. In her case, USG will help to confirm the fetal presentation and fetal heart if it is not detectable by CTG, which would aid in mode of delivery. A higher placental grading (grade 3/ 4 at 30 weeks) with a growth retarded fetus on USG may suggest prior pre-eclampsia even with low/ normal BP. (c)Patient is put in left lateral position. Senior mid wife, obstetrician, anesthetist and porters are called and neonatologist informed. If the mother is in hemorrhagic shock, oxygen started, venous access is secured and blood sent for complete blood count, grouping and cross match 4-6 units, and coagulation profile. Intravenous fluids are started. This may improve fetal heart rate. Hematologist is involved for management of major haemorrhage. Placental localization is confirmed from previous notes or by portable ultrasound and PP ruled out. Vaginal examination is done to assess cervix and rule out cord prolapse if ROM. Consultant obstetrician should take decision. If the delivery is imminent, amniotomy may help. Persistent bleeding and/or fetal distress in abruption or placenta previa or cord prolapse will need urgent caesarean section. Theatre and neonatal unit is informed. Informed written consent is taken from the patient regarding the surgery, complications like haemorrhage requiring transfusion or hysterectomy and prematurity of the baby. She is informed that baby may need NICU admission and may be transferred if NICU not available. Senior theatre staff needs to be present. If the mother is in shock or clotting defects present general anesthesia may be needed. Postpartum, she is transferred to HDU for 1:1 care. Along with vitals, urine output is monitored hourly as she is at risk of acute renal failure. Physician may be consulted to maintain adequate fluid balance. Blood results are monitored 6-12 hourly as she has high risk for disseminated intravascular coagulation. Coagulation defects are corrected at earliest in liaison with hematologist. TED stockings are given. LMWH is started if coagulation profile normal. Detailed debriefing of the patient and partner is done in the postpartum period.
		Posted by Asma kamal K. Thu Aug 7, 2008 10:30 pm
Abruptio placentae is the most probable and important cause for her symptoms.This is an obstetric emergency associated with feto-maternal morbidity and mortality. I will call for help (SHO,nurses,midwife,senior obstetrician and porter) and inform senior hematologist,laboratory, operation theater, ITU, NICU staff about the emergency. Urgent assessment of the patient conciousness level, airway,breathing and circulation(pulse,B.P,oxygen saturation) will be done and resuscitation if required will be instituted(oxygen,i.v fluids).Two 14 gauge cannula will be passed and blood send for grouping and cross matching (4-6 units blood),FBC, clotting profile,U & E. If the patient is stable than I will ask her about the amount of blood flow, passage of clots, any change in the flow and its exact association with abdominal pain. To find out whether she is in labour (50% with abruptio placentae go into labour) i will ask about the nature of pain(intermittent or continuous) . To look for the cause of the problem I will ask her about any history of blunt trauma to the abdomen(abruption), number of fetuses, polyhydramions, smoking (all associated with abruption). Absence of provoking event and previous episodes of vaginal bleeding will highly suggest placenta previa. If possible I will review her antenatal record(ultrasound) to look for the placental localization as 10% of abruption is associated with placenta previa and vise versa. On abdominal examination I will look for the fundal height whether corresponding to gestational age or not , lie , presentation, engagement of presenting part (engaged presenting part will rule out major placenta previa), uterine contraction, tenderness or hardness(positive in abruption) and take fetal heart rate. A gental sterile speculum examination will be done to rule out local genital tract causes, assess amount of bleeding and if possible cervical length and dilatation. (b) The role of ultrasound in this case is very important. With the help of transabdominal ultrasound we can easily exclude an anterior placenta preavia and large retroplacental abruption. It will also confirm viability of the pregnancy and presentation. Transabdominal ultrasound to diagnose posterior placenta previa, and small abruption or abruption in posterior palcenta is not very effective. Transvaginal ultrasound is more helpful in diagnosing posterior placenta ptrevia. Ultrasound examation is cheap, easily available(portable machienes) but operator dependent with inter and intra observer difference, lack reproducibility, training and good quality machines(cost implications) (C)Late deceleration on CTG with materal antepartum hemorrhage is an indication for emergency delivery of the baby. The safest mode of delivery for the baby and the mother if bleeding profusely will be by caesarean section. The situation will be explained to the patient and the partner along with its inherent risk to the mother(PPH, DIC, renal failure, risk of massive blood transfusion) and the baby(prematurity, hypoxic injury,mortality). Management option(LSCS) need and associated risk(uterine incision,G.A) will be explained along with the possibility of added procedure in case of severe hemorrhage like B-lynch suture,uterine artery liagation/embolisation and hysterectomy discussed. An informed consent will be obtained. Patient will be transferred to operation theater with 4 unit of blood in hand(transfusion started if clinically needed), senior obstetrician , senior anesthetist and peadiatrician called. She will be operated by the senior obstetrician with upper segment incision as at this gestation lower segment is not well formed. Early and timely decision regarding B-lynch suture , internal iliac ligation or hysterectomy will be done. Blood transfusion and if required correction of caogulopathy will be corrected in consultation with the hematologist.Patient will be monitored in the ITU for 24-48 hours postoperatively. The patient and the partener will be debriefed at the earliest. Incident form will be filled and proper documentation will be done.
