Women risk transcript — SMP305 lecture transcript

Things like that, so they should all be familiar, but it applies in general medicine, it applies in general surgery, it applies in gynae. And so our same red flags are pretty much there. We have a slightly lower threshold of obstetrics to say something is a red flag. So in labour, particularly, especially if somebody's had their waters broken either by us. Or before going into labour and we've got a low threshold to call a temperature a temperature. So in general medicine you might say 0 37.5, I don't care. In obstetrics we say, oh, OK, let's repeat it and if there's two temperatures above 37.5, then we call that a red flag for sepsis, and so we do a septic screen and give some antibiotics. If they become completely well afterwards, we can just do a short course of antibiotics, but we have generally a lower threshold because we've got a high risk of infection and with that amniotic fluid sack, etc. OK? Um, sepsis, sepsis 6, give 3, take 3 buffalo. However you want to remember it, still really important and and we do all the same things here. I don't see us giving oxygen very often, but just give oxygen if required, but the main things are cultures, fluids, and antibiotics.

So PPH in a, in a normal spontaneous vaginal delivery above 500 mL counts as a PPH um. If it's a caesarean section, it's above 1000 mL would count as a PPH. So we kind of accept below 1000 mL as kind of expected um in the caesarean section. Um, and then minor PPH would be below 1000 mL and major PPH is above 1000 mL. OK, um, or somebody who has clinical shock as a result of the PPH. So if somebody was really petite and lost 700 mL, they might be quite poorly with it. Um, crucially, the, the average person could average 70 kg, there's a great variety in what we see in obstetrics. Um, a loss of about 3 litres is considered as life threatening. For that reason, if we have somebody who's lost 1.5 litres and has still got active ongoing bleeding, which we would classify as more than 150 mL per minute, but it's very hard to actually measure 150 mL per minute. But if we've lost 1.5 and we're thinking we're still worried about bleeding, then we use a major upset. haemorrhage protocol. So you might have heard of major haemorrhage protocols or whatever for like trauma that comes in through A&E, but we have a major obstetric haemorrhage protocol and that's because um we can see a great deal of blood loss in a very, very fast period of time. And so we, it essentially allows us to get a negative blood very quickly as well as cross match blood and then the blood bank will keep giving us blood products until we say stop. And so it means that you have loads of. Loads and loads to give if we need to while we're getting control of bleeding because, because you can die

basically. Secondary PPH then is abnormal or excessive bleeding after 24 hours um and that is the definition. Some people will call secondary PPH after 12 hours um or they'll just say oh all the bleeding stopped and then it started again and therefore it's secondary but the the book definition is after 24 hours. And up to 12 weeks. It affects about 1%, maybe less of pregnancies and it's not always as severe as um primary PPH and it might be more cumulative, but it's the kind of thing where somebody might just have consistent bleeding for about 3 months after they've delivered and then we see a drop in their HV because they've just come in to see count and that would still count, OK? So the most common causes, so we spoke a bit about the placental bed and the contraction of the uterus, and so tone is far in our way, far and away sorry our most common cause of PPH and so we need to think about uterine tone, so we're gonna palpate the abdomen, see what the tone of the uterus is like, we're gonna see is it at the umbilicus, but also does it feel squishy, so is it boggy? Or does it feel well contracted and so it can feel like quite a firm, easy to palpate organ and so we're wanting it to feel firm and that's how we know that it feels well contracted. Tissue, so retain placental tissue if the placenta's not complete or if the placenta's not been delivered, sometimes it can partially detach but then the uterus can't contract properly, so they kind of interact one with the other and trauma, for example, damaged the reproductive tract during. Um, delivery, so we can get very vascular, um, episiotomies, very vascular secondary beta, 3rd degree, 4th degree, um, that then cause, um, blood loss, thrombin, so coagulopathies and vascular abnormalities. So if we think of our 40s, then we can kind of remember what things do I need to be thinking about if I'm assessing somebody with a PPH.

