1. Case 1 ALSO(UK) June 2007

2. Helens Story

3. Helen is a 30 year old woman G2 P0 at 32 weeks gestation Presents with a history of : Abdominal pain - started 60 minutes ago, followed by Heavy vaginal bleeding She denies any trauma. Smokes 20 cigarettes per day 5 brief antenatal admissions with non-specific abdominal pain. Case Presentation APH

4. BP 120/70, O Rhesus negative, Hb 13.2g/dl At booking: Case Presentation APH

5. What risk factors can you identify? Smoker Possible domestic abuse victim Case Presentation APH

6. At this point what is your diagnosis? Ante-partum haemorrhage Constant pain would suggest an abruption, until proven otherwise Remember - abruption can be ‘concealed’ or ‘revealed’ (or a mixture of both) Case Presentation APH

7. On examination Helen is pale…… Her pulse is 130 bpm, BP is 105/60 She has blood between her toes Her uterus is tender, tense, with a fundal height of 34 cm The fetal heart is 120 bpm on auscultation Case Presentation APH

8. CALL FOR HELP - send out a ‘major obstetric haemorrhage alert’ to the relevant staff Helen needs resuscitation Remember basic life support - ABC’s (give oxygen) X 2 large bore IV cannulae Take bloods Commence IV fluids Nurse with left lateral tilt (remember Mrs Tilt!!) What would you do next? Case Presentation APH

9. What blood tests should be requested? FBC Clotting screen Cross match How many units? 6 units of blood (minimum for major bleed) The results are normal. Her Hb is 10g/dl Case Presentation APH

10. What other information do you require? Fetal assessment CTG - shows heart rate of 120 per minute with reduced variability of less that 5 bpm Is she in labour? Abdominal palpation 0/5Abdominal palpation 0/5 Vaginal examination: cervix thin 9 cm dilated, vertex the spines, ROA. ARM – bloodstained liquor. Case Presentation APH

11. What next…….. Rapidly progresses to full dilatation Maternal pulse 130/min BP 95/60 Fetal bradycardia of 60/minute Case Presentation APH

12. Mother needs further resuscitation whilst fetus is being delivered How would you deliver? Head is on the perineum – vaginal delivery Is quickest and safest option Remember to call for paediatric help What do you do now? Case Presentation APH

13. The delivery Baby is delivered quickly by vacuum The baby is resuscitated and transferred to the Neonatal Unit Ergometrine given Placenta and membranes delivered along with 600mls of blood clot Bleeding is not excessive after delivery. Syntocinon infusion started prophylactically after delivery Case Presentation APH

14. APH weakens and PPH kills Why may Helen bleed? Uterine atony Operative delivery- vaginal trauma Coagulopathy (DIC) …… or all of them What are your main concerns now? Case Presentation APH

15. The estimated blood loss is 2500mls. Helen is given 5 units of blood Overnight her pulse has remained at 100 bpm. BP 120/70 Her urinary output has been 40mls per hour overnight. Her abdomen is soft and not distended with minimal PV loss Her Hb is rechecked – 7.5 g/dl Subsequent progress….. Case Presentation APH

16. Under-estimation of total blood loss [Her initial Hb of 10g/l may have been misleading] What is the most likely reason for such a low Hb despite transfusion? Case Presentation APH

17. To end Helens’ story…… Helen remained in hospital for 5 days She went home and visited her baby on the neonatal unit daily Her baby was discharged 6 weeks following the birth WELL DONE! Case Presentation APH