		Posted by Drxyz A. Fri Aug 8, 2008 06:42 am
DRXYZ a) Patient will be assessed by taking pulse and blood pressure. In case of hypovolumia the pulse will be high and blood pressure will be low. IV line will be secured. Bleeding will be assessed by checking her pad and clothing. Vaginal examination will not be done until placenta previa is excluded. If patient is hypovolumic the IV fluids like crystalloids will be started. Call for help from Senior midwife, anaesthetist to stabilize the patient. Patient will examined for symphyseofundal height, tenderness of the abdomen and palpation of the fetal parts and fetal heat rate will be noted. Blood will be taken for group and save, CBC, Clotting factor, U&E, cross-matching in case patient is severely bleeding she will be transfused. After stabilising the patient\'s condition history about amount of bleeding, provoked by coitus or abdominal trauma previous episode of bleeding, previous hospitalization and previous Ultrasonography done will be asked. After excluding placenta previa per speculum examination will be done to exclude the local cause of bleeding. Her condition will be explained to her and her partner. b) If the patient is severely bleeding, aim is to stabilize the patient before doing any investigation. If patient is stable or mild bleeding, Ultrasonography will be done to locate the site of placenta and separation of placenta. If there is acute abruption USG is not helpful as blood clot gives same echogenecity as placental tissue. so the abruption can be missed. If the placenta is posterior difficult to assess the placental abruption. Transvaginal USG is better than abdominal in detecting abruption of the placenta. If there is retro-placental clot, ultrasound can be repeated to see the increase in size of abruption with the condition that the mother and fetus are stable. with Transvaginal ultrasound placenta previa can be graded better than abdominal USG. Still posterior placenta previa can be difficult to be identified even with the transvaginal USG. The experience of the ultrasongrapher greatly influences the finding of the USG in such case. The ultrasound will also give biophysical profile and umbilical artery Doppler and biometry. c) As patient is 32 gestational age with APH (abruption placentae) and late deceleration on CTG showing that fetus is compromised. At this gestational age with such CTG best mode of delivery is caesarean section. Vaginal delivery cannot be done because this baby cannot tolerate the stress of labour and risk of hypoxia will be increased with subsequent morbidity and mortality. Blood should be available for transfusion as there is risk of PPH. Senior obstetrician, Senior anaesthetist, Senior neonatologist and senior nursing staff should be present in operation theatre. Senior anaesthetist will decide the mode of anaesthesia according to the condition of the patient. If clotting profile is disturbed, regional anaesthesia will not be given. Since the baby is preterm and there is risk of PPH so the senior obstetrician should attend the patient. Senior neonatologist is required to take care of premature baby. The patient and partner will be explained about the risks to the fetus and mother. Informed consent will be taken. After caesarean section written information will be given to the patient and partner. The data will be collected for audit.
		Posted by Simona C. Fri Aug 8, 2008 05:54 pm
(a) Justify your initial clinical assessment [7 marks]. Antepartum haemorrhage (APH) is an obstetric emergency and therefore has to be treated as such. Eventually, the management of such a patient (pt) will depend upon her haemodynamic status. If the pt is in haemorrhagic shock, after initial resuscitation and stabilization, delivery, usually by emergency caesarean section, will be undertaken. If the patient is haemodynamically stable then further steps in the initial assessment can be taken. The patient will have to be admitted to the delivery suite (DS) where close monitoring by senior staff can take place. Call for help and summon the DS coordinator or a senior midwife (MW), the senior house officer (SHO) and the senior anaesthetist. Inform consultants obstetrician and anaesthetist, alert porters and haematologists of the possible need of urgent blood requirements. Initial assessment will include monitoring of blood pressure (BP), pulse (P), oxygen saturation (Sats O2) to ensure that the patient is haemodynamically stable. Secure double iv access with large bore cannulae for iv crystalloids to be commenced, and to take blood for urgent full blood count (FBC) to check Hb levels, platelet and haematocrit, serum group and save (G&S) for Rhesus status and abnormal antibodies, cross match at least 4 units of blood, clotting profile. If pallor, tachycardia and/or hypotension then blood transfusion should be started immediately with O Rhesus D negative blood while waiting the cross-matched blood. Take a brief history on onset of symptoms, if spontaneous or secondary to a traumatic event, if pain mild or severe, if continuous or intermittent. Ask the estimate blood loss prior to arrival to hospital. Ask if recent fetal movements have been felt. Palpate abdomen for uterine tone, tenderness, irritability and for fetal presentation. Speculum examination to assess if cervical dilation or any presenting part in case of rupture of membranes. Check any previous scan to exclude placenta praevia and if not, perform vaginal examination to assess cervical effacement and dilatation. Commence electronic fetal monitoring to assess fetal wellbeing and inform neonatologist and ask to review. Finally, if delivery is not imminent, prophylactic maternal steroids for fetal lung maturity would be recommended. (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. If available in DS, ultrasound (USS) would allow a quick assessment of fetal viability and presentation, placental localization and amount of amniotic fluid. This are fairly simple and quick investigations that however require the operator to have at least basic training in USS. A more detailed assessment, including fetal growth and umbilical artery Doppler study, may require a departmental USS, which however cannot always be performed on request, especially in emergency situations. Furthermore, USS will not allow to establish a diagnosis of placental abruption as visualization of retroplacental clots may be extremely difficult. However, confirmation of fetal viability and of a normal fetal heart rate would relieve the anxiety of both the parents and the obstetric team. (c) The CTG shows late decelerations. Justify your management [8 marks]. Presence of decelerations indicates fetal distress and possible hypoxia and therefore the need to expedite delivery. Often in cases of APH vaginal delivery can be achieved easily and within an acceptable period of time, however this may not be the case for this pt as she is on her 1st pregnancy at 32 weeks gestation. Perform vaginal examination to assess cervical effacement and dilatation. If cervix (cx) favourable and delivery thought to be imminent, perform ARM to assess presence of meconium stained liquor and to expedite delivery. If cx unfavourable, decision for emergency caesarean section (EmLSCS) has to be made. Address pt/couple and explain the need of perform an EmLSCS in view of the suspected fetal compromise. Inform DS coordinator and anaesthetist of the decision so that the patient can be quickly transferred to theatre and anaesthesia (general anaesthesia may be required in case of pathological trace requiring delivery within 30 minutes from decision) can be promptly started. Obtain informed consent form and prepare the patient for theatre with im ranithidine and metoclopramide. Senior paediatrician to be present at delivery as fetal resuscitation may be required in view of both prematurity and possible fetal compromise. Perform fetal blood gases to assess fetal acidosis and perform close inspection of the placenta for presence of retroplacental clots. Uterine atony and consequent post partum haemorrhage are likely to occur. Ensure cross-matched blood is readily available. Minimize intra- and post-operative blood loss and ensure good uterine tone by mean of oxytocin (5 IU bolus after delivery of baby and 40IU infusion to be commenced during procedure). If needed, administer carboprost 500mcg intramyometrium (inform anaestesist, as this may cause increase of BP and nausea and vomit if pt awake). If bleeding continues despite all this measure, ask the Consultant to attend theatre as senior imput may be required and further measures may need to be taken. Post operatively ensure detailed documentation of events in patient notes, including detailed operative notes. Complete incident form for APH >1500mls. Arrange close monitoring of the patient (BP, blood loss, urinary output), check FBC and clotting initially every 6 hrs, or more often if required by situation. Prevent thrombo embolic accidents by use of TEDs stockings, administration of Clexan (40mg subcut daily), maintain good hydration and encourage early mobilization. Pt to leave DS only when completely recovered and stable. Debrief patient and relative of events. Arrange 6 weeks follow-up. Discharge letter to GP with datailed description of events.