Management is largely as you would expect, we still need to do our 180. Starting with A is still most important, but you can do a quick A B and then fix on something because that's our main thing. um, identify and treat the cause, so we're thinking about our 40s, we're thinking what is most likely. If we think it could be towed, just start some treatment for that and you can think about the other things. So bimanual compression is kind of your first instant before you can give any drugs, and so that essentially is a vaginal examination. Pressure on the top of the uterus and then pressure from below as well and that allows us to contract the uterus a little bit um but we need to be giving medications as well such as oxytocin analogues and so remember oxytocin was super super important hormone we give synthetic oxytocin to essentially uh mimic it and allow the uterus to contract. I don't think that the synthetic oxytocin that we give gives a glowy feeling on the inside unfortunately, but it does have the uterus.

Tissue, so if we think there's retained tissue or if the placenta hasn't come away within 30 minutes, that kind of thing, then we are, um, thinking about taking somebody to theatre for a manual removal of placenta, OK? And so that usually would be under spinal anaesthesia and then essentially we have to remove the placenta and manually, um, trauma, you need to repair it if we're finding it really difficult to repair. Because of inadequate analgesia or because of lighting or things like that, we can go to the obstetric theatres for that as well. So we often do repairs in the room, particularly if it's a second degree tear that's not bleeding too much. Positioning is slightly easier in theatre, but if somebody can't tolerate um examination and repair because they've just been having gas and air and, and then everything's a bit sore, we can use local anaesthetic, but sometimes that doesn't always. Cut it and so we can go to it if we need to um and then from them hopefully usually have been identified antenatally but not always and we'll do some bloods and stuff we're gonna cost much at least 2 units if we're worried about ongoing blood loss um but the main things are management and oftentimes by the time you've done your tone tissue and trauma, actually the bloods have only just been sent off and everything's OK

most of the time, but you still need to send the bloods in case they're not OK, uh. So secondary PPH, the most common causes are endometritis or infection and retained tissue and we also can see abnormal evolution of the placemental site which then can be related to, um, arteriovenous malformations, but the most common and important ones to know about and think about for like if you become A&E. Doctor or a GP or or an obstetrician and uh endometriitis, so we can treat that with antibiotics, so we do a full assessment and think about how unwell is somebody, oral antibiotics might be fine if the baby's not too much and retain placental tissue so we can look essentially if we see somebody who's got ongoing bleeding, if it's very. Very, very lots then sometimes we need to do emergency measures, but we'll take a swab for infection and we'll organise an ultrasound scan to check for any remaining placental tissue or blood clots, that kind of thing, um, and then we can manage those accordingly. The antibiotics we would always give even if it was placental tissue because the risk of infection is greater, OK? So VTE, sorry for hammering at home so much, it's really important. Um, we know that the risk of VTE is far greater in the postnatal period than it is in the antenatal period. So some people who are medium risk of VTE won't have Deltaparron antenatally but will be given it once they've delivered their baby. So if we can deem somebody to be moderate risk, so maybe they've got increased BMI, maybe they've had more than 3 babies, maybe they're, uh, they've had a caesarean. Usually we would look to have two risk factors from this list thereabouts to call them intermediate or moderate risk and then they would have 10 days deltaparin or or um fparin or whatever to go home with as well

as TED stockings. If somebody is high risk that usually would be 3 risk factors or more or some particularly important risk like previous history of ETE or family history of ETE and they would go home with 6 weeks of deltaparin, OK? um. And it's kind of a a team effort to identify these patients and so often the risk assessment is done by the midwives, but then the discharging doctor needs to make sure that they agree with the risk assessment and agree with the length of time to prescribe the Deltaparin for um as you can imagine compliance with this sometimes can be an issue because injecting yourself every day with Deltaparron when you've got a newborn baby it's not really an appealing thing and so getting buy-in from the patients about the importance of this is really important as well. Um, and so we think about this on sort of postnatal ward round that kind of thing, but the midwives are really important within this as well. Right, preeclampsia, so preeclampsia is defined really by high blood

