amc clinical exam
You are a HMO who is working in a tertiary hospital emergency department and just started your night shift; your first patient is a 36 year old woman, Jane, at 37 weeks of gestation and is complaining of vaginal bleeding and abdominal pain.
Your Task is to:
• Take a brief, focused history
• Perform an examination and appropriate investigations
• Explain your diagnosis
• Manage the case accordinglyHOPC: The pain started 2 and a half hour ago when she was in the kitchen at home. The pain is constant and is in all over the abdomen, the severity of the pain is changing every few minutes, sometimes 4-5 out of ten, then 7-8 out of ten. Resting or moving around does not relieve the pain. The bleeding is bright red and her underclothes and skirt stained with blood. There are no urinary or bowel symptoms, no nausea, no vomiting, no recent injury. She can not feel the baby’s movements at the moment, this is her first pregnancy, antenatal blood tests, 14 weeks and 18 weeks scans were reassuring, no DM, previous blood pressure check- ups were in normal range.
PHx: Her blood group is A Rh +, other medical history is unremarkable.
FHx: Unremarkable.
SHx: She is a teacher, married, non smoker, non drinker, no recreational drugs, NKA.
EXAMINATION: She feels clammy, looks a bit pale and is unwell and in significant pain, BP 115/60 mmHg, P 112/min, T 36.6 C, symphysio-fundal height is 38 cm, the uterus is very tender on palpation and feels hard, the presentation of the fetus can not be detected due to uterine tightening, on speculum; cervix seems closed and some blood is coming out, PV examination reveals that the cervix is soft, fully effaced but closed. Fetal heart sounds can not be heard with fetal Doppler.
Investigations:
USG (shows that the fetus is dead), Hb level is 80 g/L, WBC 6 x 10*9/L (3.5-11), Platelets 90 x 10*9/L (150-440), Sodium 135 mmol/L, Potassium 4.0 mmol/L, Urea 6.5 mmol/L (2.5-6.7) Creatinine 80 micmol/L (70-120), INR 2.2 (0.9-1.2), APTT 33 s (30-45 s), D-dimer (+).
Diagnosis: Placental Abruption!!!!
The presence of vaginal blood shows that it is a ‘revealed abruption’ but the other signs of hardened (couvelaire) uterus, raised fundal height, tachycardia and low Hb all suggest that the major part of the blood is still concealed. The BP appears normal, but this is because the woman is relatively young and fit, she is able to compensate by increasing heart rate and cardiac output. The increase in INR, decreased platelets and positive D dimmer confirm that she developed DIC and the patient is hypovolaemic.
Management:
This is an obstetric emergency. Resuscitation of the patient:
• Insertion of two large bore venous cannulae
• Crossmatch of 6 units of blood
• Request for fresh frozen plasma and platelets
• Initial fluid resuscitation with intravenous fluids, probably volume expanders
• Insertion of a central line to monitor CVP and a urinary catheter to monitor urine output
• Monitoring of fundal height and blood loss
As the baby has died there is no indication for C/S, which would put the patient at risk of further bleeding. C/S should be reserved for delivering a live but potentially compromised baby. Therefore vaginal induction of labour should be initiated. A syntocinon infusion should be commenced immediately after delivery as uterine atony and postpartum haemorrhage are common after significant abruption.
Placental Abruption: refers to the premature separation of the normally implanted placenta from the uterine wall. Especially abdominal discomfort and painful uterine contractions helps to differentiate it from placenta previa.
Placental abruption occurs when there is hemorrhage into the decidua basalis, leading to premature placental separation and further bleeding. The cause for this bleeding is often not known. If the bleeding and subsequent separations of a placenta permit access to the cervical os, vaginal bleeding will be apparent (external or revealed haemorrhage). If the placental location is higher in the uterus, or if the bleeding is more central and the margins of the placenta remain attached to the underlying uterus, blood may not escape into the vagina but is instead trapped under the placenta (concealed haemorrhage). The bleeding into the basalis stimulates the uterine muscle to contract, and the uterus will be painful and tender to touch. At times, the bleeding can penetrate the uterine musculature to such an extent that, at the time of cesarean delivery, the entire uterus has a bluish appearance (Couvelaire uterus or apoplexie uteroplacentaire). Spontaneous resolution of the condition occurs postpartum.
In severe cases of abruption placentae shock may result from the distraction and separation of the myometrial fibres. Another complication is the release into the circulation of thromboplastins from the damaged vessels, which cause widespread intravascular coagulation (DIC). The microthrombi are dissolved by fibrinogens, mainly plasmin, with the release of fibrin degradation products (D-dimer) and the possible development of consumptive coagulopathy (hypofibrinogenaemia). In severe cases some microthrombi escape lysis and are deposited in the endothelium of the vessels supplying the glomeruli of the kidneys. This may lead to tubular necrosis and oliguria or anuria.
We differentiate three grades of abruption placentae:
1.MILD:
Blood loss <500 mls, no disturbance of maternal or fetal condition. US shows the placenta is not lying in the lower uterine segment and no retroplacental clots can be seen. Bed rest is advisable and bleeding usually stops and patient can start to ambulate. If close to term labour can be induced by amnitomy provided that the condition of the cervix warrants this.
2.MODERATE:
Usually at least ¼ of the placenta has become detached and >1000 mls of blood have been lost. Abdominal pain and tenderness of the uterus are present because blood has infiltrated between its muscle fibres. Shock with rapid pulse and low BP may exist. The fetus is hypoxic and may show abnormal heart rate patterns on CTG.
Management consists of restoring blood loss (at least 1500 mls of blood) to prevent renal ‘shutdown’ and anuria, prevention or treatment of coagulopathy and monitoring urinary output. If the fetus is still alive a decision needs to be made whether to perform a caesarean section of the artificial rupture of the amniotic membranes (ARM).
3.SEVERE:
Severe placental detachment with at least 1500 mls of blood loss, shock, hard and very tender uterus. The fetus is almost always dead. Coagulopathy common.
Management as above but more blood (2500 mls at least).
Fetal death caused by deprivation of oxygen is, unfortunately, not rare with placental abruption but maternal death should be avoided nowadays with good management.
Blood Replacement Products:
• Packed RBCs, (250 ml), replaces RBC mass only
• Fresh- frozen plasma, (250 ml), all procoagulants; no platelets, supplies 150 mg fibrinogen/unit
• Cryoprecipitate, (20-50 mL/unit), fibrinogen; factors VIII and XIII, variable fibrinogen content, averages 0.25 mg/bag
• Platelets (50 mL/unit), increases platelet count 5,000-8,000/mcL/unit
Fresh whole blood (500 mL), RBCs and all procoag
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