		Posted by Vaishali Sriniv J. Fri Aug 8, 2008 06:00 pm
a)I will take detailed history of the patient. I will note down her LMP. I will ask her if she had any episode of bleeding before in same pregnancy as it may indicate placenta previa. I will try to assess the amount of bleeding by asking her the number of soaked pads. She should be asked about the nature of abdominal pain , whether it is intermittent or continuous. Intermittent abdominal pain associated with hardening of uterus is suggestive of preterm labour. Sustained abdominal pain is more suggestive of abruption. I will ask her about any history of fall, trauma to abdomen or sexual intercourse before starting of pain in abdomen. I will go through her records to note any evidence of low lying placenta on ultrasound examination . I will also look for evidence of PIH and note her haemoblobin level in her antenatal records. I will check her pulse , BP, and respiration. Tachycardia and hypotension will be suggestive of hypovolemic shock. I will look for pallor, oedema over feet. On per abdominal examination intermittent hardening of uterus with relaxation in between is suggestive of preterm labour. Tense uterus with localised tenderness is suggestive of abruption plancenta. Per speculum examination should be carried out to confirm that bleeding is through os. I will look for cervical polyp, Cervical or vaginal growth, vulval varicosities, cervical erosion as it may also cause P/V bleeding. Per vaginal examination should not be done till placenta previa is ruled out. b) Ultrasound scan should be carried out to see location of placenta. Transvaginal ultrasound is more sensitive in dignosing placenta previa than trans abdominal ultrasound. By transvaginal scan it is possible to differentiate between major placenta previa and minor placenta previa. It is possible to measure the distance of lower edge of placenta from os which will help in planning mode of delivery. Ulrasound scan is useful to judge fetal wellbeing. Ultrasound scan is not sensitive in diagnosing abruptio plancenta. It is noninvasive, cheap ,safe , easily available and useful in diagnosing placenta previa c)Patient should be managed by multidisciplinary system consisting of consultant obstetrician, consultant anaesthetist, neonatologist , haematologist and experienced midwife. Wide bore I/V canula should be put and blood should be sent for complete blood count, coagulation profile, liver function tests and blood for grouping and crossmatching. Neonatologist should be informed. Mother should be given left lateral position and I/V fluids. In evidence of heavy bleeding patient should be given blood transfusion. Evidence of late decelerations on CTG indicate fetal hypoxia so patient needs to be delivered. Mode of delivery will depend upon the diagnosis, condition of the mother and condition of the baby. If patient is diagnosed to have placenta previa and is bleeding heavily then immediate delivery by caesarean section is indicated. Patient should be counselled about need for blood transfusion, PPH, adherent placenta , hysterectomy and prematurity of the baby and informed consent should be taken. Caesarean section should be performed by consultant. If patient is suspected to have abruption, is haemodynamically stable and is in preterm labour with immediate delivery eminent then she can be subjected to vaginal delivery. But if immediate delivery is not eminent then caesarean section should be performed.
		Posted by areeba F. Sat Aug 9, 2008 01:49 pm
Differential diagnosis in this case would be either placental abruption,placenta previa or preterm labour. Initial assessment would include a quick history regarding LMP,to ascertain gestational age,amount of bleeding.anyprevious episodes of bleeding. passage of fluids.Precipitating factors fer bleeding such as trauma or coitus,fetal movements,smoking /cocaine use-as placenta previa and abruptio are common in case of smoking and cocaine use. Vital signs-pulse ,BP and temp are taken.Abdominal examination for size,tederness-tense tender abdomen is found in case of abruption.Presentation and any palpable uterine contractions are noted.Vaginal examination is defferred until placental localisation is done.external bleeding is assessed. If the pt is bleeding severely,prompt resuscitation should be undertaken.Two wide bore canulae are inserted and iv fluids started.Blood taken for FBC,group and save.4units of blood should be cross matched. Cotting profile done-as in cases of abruption clotting factors are deranged.Kleihauser test if the patient is known to be Rh negative.Oxygen given by face mask. Initially crystalloids are given and blood is replaced as soon as cross matched blood is available .Hematologist should be contacted and urgency and requirement of blood should be informed. b)USS is very useful in placental localisation.posterorly placed placenta previa is slightly diffult to localise by TAS and may require TVS.Placental abruption ,if acute are difficult to see as the echogenicity would be same as placenta.Fetal well being can be assessed,but oligohydramnios will not be recognised,unless a large amount of liqour has passed out. c)CTG with deep decelarations in this situation be highly indicative of fetal compromise and warrants urgent delivery.SCBU should be informed and arrangements made.Senior obstetrician, anesthetist and neonatologist informed.Parents should be counselled about the necessity of delivery and the neonatologist can explain prognosis for the baby.This will help alleviate parents anxiety to a large extent. Parents should also be counselled about the risk of intrapartm bleeding and PPH which may necissitate hysterectomy,Written consent is obtained. Mode of delivery would depend upon presenting part and cervical dilatation.If placenta previa has been ruled out vaginal examination is done to assess cervical dilatation.If the cervix is fully dilated and head is low,vaginal delivery can be expedited by forceps.Ventouse would be contraindicated as gestation age <34wks.Caesarian section would be done by senior obstetrician under general or regional anesthesia,as decided by the anesthetist.Baby should be delivered quickly.cord blood is taken for blood gas analysis.oxytocin infusion should be continued post partum as there is risk of PPH,Patient should be closely monitored in HDU.Foley catheter inserted and input and out chart maintained to prevent pulmonary edema and check renal function.Blood tests repeated for Hb and clotting factors and any deficiencies corrected by blood transfusion,platelets. FFP or cryoprecipitate may be required if evidence of DIC.Breast feeding is encouraged.