pressure, significant proteinuria, and gestation greater than 20 weeks, and we can. Diagnose it most commonly antenatally, we can diagnose it postnatally as well. And as well as proteinuria, we can also use end organ dysfunction as a diagnostic criteria. So if somebody's got significant AKI or significant derangement of their LFTs as well as high blood pressure, that usually would be used as a diagnosis for preeclampsia, especially. because we can't use proteinuria postnatally and that's just because of contaminants from um the birth canal, that kind of thing, OK? And eclampsia is the seizure that occurs as a result of preeclampsia and so if somebody is sei in A&E and is pregnant, often they'll think, oh this is probably eclampsia, treat as such because the treatment of eclampsia is different from the treatment of like an epileptic seizure, that kind of thing. So the mainstay is. Magnesium sulphate IV if somebody is having a seizure. Um, it is primarily thought to be a placental disorder and it's still something that is not really fully understood but it's thought that essentially there's in somebody who has or will develop preeclampsia, um, there's insufficient um invasion of the placental, uh. Um, blood vessels into the decidua and uh myometrium, and what that means is there's the greater resistance of blood flow from the maternal body into the placenta and that is what causes the higher blood pressure, but also then causes toxicity through the through the body and can cause end organ dysfunction too, um. Identifying it is really important and so we should do blood pressure at all um interactions with the midwife. um most commonly it's treated with labetalol but nifedipine is a really important um medication as well.

Consider delivery, so if it's really hard to control preeclampsia we can consider delivery but we always would deliver somebody who has been diagnosed with preeclampsia. At around 37 weeks, OK, so we bring forward our date of delivery a little bit to prevent preeclampsia worsening and eclampsia developing. Um, there are always local guidelines if you have nothing to do and you're there for a little night shift, then actually it's not, they're often really boring, but it's quite a good informative read if you did want to. Right, uh, mental health disorders, just as some definitions, um, when I wrote this lecture I was under the understanding that I think you get some more teaching on maternal, like perinatal mental health, that kind of thing, yeah? Hopefully. If you don't, then this is what you get. So definitions, so we've got 3 main sort of conditions or definitions that. We want to be able to separate from each other, so baby blues is kind of a, um, as a result of changes in hormones, so changes in hormone levels, a big drop in oestrogen, and, and also having a newborn baby is really difficult and it's usually within the 1st 3 to 10 days postnatally.

The 10 day limit is quite important in terms of differentiating it from postnatal. So baby blues are really common. Postnatal depression is is defined as any depressive episode that happens within the 1st 12 months postnatally, and the severity varies, but much like diagnosing depression, it would need to last 12, uh, 2 weeks, sorry, in order for it to be diagnosed technically. Um, it is less common but. Still relatively common, um, and if it's lasting long or affecting someone's life or functioning then medical treatment would be advised. Um, poor parapsychosis then is a severe form of mental illness which usually starts quite quickly, um, after delivery. So whereas postnatal depression can, can happen kind of at any time. Most commonly with postnatal psychosis we see it developing within days, sometimes within like 24, 40. Hours of delivery of the baby. The incidence is about 1 in 1000, so not too, too common, um, and unfortunately the, the rate of recurrence is really high, so if somebody has uh postnatal psychosis or peripheral psychosis, um, they are very likely to get it in the subsequent pregnancy and therefore they would have input from the perinatal mental health team throughout their pregnancy and certainly in the peripheal, OK?

So final little quiz. And then I think we'll be finishing a bit early. OK, so define major PPH. Yeah, so we're talking about exceeding 1000 mL, OK, um, yeah, I would have to say clinically we don't talk about major and minor all that often, but still more than 1000 mL counts as major. What are the four Ts of primary PPH? Absolutely. Tone, tissue, trauma, thrombone, very good. Give two factors which increase the risk of venous thromboembolism. Great. So yeah, absolutely. All very good. Admission, very important. Raise BMI previous BT. The prolonged hospital stay, all of that stuff very important well done. Which features are diagnostic of preeclampsia. Yeah, so it is hypertension, gestation more than 20 weeks and significant proteinuria. Headache is a symptom of preeclampsia, um, and seizure then would be eclampsia. Great, that is the end. Please, before we go. Any questions, I'm happy to take, but would you be able to do a feedback form for me please? I. And do you guys have access to the slides? Yes, good stuff. I think there was a problem with that last time. Have you got more lectures today? Yeah. At 12 Be.

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