2. Top Emergencies

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?

5.  WHAT IS THE DIAGNOSIS ?

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.

7. WHAT ARE THE CAUSES ?

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?

11. ABRUPTION

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.

13. Placental Abruption

14. Placental Abruption

15. Placental Abruption
Risk factors
 Increased blood pressure
 Trauma
 Drug use - cocaine
 Smoking/poor nutrition
 Chorioamnionitis
 Twins/polyhydramnios

16. PLACENTA PREVIA

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)

20. Placental Abruption

22. HOW WILL U MANAGE ?

23.  INITIAL RESUSITATION
 Secure 2 large IV cannula
 Arrange blood
 Call for help
 Send blood for investigations and cross matching

24. SPECIFIC MANAGEMENT?

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 ?

30. WHAT IS THE DIAGNOSIS ?

31. Postpartum haemorrhage
 Estimated blood loss ≥ 500ml
 Primary: within 24hrs of delivery
 Secondary: 24hrs-6weeks post delivery

32. WHAT R THE CAUSES ?

33. Causes (4 Ts)
 Tone: uterine atony
 Tissue: retained placenta or retained products,
 Trauma: cervical or perineal, or ruptured uterus,
 Thrombin: coagulation disorder

34. WHAT ARE THE RISK FACTORS
FOR PPH ?

35. Risk factors
Antenatal • Proven abruption
• Placenta praevia
• Multiple pregnancy
• Pre-eclampsia
• Previous PPH
• Obesity
• Anaemia
Apparent during labour • Caesarean section
• Instrumental delivery
• Long labour > 12 hours
• Pyrexia in labour
• Retained placenta
• Mediolateral episiotomy
Antenatal or intrapartum • Morbidly adherent
placenta
Most cases of PPH have no
identifiable risk factors

36. PPH MANAGEMENT ?

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

38. SPECIFIC MANAGEMENT ?

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

41. MEDICAL MANAGEMENT ?

44. Newer Therapies ?
 B-Lynch Brace Suture
 Angiography and selective embolization
 Recombinant activated Factor VII

45. B-Lynch brace sutures

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

50. ROLE OF HYSTERECTOMY ?
HYSTERECTOMY LAST BUT
DEFINITIVE

51. Stepwise devascularization

52. Pelvic Hematoma DO NOT IGNORE

53. Thank you