		Posted by Farkhanda A. Sat Aug 9, 2008 06:50 pm
This is a case of ante partum haemorrhage (APH) which occurs in about 1% of pregnant women. However , mild bleed in antenatal period is relatively more common. This is an obstetrics emergency and pregnant lady needs to be assessed quickly to see if she is haemodynaemically stable or compromised. I will ask the woman if she is well to answer or accomanyinging patner or relative. About abdominal pain I will enquire ,if it is constant as in placental abruption or intermittent to rule out contraction or irritable uterus. If bleeding is moderate, I will ask help from senior house officer and mid wife for Intravenous access and to compensate bleeding by starting fluids to keep her stable. If cause of bleeding is cervix or vagina, bleeding more probably will be mild. I will examine her by checking her blood pressure (may be very low) or pulse which may be tachycardiac as a sign of compromise due to bleeding. In abdominal examination I will look for any tenderness and it may be woody hard if it is placental abruption. I will note any intermittent uterine contractions to exclude or rule out preterm labour. Bleeding due to placenta praevia is painless and usually there is a history of recurrent bleed and mother is already aware of it. I will ask the midwife to commence cardiotocogram (CTG). T o assess the bleeding severity, I will check any pad which she is wearing ,if it is fully soaked or not. I will do speculum examination to see if blood is pouring from the cervix , then it may be placental abruption or placenta praevia. If it is mucousy and mixed with liquor, then it may be show and she may be in labour. If not proper bleeding but blood stained discharge, this may be due to extensive cervical ectropion or may be some infection including sexual ly transmitted such as trachomatus vaginalis. I will avoid bimanual examination unless mid treimester ultrasound had excluded low lying placenta. B Ultrasound (USS) has an evolutionary role in obstetrics but still it has some limitations in certain aspects. It has high sensitivity in localisation of placenta by per abdominal prob and transvaginal route. As far as placenta praevia is concerned, it can be easily excluded. USS is not very reliable to confirm or exclude placental abruption which is not very big or it has also not very important role in case of vasa praevia that can be a cause of bleeding, but only on artificial rupture of membranes. In a massive abruption to some extent it is helpful. Placental abruption can be diagnosed clinically with more confidence only if placenta pravia is excluded by USS already. C CTG shows deep decelerations. This is pathological pattern which is due to foetal hypoxia and acidosis. Put the patient in left lateral position to release the autocaval compression. I will access IV route by wide bore grey cannula, take bloods for full blood count (FBC) group and cross match at least 4 units, clotting profile. Urea and electrolytes, and liver function test. I will give oxygen by mask. These measures may improve deep decelerations. I will involve obstetrics consultant, warn special care baby unit (SCBU), and anaesthetist. If her bleeding settled and cervix is favourable and placenta praevia is excluded, I will do amniotomy. This will shorten her labour and she will have vaginal delivery. However vaginal delivery is not the main aim. At 32 weeks, when baby is already compromised, caesarean section is the better option. While during preparation of caesarean section, if there is chance giver her at least one dose of steroid betamethasone 12 mg intra muscular. Neonatologist should be present at the time of delivery. There is high risk of post partal haemorrhage, so while during taking written consent, it should be mentioned about possibility of caesarean hysterectomy in case if bleeding is not controlled . Oxytocin infusion of 40 units in 500ml of normal saline must be ready at the time of caesarean section to contract the uterus and blood must be in hand. Type of anaesthesia depend on platelet count, wish of the patient and decision of anaesthetist . I will start thromboprophylaxis after discussing with anaesthetist and mid wife to wear her deterrent stockings. For first 24-48 hours I will ask the staff to keep her in delivery suite high dependence unit. I will explain all events retrospectively to her and her partner. I will ask to check her haemoglobin on 2nd or 3rd day. She will be encouraged for breast feeding or milk extraction if baby ( most probably) is in SCBU. Before discharge , I will discuss contraception also.
