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Ростовский Государственный Медицинский Университет

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Медицина общая

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Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Riskfactors

Domesticviolence(askifrepeatedpresentations) Anticoagulantuseorcoagulopathies PreviousAPH Smokinganddrugabuse For placental abruption: previous abruption, pre-eclampsia, fetal growth restriction,non-vertex presentations, advanced maternal age, premature rupture of membranes, intrauterine infection, abdominaltrauma For placenta praevia: previous placenta praevia, previous caesarean section, previous termination,multiparity,advancedmaternalage,multiplepregnancy,deficientendometriumdueto pastprocedureorinfection,assistedconception.

PreventingAPH

ThefollowinginterventionsmayreducetheriskofAPH:

Stoppingsmokingandtheuseofillicitdrugs Avoidingvaginalandrectalexaminationsinwomenwithplacentapraevia Avoidingpenetrativesexualintercourseinplacentapraevia.

History

Onsetofbleeding Amountofbleeding(seeBox58.1Quantifyingbloodloss) Associatedpain—ifcontinuousthinkabruption,ifintermittentthinklabour Triggers—trauma,sexualintercourse,exercise Associatedruptureofmembranes Presenceoffetalmovements Cervicalsmearhistory Presenceofriskfactorsforplacentapreviaorabruption Current medication (particularly LMWH or warfarin—patients taking these medications should withholddosesiftheyhaveanyvaginalbleeding andattend hospitalfor urgentassessmentwith haematologyinputtoadviseaboutfuturedoses) Obstetrichistory Knownplacentaorvasapraevia.

Box58.1Quantifyingbloodloss

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Spotting=spotting/staining/streakingnotedonunderwear Minorhaemorrhage=self-limitingbloodloss<50mL Majorhaemorrhage=bloodloss50–1000mLwithnosignsofshock Massivehaemorrhage=bloodloss>1000mLand/orsignsofclinicalshock(seeChapter94) Remember,bleedingmaybeoccult(e.g.concealedplacentalabruption).

Examination

Examinewithseniorsupport.InitialassessmentshouldbewithanABCDEapproachwith ongoingresuscitationmeasures(see‘Management’).

Abdominalpalpation

Assessforuterinecontractions Tenseor‘woody’uterussuggestsabruption.

Speculumexamination

Toassessforcervicaldilatationoralowergenitaltractcauseofthebleeding Ifthecervixappearssuspicious,referthepatientforcolposcopy.

Digitalvaginalexamination

Donotperform a digital vaginal examination ifthere is any suspicionof placenta praevia—an USSshouldbedonefirsttoexcludethis.

Investigations

Maternal

Bloods

Minorhaemorrhage:FBC(coagulationprofileonlyifplateletsabnormal),groupandsave Majorhaemorrhage:FBC,coagulationprofile,U&E,LFT,cross-match4units(+VBG) IfrhesusDnegative:Kleihauertest(toquantifydegreeoffetomaternalhaemorrhage(FMH)and

thereforegaugedoseofanti-DIg).

Ultrasound

Toconfirmorexcludeplacentapraevia,ifthesiteoftheplacentaisnotyetknown.

Fetal

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Fetalinvestigationsshould be performed onlyoncethe mother is stable orresuscitationhas beencommenced.

Externalauscultationofthefetalheart:<26weeks Cardiotocograph (CTG): >26 weeks where knowledge of the fetal condition may influence the timing/modeofdelivery Ifthefetalheartcannotbeheard,performUSStodetermineviability.

Management

Acutemanagement

SeeTable58.1andTable58.2.

MassiveAPH(bloodloss>1000mL±signsofclinicalshock)

The mother’s life should always take priority, regardless of fetal gestation. She must be resuscitated and stabilized first, beforeany decisions are maderegarding delivery of the baby.

