3. Top Emergencies
Antepartum haemorrhage
Postpartum haemorrhage
Severe pre-eclampsia
Acute ectopic pregnancy
4. CASE 1
26yrs primi 8months pregnancy with bleeding pv.
WHAT IS THE DIAGNOSIS?
WHAT R THE CAUSES ?
HOW WILL U DIFFERENTIATE?
HOW WILL U MANAGE?
6. ANTEPARTUM HEMORRHAGE
Antepartum haemorrhage (APH) is defined as
bleeding from or in to the genital tract, occurring from
24+0 weeks of pregnancy and prior to the birth of the
baby.
8. Antepartum haemorrhage
1.Uteroplacental causes
a) Placental abruption
b) Placenta praevia
c) Uterine rupture
2.Cervical lesions
3.Vasa praevia
4.Unexplained
5.Excessive show
Bleeding at > 24weeks (<24 weeks is miscarriage)
9. Definitions
Placental abruption: part of the placenta becomes detached from the
uterus
Placenta Praevia: The placenta is inserted wholly or in part into the lower
segment of the uterus and therefore lies in front of the presenting part.
** AVOID PV exam; placenta
praevia may bleed catastrophically **
10. HOW WILL U DIFFERENTIATE BETWEEN
ABRUPTION AND PLACENTA PREVIA?
12. Placental Abruption
Painful third trimester bleeding.
Associated with PIH
1:120 pregnancies, approx. 1%.
Recurrence rate of 10%.
Port wine stained amniotic fluid.
Mark line at top of fundus at presentation and follow
fundal height serially.
17. Placenta Previa
Painless third trimester vaginal bleeding
1:200 - 1:250 pregnancies average
1:50 grand multiparas,1:1500 nulliparas
Undiagnosed third trimester bleeding, consider a
double set-up in the OR.
Biggest risk factor is prior C-section, which confers a
1% risk.
18. Signs and symptoms
Placental abruption Placenta praevia
Shock out of keeping with visible
loss
Shock in proportion to visible loss
Pain constant No pain
Tender, tense uterus (hypertonic) Uterus not tender (hypotonic)
Normal lie and presentation Both may be abnormal
Fetal heart absent/distressed Fetal heart usually normal
Coagulation problems Coagulation problems rare
Beware pre-eclampsia, DIC, anuria Small bleeds before large
19. USG plays major role
TAS(Trans abdominal)
TVS(Trans vaginal)
TPS(Trans perineal)
25. Abruption
Delivery is generally indicted unless the fetus is very
premature and both the mother and fetus are stable
DIC occurs in 4-10% of cases and usually is apparent by
8 hours after onset if symptoms
Renal failure is the most common cause of maternal
mortality
26. Placenta previa
MANAGEMENT
Total - needs operative delivery.
Partial and Marginal - may consider a vaginal delivery
as the baby’s head may tamponade the placenta during
descent
Consider fetal hemorrhage in addition to maternal
hemorrhage.
27. Case 2
Called for a woman who has just given birth
Delivery performed by new midwife
Upon Arrival patient is pale and the bed is soaked in
blood
28. Case 2 Continued
P 165, BP 80/p, R 32, SaO 98% on NRB
Continuous hemorrhage noted as you move her to the
bed
29. WHAT IS THE DIAGNOSIS ?
WHAT R THE CAUSES ?
HOW WILL U MANAGE ?
37. INITIAL RESUSITATION
1. Call for help
2. ABC
a) O2
b) Large bore IV access x 2
c) FBC, coag, cross match
d) Urinary catheter
3. Identify cause(s) of PPH
4. Control bleeding
5. Replace the blood loss
39. stages in management in vaginal
delivery
1. Ensure 3rd stage complete – if not
MROP
2. Rub uterine fundus to stimulate
contraction +/- bimanual compression if
required to stop uterine bleeding
3. Assess for cervical/vaginal wall/perineal
tears – if present, repair
40. stages in management
4. Medical management of atony with
oxytocic medicines
a) Syntocinon
b) Ergometrine
c) Carboprost
d) Misoprostol
5. Surgical management
a) Intra uterine balloon device
b) B lynch suture if at Caesarean section
c) Uterine artery embolisation/ligation
d) Hysterectomy
47. UTERINE COMPRESSION SUTURES
SQUARE VERTICAL
Cho JH, Jun HS, Lee CN: Haemostatic Suturing Technique For uterine Bleeding during
Cesarean Section delivery. Obstet Gynecol 200 0 96:129-131
A Straight needle is passed anterior
to posterior and passed over fundus
and ligated anteriorly.
Multiple square sutures are
Passed intramurally and tied
at
Various points.
48. Selective Artery Embolisation
Advantages
Preserves Fertility
Useful in Haemorrhage associated with Placenta
praevia
Disadvantages
Requires 24hr availability of radiological expertise.
Patients must be stable
Complications include: Necrosis of uterine wall,
contrast adverse effects, local haematoma formation
49. Recombinant Activated Factor VII
Novoseven is FDA approved for bleeding episodes in
hemophilia patients
It has been effective in nonhemophiliac patients with
extensive organ damage, hemorrhage and
coagulopathy that did not respond to transfusion