		Posted by SK K. Sun Aug 10, 2008 03:58 am
My first priority will be confirming maternal hemodynamic stability before proceeding to history taking or else preliminary measures will be taken in stabilizing her. A> Detailed history of duration and amount of bleeding would help in assesing blood loss. I would ask for any precipitating cause eg: abdominal trauma as is likely to be asoicated with abruption. also I would enquire for perception of fetal movements as would indicate fetal wellbeing grossly. I would ask for history of any obstetric complication eg: PIH, polyhydrominious, leaking as all of these could be associated with abruption. Similarly I would rule out chronic illness eg: chronic hypertension and anemia(especially megaloblastic) which could be associated with abruption. A history of smoking & use of illicit drugs will place her at risk of abruption. I would note her parity& mode of previous delivery as likely to affect mode of delivery now. I will also review her obstetric records so as to confirm gestational age, status of placenta, any anomalies associated in fetus, associated polyhydrominous. I would proceed to clinical examination, note vitals, bp, temp, degree of pallor as all indicate degree of blood loss .P/A examination to confirm SFH, uterine tenderness, contracting or relaxed, fetal heart rate, presentation.After her permission perform per speculum examination to note bleeding, local cause for bleeding , differentiate if it is frank blood or show.P/V: to note bishops & if patient is in labour (provided placenta previa is rulled out) Theraftter I would secure two large bore iv cannule & sent blood for investigation as will further aid in assessment of condition . I would send for FBS, clotting screening, platelet count, U & E, FDP ,crossmatch the blood and blood products. I would start CTG to note fetal condition and arrange for USS. A) USSS at 30 weeks will not help in accurate dating of pregnancy but is of value in noting BPP. Location of placenta can be confirmed by scanning . Also may be useful in noting retroplacental clot but abruption is mostly a clinical diagnosis though . May also help in noting any uterine fibroids which have precipitated pain & preterm labour. c) Most likely diagnosis is abruption. And mainstay is delivery. However Vaginal delivery is not contraindicated provided feto-maternal well being is ensured. Administer steroids for maturity as are helpful even if 1 hour gained befor delivery .Late deceleration indicte fetal compromise & urgent delivery is mandatory. Lab investigation need to be reviewed as any e/o D/C would mandate correction before embarking on any intervention. Obviously maternal condition needs to be prioritized to fetal. Important to keep patient & relatives informed and involve them in decision making. Accurate documentation is essential. Hematologist, senior obstetrician, OT staff, pediatrician, SCBU need to be informed.If patient is in advanced labout and delivery is imminent, curtail secondary stage with instrumental delivery.If delivery not immenent then post for caesarean provided DIC if present is corrected with blood & blood products. Senior obstetrician to attend cesarean section as high chance of couvelaire uterus, PPH. Strict monitoring of vitals, urine output, input of fluids,vigilant for PPH. Patient to be monitored in HDU with review during rounds.Important to brief the patient again regarding the happenings .
		Posted by Manoj M. Sun Aug 10, 2008 04:04 am
(a) Intial assessment involves taking history of the type and severity of abdominal pain as this may suggest ongoing massive abruption and helps to assess analgesic requirement of the patient. A history to quantify the amount of vaginal blood loss will also suggest the seriousness of the underlying event. History should also involve to suggest if pain started before bleeding or bleeding started before pain as former could be more likely due to an abruption and the latter could be a bloody show with pre-term labour. History of any loss of liquor should also be asked but difficult to differentiate with bleeding. History of fetal movements may also suggest fetal well being but usually difficult to appretiate when patient in pain. Her notes will be helpful with informations like her recent haemoglobin levels, rhesus status, informations from previous scans could excluding placenta previa which will help in managing her. Her pulse and blood pressure should be assessed as this will suggest she is stable or unstable and can act accordingly if she need resuscitation. Pallor will also suggest significant blood loss. Abdominal examination to asses tenderness is generalised and constant suggestive of abruption or intermittent suggestive of uterine contractions, Symphysis fundal height may suggest a small for gestation and underlying placental disease. Abdominal palpation for presentation and lie of fetus is important as may warrant delivery soon. Electronic fetal monitoring for fetal condition with the current event and to assess if imminent delivery required. Intravenous acess should be obtained and bloods sent to labs for haemoglobin estimation and also cross match blood for transfusion if needed. Bloods should be sent to exclude underlying preeclampsia and coagulopathy. Speculum examination of vagina may be difficult with ongoing bleeding but may suggest cervical changes with the event and useful to exclude rupture of membranes and take vaginal swabs and exclude cervical lesions like malignancies. Manual vaginal examination should be undertaken when suspected preterm labour to assess cervical changes, fetal station, position and confirm presentation. (b) In this current situation Ultrasonography has only limited role and depends on the expertise available to do the same. An Ultrasound scan can confirm if the fetus is alive or dead, it is useful to confirm presentation and lie of the fetus which is helpful if imminent delivery is anticipated. This can also exclude a placenta previa which may help in planning her delivery but it is difficult to diagnose an abruption with the limitation of ultrasonography. An ultrasound may pick up other findings like large fibroids in lower segment which may obstruct normal labour. (c) This is a pathological CTG and suggest fetal compromises which needs urgent delivery. Unless she is about to have a vaginal delivery a category 1 caesarean section should be organised once maternal resusciation is complete. Maternal resuscitation is the priority as resuscitating her may improve the CTG and allow more time for steroids and delivery. Place her in left lateral position, start facial oxygenation, resuscitate with intravenous fluids and blood if necessary. This needs urgent input from Senior Obstetritian, Senior Anaesthetist, Paediatritian, Haematologist, Midwives. As she is bleeding and fetal compromise she may need a general anaesthesia for caesarean section. Delivery with a lower transverse segment caesarean section is ideal compared to classical caesarean section for curent complications with bleeding and future pregnancies. Haemorrhage at delivery should be managed with uterotonics, uterine embrace sutures and avoid caesarean hysterectomy. Blood loss should be replaced with transfusion as necessary with liasion with haematologist in situations of massive haemorrhages. She should be monitored post delivery for preeclampsia, HELLP syndrome on labour ward untill she is stable to be transferred to the ward. Thromboprophylaxis should be considered following delivery as increased risk of thromboembolism. She should be debriefed regading the event following delivery and outcome of her baby and prognosis explained
		Posted by SHAGUFTA T. Sun Aug 10, 2008 10:02 pm
