obgyn presentation: post-partum haemorrhage
TRANSCRIPT
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WEEK 7 PRESENTATION
POST-PARTUMHAEMORRHAGE
Jeremy Yang
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Case
Mrs Jones rang the Labour Ward asadvised by her general practitionerbecause she had noted a small amount ofvaginal bleeding. It was one week before
her due date.
What advice wou d !ou "ive he#$a% No actio&' it(s &o#)a to * eed this
adva&ced i& +#e"&a&c!, It(s +#o*a* ! a* ood! show' a&!wa!, Co)e i& whe&active a*ou# *e"i&s.
*% Advise he# to visit PAC so a +#o+e# H/'E/ a&d I/ ca& *e u&de#ta0e&, A&!
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Causes o1 * eedi&" i& 2 #d t#i)este#
Serious and not to be missedlacental abruptionlacenta praevia
!asa praevia hysiological
"loody show of labour #ther
$"%contact bleeding$ervical polyps
Ta0e a histo#! Pe#1o#)
e/a)i&atio& 3o
i&vesti"atio&s
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What a#e the 1u&ctio&s o1 the )idwi1e')edica sta4 a&d su++o#t +e#so&s i&
achievi&" a &o#)a de ive#!$
Midwi1e &mid = with' wif = woman(
A professional who works in partnershipwith pregnant women, giving necessarysupport, care and advice throughout
pregnancy, labour and early postpartum
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The #o es o1 the Midwi1e )egular community antenatal checks throughout
pregnancy and up to *+%,- postpartum ducation and counselling
Lifestyle advice"reastfeeding
arenthood
Se/ual%gynaecological health 0uides the woman to appropriate medical care or
assistance if complications detected duringpregnancy
Many midwives are also )1s 2 perform nursingduties in hospital
Low3risk pregnancies can be followed in its full
course by midwives only . "ut if there arecomplications% increased risks4
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3octo#s - See& i1 the +#e"&a&c! isco&side#ed hi"he# #is0 tha& &o#)a ' e,",
Increased risk on early pregnancy screening $omplications of pregnancy Signi5cant #6/ et#6 and drugs $omple/ social cases Mental health issues &maternal( #ther medical conditions &maternal and fetal(
Whe#e$ 7S or 7$' clinics &71$' 6)71$' 87 S%$$'
IM6S' 8$79(' hospital
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Ro e o1 the su++o#t +e#so& 5e,", +a#t&e#'1a)i !' 1#ie&d% To +#ovide e)otio&a a&d +h!sica
su++o#t to the wo)a& du#i&" a*ou# &butalso throughout pregnancy($hanging the kitty litter' doing the housework0iving massage' helping shower' pain
management techni:ues6elping pack for' and transport to hospital 9aking her mind o; labour in early stage'distractions
0etting food%drink and ensuring regular eatingand emptying bladder7ssisting midwives with positioning duringcontractions etc.0iving words of comfort and encouragement"eing by her side at all times
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M#s 6o&es has ust de ive#ed a 89::"i&1a&t a1te# 2h#s a*ou#, She is
* eedi&" heavi !,
Post-+a#tu) * ood oss ; what(s&o#)a a&d what(s &ot$
NORMA< < = ,>>mL in ? st hour 1!8'=@,>mL after $%S
A=NORMA< &i.e. ? o 6(< A,>>mL in ? st hour 1!8
A?>>>mL in ? st hour #) causeshaemodynamic compromise 2 severe 6 obstetric emergency
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How wou d !ou )a&a"e this +atie&t$
Simultaneously' not se:uentially< I> access Mo&ito#i&" ? i&vesti"atio& A##esti&" hae)o##ha"e
Resuscitatio&
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How wou d !ou )a&a"e this +atie&t$
Simultaneously' not se:uentially< I> access
?+ or ?B gauge cannula &or /-( Mo&ito#i&" ? i&vesti"atio&
7ppearance' " ' 6)' C%3 urine output&catheter(D3match' E"$' coagulation studies
A##esti&" hae)o##ha"e Resuscitatio&
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How wou d !ou )a&a"e this +atie&t$
Simultaneously' not se:uentially< I> access Mo&ito#i&" ? i&vesti"atio& A##esti&" hae)o##ha"e
Ute#i&e )assa"e=i)a&ua co)+#essio&=a oo& ta)+o&ade@st i&e Medica Re+eat dose 9-@:IU
s!&toci&o&' o# o#"o)et#i&e' s!&to)et#i&eB&d i&e Medica Miso+#osto 5o4- a*e %Su#"ica Radio o"ica ute#i&e a#te#!e)*o isatio&
Resuscitatio&
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How wou d !ou )a&a"e this +atie&t$
Simultaneously' not se:uentially< I> access Mo&ito#i&" ? i&vesti"atio& A##esti&" hae)o##ha"e
Resuscitatio&Restore blood volume and O 2 carryingcapacity
Eluids &6artmannFs G colloid up to H,>>mL(
# - by mask ?>3?,mL%mineep pt warm' and warm uids if possible
)"$ transfusion 7S7 ' #3 if critically needed&and EE ' cryoprecipitate if coags deranged(
7fter -K blood' add ?K EE with every additionalunit of blood
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3iscuss the causes o1 +ost+a#tu)hae)o##ha"e
TONE. 2 uterine atony &most common'@> 6 cases(
TRAUMA. 2vulval%perineal%vaginal%cervical%$3section&-> of cases of 6(
TISSUE 2 retained placental tissue&?> of cases of 6(
THROM=IN. 5coa"u o+ath!%; 3IC'o&"oi&" the#a+eutic a&ticoa"u atio&')ate#&a * eedi&" diso#de# 5 rarely theprimary cause of 6(
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Ris0 1acto#s 1o# PPHAssociated with a su*sta&tia i&c#ease i& #is0 o1 PPH antepartum haemorrhage &especially placental abruption and
placenta praevia( 6 with a previous pregnancy known abnormal placental adherence &e.g. accreta' increta or
percreta( multiple pregnancy &e.g. twins and higher order multiples( disorders of haemostasis inherited bleeding disorders
Associated with a si"&i ca&t thou"h s)a e# i&c#ease i&#is0 grand multiparity &more than 5ve previous births( pre3eclampsia macrosomia maternal obesity elective or previous LKS$S
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Ris0 1acto#s 1o# PPH3u#i&" a*ou# a&d *i#th need for' and use of' o/ytocics in labour prolonged labour &especially prolonged second
and%or third stage( pyre/ia instrumental and surgical delivery episiotomy placental retention
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3iscuss the di4e#e&ces *etwee& +#i)a#! a&dseco&da#! PPH
Bo
PPH /cessive uterine bleeding A-+hrand =B%,- postpartum' most commonly @3?+ days postpartum
Main causes )etained placental tissue C%3 infection &e.g. endometritis(