CALLFORHELP

Put out a major obstetric haemorrhage crash call as per hospital protocol. This should alert:

Aseniormidwife Anobstetricregistrar±consultant Ananaestheticregistrar±consultant Porterstocollecturgentspecimensanddelivercross-matchedblood Bloodbank±consultanthaematologistoncall Aseniorpaediatrician/neonatologistincaseofanemergencydelivery.

Designateonememberoftheteamtorecordevents,fluids,drugsgiven,andvitalsigns.

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Table58.1ABCDEapproachinmassiveAPH

Typicalrangesforvitalsignsareprovided,butuselocalprotocols/obstetricearlywarningscoresifavailable

A + B

AssessAirway+Breathing

Respiratoryrate—<10/minor>30/min Saturations—<95% Administerhigh-flowoxygen(10–15L/min)viaafacemask

C EvaluateCirculation

Heartrate—<40bpmor>120bpm Systolicbloodpress ure—<90mmHgor>160mmHg Diastolicbloodpress ure—>100mmHg Insert2×largebore(ideally14G)IVlinestocommencefluidresuscitation(Table58.2) Sendbloods forFBC,assess mentofFMHifrhesusDnegative,coagulationprofile,U&E,LFT,andcross-match4units ofblood Positionleftlateraltilt Keeppatientwarm Insertcatheterforfluidbalancemonitoring Transfusebloodassoonas available—untilthenupto2Lofwarmedcrystalloidsolution GiveotherbloodproductsifrequiredasperTable58.2

D AssessthefetusanddecideonDelivery

Table58.2FluidtherapyandbloodproducttransfusioninAPH

Crystalloid Upto2Lcrystalloidsolution

Blood Ideallycross-matched

Ifcross-matchedbloodisunavailableandtheclinicalsituationisurgent,givegroup-specificor O-negativeblood Considertheuseofcellsalvageifavailable

FFP

4unitsofFFP(12–15mL/kgortotal1L)

Forevery4units ofredcellsOR IfPTand/orAPTTare>1.5×normal

Pooledplatelets Ifplateletcount<75×109/L

Cryoprecipitate*Iffibrinogen<2g/L

Withcontinuingmassivehaemorrhageandwhileawaitingcoagulationstudies,upto4unitsofFFPand

10unitsofcryoprecipitatemaybegivenempirically.

Source:datafromMavridesE,AllardS,ChandraharanE,CollinsP,GreenL,HuntBJ,RirisS, ThomsonAJonbehalfoftheRoyalCollegeofObstetriciansandGynaecologists.Preventionand managementofpostpartumhaemorrhage.BJOG2016;124:e106–e149;

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/

If there is any concern that the patient has developed disseminated intravascular

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coagulation(DIC),urgenthaematologyadviceshouldbesought.

APHupto1000mLwithnoclinicalshock

AdmittohospitalifAPHisheavierthanspottingorbleedingisongoing:

ObtainIVaccess(1largeborecannula)

Commencecrystalloidinfusionifrequired.

Treatmentafterstabilization

Antepartum

IfthepatienthasasignificantAPHbetween24+0and34+6weeks,considergivingasinglecourse ofsteroids Following unexplained APH or APH due to placental abruption, the pregnancy should be reclassified as ‘highrisk’,subsequentantenatalcareshouldbeconsultantled, andserialgrowth scansperformed Administer anti-D Ig if required to a non-sensitized rhesus D-negative woman after any presentationwithAPH(irrespectiveofwhethertheyhavereceivedroutineprophylaxis):

Administeratleast500IU(additionaldosemaybeindicatedfollowingtestforFMH)

Ifrecurrentbleedingafter20+0weeks,giveat6-weeklyintervals.

Intrapartum

If there is fetal compromise, a caesarean section should be performed, with simultaneous resuscitationofthemother Continuous fetal monitoring should be used in women with active bleeding, previous major or recurrentminorAPH,orsuspicionofabruption Patients with APH should receive active management of the third stage of labour due to the elevatedriskofpostpartumhaemorrhage(PPH;seeChapter65).Thisshouldbewithergometrine-

oxytocin(Syntometrine®)unlesscontraindicated.