A) Most likely cause of abdominal pain with vaginal bleeding is placental abruption but Placenta previa & preterm labour should be excluded. APH with heavy bleeding is an acute obstetric emergency which needs urgent management. First I will assess her haemodynamic status by Pulse, BP, RR, SPO2, if stable I will take detailed History, if unstable I will start Resuscitative measures first, I will check her conscious level & start resuscitation—call for help from senior Obstetrician, Anesthetist, midwife & alert Hematologist. I will maintain her airway, breathing, give facial oxygen,start I/V line with 2 large bore cannula started( give crystalloids/ colloid ). I will send blood for FBC (to look for Hb & platelet—risk of anemia & coagulopathy). Group & C/M, baseline LFT, RFT, U&E(to monitor her condition), coagulation profile done (risk of DIC with abruption). Arrange blood & transfuse according to maternal condition & blood tests. In history, I will ask duration & severity of pain, whether constant or intermittent to favour diagnosis of Abruption or preterm labour. 50% of abruption will be in established labour. I will ask her about amount of bleeding (if she passed heavy clots, no. of pads soaked) to assess severity. H/O any blunt trauma to abdomen (suggest abruption). H/O any previous episode of bleeding, hospitalization suggest placenta previa. I will enquire about any previous (2nd trimester) scan done for placental site, multiple pregnancy, polyhydramnios. On examination of abdomen, I will palpate for uterine tone—hard, tense, not relaxing in between will suggest placental abruption, if intermittent contraction will suggest preterm labour. I will also check fundal height, lie, presentation, Fetal heart rate (sonicaid). CTG done to look for fetal condition. Speculum examination to look for any vaginal or cervical cause of bleeding, assess amount of bleeding, cervical os, but V/E should not be done unless placenta previa excluded. B) Ultrasound will help in localization of placenta, to exclude Placenta previa. In 10% of abruption, placenta previa coexist. It can detect major abruption but poor sensitivity in detection of small retroplacental bleed. TVS is more accurate than TAS for classifying Placenta previa but TAS is quick & easy to perform. USG will also help to assess fetal well being—FHR, lie, presentation. But USG will not alter her plan of management which is to be decided by mother’s & fetal condition. C) Late deceleration on CTG indicates fetal hypoxia & compromise and need for urgent delivery. Multidisciplinary team approach is indicated involving senior Obstetrician, Anaesthetist, Neonatologist, SCBU staff & haematologist alerted. Mode of delivery will be decided by senior Obstetrician in view of her cervical status & prematurity. If she is in preterm labour with favourable cervix & delivery is imminent, Operative vaginal delivery by Forceps is justified. If cervix is unripe, os closed, LSCS with informed consent to be undertaken. Mode of anesthesia will be decided by Senior Anesthetist but GA will be preferred in view of her bleeding & urgency. Neonatologist to be present at time of delivery. Post Operative monitoring according to her condition, if bled heavily blood transfusion considered. Thromboprophyllaxis given. Debriefing to the mother & her partner about all events should be done. Documentation done. Followup & contraception explained before discharge.
		Posted by San S. Mon Aug 11, 2008 01:47 am
(a) Justify your initial clinical assessment [7 marks]. It is important to abtain a history of the site of pain to ascertain if this is uterine in origin. A constant pain may indicate placental abruption whereas an intermittent pain may indicate uterine contractions. It is important to establish the amount of bleeding to assess significance. A previous scan is useful to rule out low lying placenta. A history of headache, visual disturbances, epigastric pain and high blood pressure (BP) and protreinuria may indicate an abruption secondary to raised BP. It is also important to establish fetal well being by enquiring about fetal movements and perfoming a CTG. Objective evaluation of haemodynamic status with BP and pulse measurements are important abd iv access, FBC, U&Es, LFTs, group and save or X-matching of blood(if she has had significant bleeding) and clottings obtained to assess reason, extent and assess signs of coagulopathy associated with massive antepartum haemorrhage and placental abruption. IV fluids should be given to resuscitate patient, she should be kept NBM in case of need for operative delivery if haemodynamically unstable. Abdominal examination can clinically assess engagement, lie, presentation of fetus and uterine tenderness, and contractions. A tense abdomen may rise suspicion of placental abruption. A speculum examination should be carried out to assess the cervix, cervical dilatation and amount of bleed. Vaginal examination can be carried out if there is evidence of uterine contractions and that previous scan has rule out low lying placenta. Senior obstetrician, anaesthetist, neonatologist and delivery suite coordinator should be informed of admission and patient should be transferred to delivery suite for further management. (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. Ultrasound may have a role if this patient has not had a scan in this pregnancy to identify placental site. Ultrasound has low sensitivity and specificity in detecting placental abruption although in expert hand that it may be of some value. In acute situation like this, ultrasound would have insignificant role and should not be a factor for delay in management and delivery in this patient if clinically indicated. Placental abruption should be a clinical diagnosis. A subsequent scan may be of value if her symptoms and bleeding settled and there is no evidence of fetal compromise to assess fetal well-being. (c) The CTG shows late decelerations. Justify your management I would explained the CTG and clinical findings to the woman and arrange delivery by caesarean section unless vaginal delivery is imminent. I would inform the senior obstetrician, anaesthetist, corrodinator midwife, neonatologist, haematologist and blood bank regarding the delivery. It is important to X-match her for 4 units of blood in view of her increased risk of bleeding during and after the delivery. The woman should be consented for the procedure including risk of blood transfusion, extra haemostatic surgical procedures in case of massive haemorrhage. I would liase with anaesthetist regarding the type of anaesthetic use for the procedure as general anaesthetic may be required in case of coagulopathy and if she is haemodynamically unstable. A senior operator is required for the delivery and oxytoxics drugs readily available and administered in event of haemorrhage. X-matched blood should be available for the delivery in case of need for transfusion. O negative blood or group specific bloods can be used while awaiting x-matched blood. A drain could be left in-situ after the caesarean section in view of increased risk of postpartum haemorrhage. An experience neonatologist should attend the delivery due to fetal compromise and risk of needing neonatal resuscitation at delivery. After delivery, she should be nursed in highe dependency unit on delivery suite with one to one care. It is important to minitor her BP and pulse half an hourly and urinary output hourly to identify signs of hypovolaemia in view of risk of post partum haemorrhage. Her bloods for FBC, U&Es, LFTs and clottings should be repeated 6 to 8 hourly depending on previous blood test abnormalities, blood loss and signs og coagulopathy. Patient and her family members should be debriefed of the evnt after the delivery.
