Maternal Health at the District Hospital Family Medicine Specialist CME Oct , 2012 Pakse

Objectives ● Use cases to review common causes for maternal morbidity and mortality in the community ● Review strategies to improve maternal health at the district or village health centre level

Case 1 ● A 20 yo G2P1 comes to the district hospital complaining of lower abdominal pain. ● She states she hasn't had her menses for 8 weeks now, but yesterday started bleeding.

Physical Exam ● PR = 110 bpm, BP = 96/54, T=36.4 ● Pale, sweaty, c/o pain in lower abdomen ● Abdomen tender suprapubically and RLQ ● Speculum exam reveals ++dark blood in the vagina ● Tender adnexa, and possible mass felt in RLQ

What is the Differential Diagnosis? ● Ectopic Pregnancy (most likely) ● Septic abortion ● Pelvic inflammatory disease / tubo-ovarian abscess ● A positive pregnancy test confirms your diagnosis of ectopic pregnancy

What Do You Do Now? ● Apply Oxygen, if available ● Start an IV, and give 2 L of crystalloid stat, and more depending on condition ● Consider blood transfusion if available ● Arrange for patient to be transferred quickly where she can have surgery to remove the ectopic pregnancy

Discussion ● What challenges to you face in the district hospitals with: – Diagnosing ectopic pregnancy? – Treating ectopic pregnancy?

Case 2 ● A 30yo G6P5 presents to your district hospital at 38weeks GA ● She states she started having bleeding a few hours ago, and now its running down her leg

What Else on History? ● No pain with the bleeding, but did start having some contractions in the last few hours ● Feels baby moving ● Last deliveries were uneventful and quick ● Otherwise healthy, with no medical problems ● She has had no ultrasounds

What Physical Exam Would You Do? ● Vital signs – P=105, BP=90/50, T=37.0 ● Abdominal exam – uterus soft, non-tender, head high above symphysis ● NO speculum or vaginal exam

Antepartum Hemorrhage

What is Your Diagnosis? ● Placenta Previa

What Can You Do at the District Hospital? ● Start IV, give fluid resuscitation ● If available, consider blood transfusion ● Immediately arrange for C/S, transfer out of District hospital if not available

Discussion ● Is transportation out of the district or village hospital a problem in your community?

Case 3 ● A 28yo G7P7 has just delivered. ● Immediately after the placenta delivers, there is a large gush of blood, and then continuous trickling of blood. ● You feel her uterus and it feels boggy/soft.

Questions 1) What are the most common causes of post- partum bleeding? 2) What can you do in the district hospital to stop the bleeding?

Causes of Post-Partum Hemorrhage ● Uterine Tone ● Retained Tissue ● Trauma to cervical/vaginal tissue ● Bleeding Disorders

● Uterine Tone – the most common cause, the uterus won't contract – Prolonged labor – Rapid labor – Uterine overdistension (multiple gestation, polyhydramnios) – Multiparity

● Uterine Tone – Treatment involves: ● Bimanual massage of the uterus ● Administration of uterotonic agents, ie: oxytocin IV/IM, misoprostol PO/PR/PV, carboprost IM/IMM, ergometrine IV/IM

Bimanual Uterine Massage

● Tissue in uterine cavity – Placenta tissue or even clots in the uterus or upper vagina can prevent uterine contraction – Manual removal of the entire placenta, small pieces of placental tissue or even clots from the uterus or vagina will correct this

● Trauma to cervical or vaginal tissues – Lacerations to the tissue can be a large source of bleeding – must be recognized and repaired

● Bleeding Disorders – Patients may have an underlying bleeding disorder – Patients may develop an acute problem with bleeding in cases of sepsis, massive hemorrhage or trauma – Treatment may require transfusion of clotting factors

Prevention of PPH ● Active Management of the Third Stage of Labour (recommended by WHO) – Giving uterotonic immediately after delivery – Early cord cutting and clamping – Controlled cord traction

Case 3 (cont'd) ● After doing bimanual massage, her uterus begins to firm up ● An IV in started, and she is given 20U of Oxytocin in 1L of normal saline ● You change your gloves, and on exploring her uterus remove a small piece of retained placenta, and multiple large clots

● After examining her cervical and vaginal tissue, you find no lacerations ● Her bleeding slows to expected within 15 minutes

Discussion ● What can be done to encourage women to deliver in hospital instead of at home? ● Have there been any strategies that have worked in your community?