The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes326
EMQ1462
SBA2091
Do you realy want to delete this discussion?
Forum >>

Mock essay from module 10

Mock essay from module 10 Posted by clarice M.
Justify your management of a woman who has retained her placenta following a spontaneous vaginal delivery.

I was wondering if anyone else would like to contribute to this question:

A summary of my points are as follows (p.s. I do not know what the gold standard answer is):

History to assess risk factors for retained placenta (previous C/S, Uterine anomalies, history of retained placenta). Note time of delivery of baby and if patient had opted for a physiological or active 3rd stage. If active 3rd stage was chosen, what medication was given and at what time to avoid an overdose and to avoid delay of manual removal in theatre.

Check notes for placental site, other scan findings such as succenturiate lobe

Examine patient: pulse and bp, estimated blood loss to check that patient is haemodynamically stable. Palpate abdomen to identify atonic uterus and perform VE to check if cord is still attached, placenta not partially extruded through cervix.

Site iv access, obtain blood for full blood count and group and save as retained placenta associated with post partum haemorrhage.

Treatment: If patient had a physiological 3rd stage, give im syntocinon and wait 30 mins before attempting to deliver the placenta. If the patient had active 3rd stage, try proximal clamping or give 20 units of syntocinon in 20mLs normal saline via umbilical cord. If unsuccessful after 30 minutes, prepare for manual removal in theatre. Inform senior colleague if the patient requires a manual removal in theatre as complications can occur and senior assistance may be required.

Issues re: consent: Retained placenta is common and occurs in 3/100 pregnancies. Procedure will be done under general or regional anaesthesia-will have opportunity to discuss this with anaesthetist.

Main benefit is to minimise risk of PPH.

Risks: infection, bleeding, uterine perforation, fragments of products may be retained resulting in delayed postpartum haemorrhage. If blood loss is significant, blood transfusion may be necessary. If uterine perforation suspected, further surgery may be undertaken to investigate and repair damage

If proceedure uneventful, should not delay discharge from hospital.
After the procedure, debrief regarding efficacy of removal. Advise regarding symptoms of infection, when to seek medical attention.
Posted by Manoj M.
If it is preterm delivery manual removal can be difficult and may need careful blunt currettings to complete procedure.
Role of ultrasound if manual removal in piece meal.
With subsequent pregnancy recurrance risk.
Posted by Priti T.
If there is atonic uterus with retained placenta then I/M carboprost 250mcg upto 8 dosage can be tried.Or misoprostol per rectally can be given also.
If it is placenta accreta and can\'t be removed manually,then we can leave it and try for Methotrexate to resolve it.
please let me know what others think about it.
Posted by PAUL A.
You are making a basic mistake. You have already been given the diagnosis - she has retained her placenta. A Hx of risk factors is irrelevant as it will not change the diagnosis.

A woman has been referred with watery vaginal loss at 30 weeks - Hx for risk factors of PPROM will be relevant.

A woman has been refered with PPROM at 30 weeks gestation - there is no point in taking a Hx for risk factors. Hx helps you make a diagnosis and is irrelevant when you are given a diagnosis.

No point in checking notes for placental site... this will not help you in any way.

Justify your management: retained placenta is associated with PPH and maternal morbidity therefore prompt assessment is needed...

Key factor is bleeding. If she is bleeding, then she needs imediate MROP irrespective of time after delivery / management of third stage.

If not bleeding then you can try conservative techniques.

A woman who has undergone MROP should stay in hospital for longer than one who delivered her placenta spontaneously
Posted by clarice M.
Forgot to add:
Apply countertraction when attempting to deliver the placenta to avoid a uterine inversion
Posted by clarice M.
Thanks for your comments Dr Ayuk, hope to avoid repeating the mistake on the real day.
Posted by S D.
Just to add, prophylactic antibiotics during MROP and bladder catheterisation if regional anaesthesia. Making sure that the uterus is empty and accurate documentation of findings.
Posted by Mark D.
gud attempt at discussing the difficult n confusing saqs,keep it up clarice.

what is the risk of rec in next preg?

also incr risk if pla prev n accreta in next preg.
Posted by Farzana N.
risk of recurrence is ~6.2%