		Posted by Iffat ara M. Mon Aug 11, 2008 01:48 am
A):As this is obstetrical emergency is associated with increase maternal and fetal mortality. Delay of management can lead to poor prognosis. I would lie to call for help which includes senior obstetrician senior midwife senior hemaharmatologist & anesthetist1. I will asses the condition of patient if hemodinamically stable I would lie to as about nature of bleeding(either mild heavy or passage of cloths) to asses the amount of blood loss. I would as about nature of pain(its seniority onset, continuous, intermittent),to exclude preterm labor. I would as about smoking drug intake lie cocaine, trauma to look for causative factor for abruption. I will as about any leaking P/V (to rule out prolonged rupture of membrane). I would check her BP, pulse & temperature. I would obtain I/V access with two 14G branulaes. In the mine time blood will be taken for FBC, blood grouping & Rh typing, Urea & electrolytes & blood coagulation profile. I will arrange 4 units of cross match blood. Kleihaur test indicated if Rh –ve then I would like to examine her abdominally, to Assess the feudal height( is it corresponding to gestational age or more then gestational age) which will give some clue to abruption with the palpation I will note the condition of uterus( is it soft or hard, tender and irritable) to exclude abruption. I will try to check fetal lie & fetal parts which are not easily palpable in abruption. Fetal heart sounds which are not audible due to woody hard uterus in abruption. I will have a look for vaginal bleeding(is it mild or profused) .I will not examine her vaginally until placenta previa is ruled out. B): As abdominal ultrasound is not accurate diagnostic tool but we can see only if large anterior retroplacental hematoma or anterior low lying placenta. But wee can confirm with abdominal ultrasound the presentation of fetus, viability of fetus & amount of liqour(to rule out the polyhydramnios). Comparatively trance vaginal ultrasound is more informative in diagnosing the placenta previa especially if posteriorly located . Ultrasound is cost effective & easily accessible. As portable ultrasound is available now a days. C): Mode of delivery would depend upon clinically condition of patient & baby. Further presenting part of baby & cervical assessment will be encounter in planning the mode of delivery. After ruling out placenta previa, I will examine her vaginaly to see the condition of cervix(as 50% cases of abruption are in labor). If cervix is favorable & cephalic presentation I will do ARM, to see the meconium or blood stained liquor. As delivery should be prompt, If fully dilated so instrumental vaginal delivery will be done . But it needs close monitoring like fetal scalp electrode & other measures like left latral position, oxygen inhalation & hydration of the mother which some time improve the CTG findings. If persistent deceleration( no acceleration or loss of beat variation) which indicate pathological CTG so emergency caesarean section (category 1) would be the other option. In the mean time I will inform the serious neonaotologist & anesthetist will be informed. Decision of type of anesthesia will depend upon the opinion of anesthetist & wishes of patient. Senior obstetrician will operate. I will give all information about these interventions to the patient & I will take informed consent for the cesarean section & hysterectomy. Incident form will be filled properly & there should be proper documentation.
		Posted by Manoj M. Mon Aug 11, 2008 04:38 am
A healthy 30 year old primigravida presents at 32 weeks gestation with a 3 hour history of abdominal pain and vaginal bleeding. (a) Justify your initial clinical assessment [7 marks]. (b) Critically evaluate the role of ultrasound scanning in investigating her symptoms [5 marks]. (c) The CTG shows late decelerations. Justify your management [8 marks]. The initial clinical assessment is aimed at stabilising the patient’s condition and planning for the timing of delivery of the fetus if necessary. A review of the patient’s antenatal notes should be done. This would give information on high risk factors,like associated pre-eclampsia or diabetes. The site of the placenta can also be noted. Her Rhesus status can also be noted form her notes if done previously. A history from the patient is necessary to assess the intensity of the pain and if this was the first episode. Presence of fetal movements from the history should be noted. The amount of bleeding should be asked for as this may indicate severity. Any presence of tightening can indicate preterm labour or abruption. Any history of fall that may have triggered this episode must be asked. An examination of the patient will help in the deciding urgent resuscitation if there is severe compromise. Signs of pallor must be looked as this indicates cardiovascular compromise. Her pulse and blood pressure must be noted. Presence of tenderness of the uterus indicates abruption. The lie of the fetus and presentation is to be noted as breech is more common in preterm. A speculum examination must be done to look for active vaginal bleeding which will need urgent intervention. A vaginal examination can be done if the placenta is not low lying and if the patient has contractions to assess the cervical dilatation. An ultrasound would be helpful in evaluating the presentation of the baby and also locating the placenta. The fetal heart can also be visualised in real time and this is critical if heart beat cannot be heard externally. This can also reassure the patient. The placenta may be useful in detecting any retroplacental haemorrhage, liquor volume or growth. However in an acute scenario like this the role of ultrasound is justified only for basic examination like placental localisation and fetal heart beat. A trained person is necessary to conduct the examination. The role of ultrasound in detecting abruption is controversial. It may moreover be falsely reassuring. This is a sign of fetal distress and warrants urgent delivery. Help must be requested for from the anaesthetist, paediatrician, consultant obstetrician and the senior midwife. The patient must be cannulated for venous access and blood must be taken for grouping saving and cross-matching. The haematologist must be alerted in case blood transfusion is required. A full blood count will indicate level of anaemia and clotting screen must be done to evaluste coagulation. IV fluids must be commenced if there are signs of hypovolemia. The patient must be appraised of the situation and her consent must be taken before any intervention. A vaginal examination must be done and if the patient is fully dilated and if the presenting part is well below a forceps delivery may be carried out. However if the cervical os is closed then consent must be taken for an urgent caesarean section. The special care unit must be informed. At the caesarean section the lower segment may not be well formed as it is a preterm delivery. Therefore the surgeon must be prepared for an J or T shaped extension of the uterine incision. Post partum haemorrhage is a complication that should be expected and the local protocol must be followed. At delivery presence of any retroplacental clots or any other factors leading to this preterm delivery must be looked for. Cord gases must be taken and an incident form must be filled. The patient and partner must be debriefed of the entire event.
