Case 1 ALSO(UK) June 2007. Helens Story Helen is a 30 year old woman G2 P0 at 32 weeks gestation Presents with a history of : Abdominal pain - started

Case 1

ALSO(UK) June 2007

Helens Story

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

byHeavy vaginal bleeding

She denies any trauma.

Smokes 20 cigarettes per day 5 brief antenatal admissions with non-specific

abdominal pain.

Case Presentation APH

• BP 120/70, O Rhesus negative, Hb 13.2g/dl

At booking:At booking:


What risk factors can you identify?What risk factors can you identify?

• Smoker

• Possible domestic abuse victim


At this point what is your At this point what is your diagnosis?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)


On examinationOn 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


• 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?What would you do next?


What blood tests should be What blood tests should be requested?requested?

• FBC• Clotting screen• Cross match How many units?How many units?

6 units of blood (minimum for major bleed)

The results are normal. Her Hb is 10g/dl


What other information do you What other information do you require?require?

Fetal assessmentFetal assessment

• CTG - shows heart rate of 120 per minute with reduced variability of less that 5 bpm

Is she in labour?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.


What next……..

• Rapidly progresses to full dilatation

• Maternal pulse 130/min

• BP 95/60

• Fetal bradycardia of 60/minute


Mother needs further resuscitation whilst fetus is being delivered

How would you deliver?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?What do you do now?


The deliveryThe 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


APH weakens and PPH kills

Why may Helen bleed?Why may Helen bleed?

• Uterine atony • Operative delivery- vaginal trauma

• Coagulopathy (DIC) …… or all of them

What are your main concerns now?What are your main concerns now?


The estimated blood loss is 2500mls. Helen is given 5units 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…..Subsequent progress…..Case Presentation APH

• Under-estimation of total blood loss

• [Her initial Hb of 10g/l may have been misleading]

What is the most likely reason for such What is the most likely reason for such a low a low

Hb despite transfusion?Hb despite transfusion?


To end Helens’ story……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!WELL DONE!


Documents

Case 1 ALSO(UK) June 2007. Helens Story Helen is a 30 year old woman G2 P0 at 32 weeks gestation Presents with a history of : Abdominal pain - started