Obs - APH

Question 1

G2P1 history of caesarean section, at 37 weeks of gestation, NDH A&E per vaginal bleeding and
abdominal pain.

Ddx?

Answer 1

Placenta abruptio
Placenta previa
Uterine rupture
Scar rupture

Question 2

Initial management?

Answer 2

1. resuscitation:NPO, vitals, fetal heartbeat, ABC

2. Confirm diagnosis: 
PE: abdominal exam, speculum, pv
Ix: CBC LRFT clotting Xmatch
USG for retroplacental clot, fetal viability, PP
CTG for uterine irritabilitu

3. Plan delivery
   Nonviable: expectant management
   Viable, confirm abruptio: emergency CS within half an hour

Question 3

Confirmed abruptio, BP 100/60, CTG viable, reduced variability, next step?

Answer 3

Immediate delivery.

stabilise patient and give IV fluid on ambulance

Alert PWH labour ward and paediatrician on standby, escort patient there with doctor

Question 4

BP100/60, P100, Hb9, INR 2 plt 90, intrauterine death confirmed: discuss mode of delivery

Answer 4

Dx is hypovolemic shock with suspected disseminated intravascular coagulation.

Mx
1. Resuscitation, maintain circulation (Transfuse up to 4 units of FFP and/or 10 Units of Cryoprecipitate empirically), call for help

2. Deliver foetus, with hx of C/S, explain risk of scar rupture and notify senior to give misoprostol
   analgesics
   s/s uterine rupture
3. Postpartum
   High risk of PPH, give IV syntocinon and crystalloids
   Investigation of IUD, maternal bacteriology/serology/endocrine/autoimmune, fetal blood/swab/genetic analysis/postmortum, etc
   Psych