		Posted by Atashi S. Tue Aug 12, 2008 12:35 am
a) I will assess her regarding the amount the bleeding and her general condition including foetal compromise. History of trauma or direct hit to the abdomen need to be asked. I will note pulse, BP, degree of anaemia , amount of pad soaked and amount of P/V bleeding. I will review her previous antenatal ultrasonography to exclude placenta praevia. Airway breathing and circulation need to be checked. If bleeding is heavy and patient in a state of shock then I will start I/ V access with Hartsman solution or normal saline and O2 is to be given by facial mask. A sample of blood should be sent for full blood count, group and save, clotting screen and U&E. Abdominal examination to be done to detect tense , tender abdomen, presence of hard contracted uterus or presence of uterine contraction in between relaxation. Gentle per speculum examination is to be done to note amount of visible vaginal bleeding or show and condition of the cervix to exclude local cervical cause of bleeding. Continuous CTG monitoring is to be started to monitor foetal condition. b)Ultrasonography is helpful for diagnosis of placenta preavia. It is also helpful for assessment of foetal condition. It will also detect retroplacental haemorrhage but small abruption can be missed. Its sensitivity is higher in diagnosing placenta preavia but it is associated with intra or inter observer error. Foetal growth and amount of liquor can be assessed for foetal surveillance when bleeding is minimum and patient should be kept in observation for a couple of weeks. c)Late deceleration indicate foetal compromise. It needs prompt delivery. I will explain all the situation including maternal and foetal condition to the patient. I will take informed consent. Delivery should be done by caesarean section. I will call senior obstetrician, consultant anaesthetist, senior midwife, neonatologist and consultant haematologist. If platelet count is more than 80,000 per litre of blood then C/S is to be done under regional anaesthesia. At this gestational age, as lower segment is not formed, upper segment caesarean section is to be done. Morbidity including risk of scar rupture in the future pregnancy related to upper segment caesarean section need to be discussed with the patient. As there is risk of post partum haemorrhage, haematologist should be informed and caesarean section should be done with at least 4 unit of blood kept in hand. SCBU should be informed for management of a premature baby.
		Posted by Najah Ali A. Tue Aug 12, 2008 05:06 pm
I will check the patient condition by measuring the blood pressure, pulse ,asses her breathing and explore the severity of bleeding , I will resuscitate if necessary calling for help the most senior obstetrician, anesthetist , clinical midwife , collecting blood as needed and cross match 4-6 units , alert the hematologist about the urgency of blood need. I will commence fast crystalloid/ colloid fluid for rapid intravascular space expansion. If the patient is heamodynamically stable, I will take detailed history the severity of bleeding , did she passed any clots or is flooding , did she experienced any attack before, Is it precipitated for example with coitus or abdominal trauma .I will enquiry about the chronicity of her symptoms as with placental abruption the pain always preceded the bleeding while in placenta preavia the bleeding usually painless and the pain if occurred will be after . By this time I will review the patient\'s case note if available ascertain her gestational age ideally by early ultrasound review the number of fetuses, location of the placenta , ascertain her blood group and Rh state . I will order anti D-IgG if her Rh is negative , and to start corticosteroid course, to reduce RDS ,IVH, NND and NICU duration .I will assess the fundal height, lie of the fetus , assess abdominal tenderness , tightness and the duration ,and I will record any fetal movement felt . Local speculum examination to assess activity of bleeding, assess the cervical situation , dilatation , any polyp or obvious pathology ,pinkish thin bleeding denote the presence of leaking with bleeding .No vaginal examination till placenta praevia is ruled out either by previous scan or by quick bedside portable U/S ,with evaluation of the fetal lie and viability if fetal heart is un audible by CTG . (b) Using U/ S to detect the placent al location ideally by TVS as it more sensitive than TAS and safety is reassured , using color flow Doppler can detect morbidly adherent placenta , however it has low sestivity to diagnose abruption placenta ,or to detect vasa prevea .Umblical artery Doppler can assess the placental bed vascular resistance .Using middle cerebral artery Doppler as an indirect method with 100% sensitivity to detect fetal anemia .Adequate machine properly trained operator is needed to avoid miss leading diagnosis which can lead to un necessary intervention . (c) Late deceleration is sign of fetal compromise, however I will assess CTG all over in conjunction with the clinical scenario as a whole. Previous reassuring CTG, hemodynamically stable mother with controlled bleeding in presence of shallow late deceleration wih quick recovery, I will adopt expectant management for the time being, put the patient in left lateral position, commence IV fuid, applying high oxygen mask, checking her BP & pulse. If condition is not reassuring, imminent delivery is needed. I will call for help from senior obstetrician, Anesthetist, clinical midwife, inform Neonatologist & communication with SCBU staff. I will assess cervical condition, if fully dilated & safe vaginl delivery is expected, I will proceed, otherwise urgent C/Section is needed. Updating the mother & her partner about situation, need for blood transfusion, blood product should be emphasized before informed consent obtained. Emergency C/S under regional anesthesia if no contraindication is the aim, & C/S must be conducted at most senior level. Neonatologist o be present at time of delivery. Active Mgt of 3rd stage of labour, secure hemostasis & any mishap occurred should be managed in line with unit protocol. Post partum, close observation for BP, Pulse, lochia, VTE prophyllaxis as needed. Clear explanation to the patient & her partner if any complication arise. Breast feeding & contraception advised, need for followup explained.
		Posted by H H. Sun Aug 17, 2008 04:05 pm
Model answer please
		Posted by Najah Ali A. Mon Aug 18, 2008 01:06 am
Dear Dr Paul, I send my answer to this question on 12/8/08,today the model answer appeared but my answer is not yet checked. Can you please check it for me? Regards, Najah