Postpartum

Thromboprophylaxis should be commenced as soon as the immediate risk of haemorrhage is reduced,asbothhaemorrhageandbloodtransfusionareriskfactorsforVTE Debriefbyaseniorobstetricianbothattheearliestopportunityaftertheeventandatafollow-up appointmentin4–6weeks Clinicalincidentreportingshouldbeundertakeninmajorobstetrichaemorrhage.

Specialconsiderations

Eachwomanmustbeassessedonanindividualbasis.Forexample,ifawomanpresents

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with spotting and has a past history of intrauterine fetal death resulting from placental abruption,thenhospitalizationwouldbeappropriate.

Furtherreading

1. RCOG (2018). Placenta praevia and placenta accreta: diagnosis and management (GTG27a). Availableat:https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg27a/

2. RCOG (2018). Vasa praevia: diagnosis and management (GTG27b). Available at:

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg27b/

3.BritishCommitteeforStandardsinHaematology(BCSH)(2014).BCSHguidelinefortheuseofanti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Available at:

https://onlinelibrary.wiley.com/doi/full/10.1111/tme.12091

4. RCOG (2015). Blood transfusions in obstetrics (GTG47). Available at:

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg47/

5. RCOG (2019). Maternal collapse (GTG56). Available at: https://www.rcog.org.uk/en/guidelines-

research-services/guidelines/gtg56/

6.NHSCervicalScreeningProgrammes(NHSCSP)(2010).ColposcopyandProgrammeManagement: Guidelinesfor the NHSCervical ScreeningProgramme,2nded. Sheffield: NHSCSP.Availableat:

http://www.cancerscreening.nhs.uk/cervical/publications/nhscsp20.html

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Chapter59

Diabetesinpregnancy

Guidelines: NICE NG3 (Diabetes in pregnancy: management from

preconceptiontothepostnatalperiod):https://www.nice.org.uk/guidance/ng3

JointBritishDiabetesSocietiesforInpatientCare(Managementofglycaemic control in pregnant women with diabetes on obstetric wards and delivery units): https://www.diabetes.org.uk/professionals/resources/shared-

practice/inpatient-and-hospital-care/joint-british-diabetes-society-forinpatient-care/management-of-glycaemic-control-in-pregnant-women-withdiabetes-on-obstetric-wards-and-delivery-units

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Approximately5%ofpregnanciesarecomplicatedbyeitherpre-existingdiabetesmellitus orgestationaldiabetesmellitus(GDM).Diabetesinpregnancyisassociatedwithanumber ofriskstobothwomenandtheirbabiesincludingmiscarriageandstillbirth(Table59.1).

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Table59.1Complicationsofdiabetesinpregnancy

Maternal Fetal

Miscarriage Congenitalmalformation

Pre-eclampsia Macrosomialeadingtoshoulderdystocia

Pre-termlabour Polyhydramnios

Worseningcomplicationsofdiabetes(e.g.retinopathy) Birthinjury

Stillbirth Perinatalmortality

Perinealtrauma Postnataladaptationproblems(e.g.hypoglycaemia)

Preconceptioncareforwomenwithdiabetes

Themostimportantpartofpreconceptioncareisforthepatienttoachieveblood glucoselevels withinthetargetranges (Box59.1) andHbA1c<48mmol/mol, asthisreduces many oftherisks associatedwithdiabetesinpregnancy(e.g.miscarriage,congenitaldefects,stillbirth) HbA1c:

Checkmonthly Aimfor<48mmol/mol(6.5%)ifachievablewithoutcausinghypoglycaemia.Reassurewomen thatanyreductiontowardsthistargetwillreducetheriskofcongenitalmalformation

If>86mmol/mol(10%),stronglyadvisewomennottogetpregnantbecauseoftherisks Use metformin as an adjunct or alternative to insulin in the preconception period and during pregnancy(allotheroralbloodglucose-loweringagentsshouldbediscontinuedbeforepregnancy) Performretinalassessmentifnotdoneinlast6months Performrenalassessmentsbeforecontraceptionisdiscontinued.Refertonephrologyifcreatinine

≥120μmol/litre,urinaryACR>30mg/mmol,oreGFR<45/min/1.73m2. StopACEinhibitors,ARBs,andstatinsandfindalternatives

AdvisewomenwithaBMI>27kg/m2toloseweight Encourageappropriateuseofcontraceptiontoavoidunplanned pregnanciestoreducetheriskof problemsduringpregnancy,ideallyuntilCBGmeasurementsarewellcontrolled Recommendfolicacid(5mgOD)toreducetheriskofneuraltubedefects Providethewomanwithaglucosemeterforself-monitoring,andaketonemeterifT1DM.

Box59.1Preconceptionbloodglucosetargets

Fasting(onwaking):5–7mmol/L Pre-meal:4–7mmol/L.

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Diagnosis

Whototestforgestationaldiabetesmellitus

Womenwithanyofthefollowingriskfactors:

PreviousGDM

BMI>30kg/m

Previousmacrosomicbabyweighing>4.5kg

First-degreerelativewithdiabetes

Minorityethnicfamilyoriginwithahighprevalenceofdiabetes Glycosuriaof2+ononeoccasionOR1+on≥2occasions,detectedduringroutineantenatalcare.

Investigations

HbA1c

Measureinallwomenwithpre-existingdiabetesorthosewithnewlydiagnosedGDM.

Oralglucosetolerancetest(OGTT)

PreviousGDM:PerformOGTTassoonaspossibleafterbookingandrepeatat24–28weeksifthe firsttestisnormal OtherriskfactorsforGDM(see‘Whototestforgestationaldiabetesmellitus’):PerformOGTTat 24–28weeks DiagnoseGDMifthewomanhaseither:

Afastingplasmaglucoselevel≥5.6mmol/LOR

A2-hourplasmaglucoselevel≥7.8mmol/L.

Antenatalmanagement

Patienteducation

Explain tothepatientthatgoodblood glucosecontrolduringthepregnancywillreduce therisktoherselfandherbaby,including:birthtrauma,needforcaesareansection,fetal macrosomia,neonatalhypoglycaemia,andperinataldeath.

Womenshouldbetaughttoself-monitorbloodglucose(Box59.2).

Lifestyleandsimpleinterventions

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Advise a healthy diet and refer toa dietician; emphasize that eating low glycaemic index (GI) foodsshouldreplacehighGIones Adviseregularexercise(suchaswalkingfor30minutes).

Pharmacologicalmanagement

Gestationaldiabetes

Fig.59.1Pharmacologicalmanagementofgestationaldiabetes.Glibenclamideisasecond-lineoptionfor patientswhodonotrespondwelltometforminandwhodeclineinsulin.

Riskofhypoglycaemiawithinsulintreatment

Ensure awareness of the risks of hypoglycaemia and impaired awareness of hypoglycaemia in pregnancy,particularlyinthefirsttrimester Ensureconstantavailabilityofafast-actingformofglucose(e.g.dextrosetablets) ProvideglucagonifT1DM—instructthewomanandfamilymembersinitsuse Considerinsulinpumpifadequatecontrolisnotachieveddespitemultipledailyinjections Consider continuousglucosemonitoringforpatientswith severe hypoglycaemiaorveryunstable bloodglucoselevels,undertheguidanceofanexpertjointdiabetesandantenatalcareteam.

Box59.2Bloodglucosemonitoring

The following are targets for CBG if achievable without causing problematic hypoglycaemia.CBGshouldbekeptat>4mmol/L:

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