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Abstracts / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) e128–e193
of time women spend waiting in the emergency department, whilst improving the rapid detection and management of women with life threatening conditions such as ectopic pregnancies and miscarriages with heavy bleeding. It also ensures that all women are seen in an EPU within 24 hours, in line with NICE guidelines. Once the pathway is established, we will re-audit to see whether there has been any change in practice. Although this pathway has been developed for St Mary’s Hospital, we feel it could be adapted for other sites. http://dx.doi.org/10.1016/j.ejogrb.2016.07.390 Oral Presentation 41. Maternal mortality and morbidity Scoring System & Challenges of Concealed Massive Postpartum Haemorrhage (PPH) Suad Hirsi-Farah ∗ , Femi Ajibade Royal Berkshire NHS Foundation Trust E-mail address:
[email protected] (S. Hirsi-Farah). PPH remains a leading cause of maternal mortality and morbidity. The risk of death from PPH in developed countries is about 1 in 100 000 deliveries compared to 1 in 1000 in developing country. Proper estimation of blood loss following concealed PPH remains a challenge both in diagnosis and management. Advances in methods of intraoperative &post-operative care have led to the use of scoring methods like MOWS chart for detection of early warning signs to avoid diagnostic delay. In cases of PPH timely and accurate diagnosis is essential to improve morbidity and mortality. We presented two cases which illustrated these challenges and role of modern imaging techniques in the management 37yrs old G2 para 0 + 1 with uneventful antenatal care except history RTA in the middle of pregnancy presented in early labour at 40 + 5 after 3 days of tightening at home. Labour was augmentation with oxytocin after 24 hours of SROM at 3-5 cm dilatation. She was fully dilated and pushing for 2-3 hrs. A caesarean section was done for high presenting part under regional spinal anaesthesia with blood loss of 1000mls.Immediately post C-section she has MOWs of 3 (PR of 117, T 36.7 & RR of 17) with well contracted uterus and minimal lochia. The vital signs continue to deteriorate e over 42 hrs despite transfusion of 4 units of blood and fluid resuscitation. She started complaining of increasing Lt sided abdominal pain, referred to the Lt leg 42 hrs post-op with PR 124 - 170 b/minwith sinus tachycardia on ECG, BP 91/57 and repeat Hb of 62. She had emergency laparotomy for suspected intra-abdominal bleeding after active resuscitation. Findings at laparotomy were a retroperitoneal mass/collection on the left of the abdominal. Involvement of the surgical team was initiated with an agreement for conservative management till further imaging was done in the morning. Bed side abdominal Scan in the morning confirmed retroperitoneal bleeding/Haematoma. She was transferred to JRH, Oxford for embolisation of leaking iliac vessel. She was subsequently managed conservatively over 3 months. The haematoma full resolved over 3months with various pressure effect on surrounding structure like ureter & multidisciplinary involvement The 2nd case was a patient in her second pregnancy who had an uneventful antenatal care except a RTA about 37weeks which involved another car running into the back of a car she was a passenger. In her first pregnancy she presentedwith foetal distress, significant APH and rapid progression to full dilation at term. She subsequently in that 1stdelivery had insertion of Rusheballoon for PPH. She was physiologically traumatised by the experiences of first delivery which lead to the request
for elective C/section in this 2nd pregnancy. At the beginning of the elective c/section she started complaining of Rt shoulder tip pain. The C/section was uninventive except a significant varicosity of the right broad ligament. In post-operative recovery she slowly progressed to a state of hypovolemic shock as revealed by vital signs scoring. She was subsequently taken for emergency laparotomy which revealed bleeding in to the retroperitoneal space on the right with deviation of a buggy looking uterus with intact non bleeding incision site She subsequently had subtotal hysterectomy and opening up of the Right broad ligament/retroperitoneal space with evacuation of some blood clot. Post Laparotomy imaging revealed retroperitoneal haematoma which took about three months to significantly reduced in size These are casesof concealed massive retroperitoneal hematoma from possible rupture of pelvic vessels during c/section with prior gentle RTA during antenatal period. Concealed Haemorrhages associated with pregnancy can be intrauterine, intra-abdominal bleeding or hematomas and are difficult to diagnose. The incidence of haematomas varies widely from 1:300 to 1:1500 deliveries. The most common locations of postpartum haematoma are Vulva, vaginal/paravaginal and retroperitoneum. It difficult to give the true incidence of retroperitoneal haemorrhage associated with pregnancy. These cases has an association of Non traumatic RTA, C-section and post–operative retroperitoneal Haematoma. However considering the process of labour and Csection it difficult to attribute any of these factors to this case except to assume is a case of spontaneous rupture of a vessel during process of labour and C/section delivery. Literature review highlighted the complexity of the management of retroperitoneal hematomas in obstetrics but has been improving with advances in investigative strategies, Treatment options and Critical care speciality. In bothcase early scoring of vital signs monitoring had helped to suspicion of a critical medical situation with potential high morbidity and possible mortality. Advances in Imaging techniques have contributed to early diagnosis and follow-up management. It also highlighted the potential use of bed side abdominal ultrasound on labour ward for early diagnosis of such condition. Such rare cases support the need for training and use of general abdominal ultrasound for all clinician involved in obstetrics critical care. The cases further highlighted the importance ofearly scoring methods like MOWS chart in care of patients on labour ward This coincidental clinical situation has prone this patient to have over 8 weeks of involvement with various clinicians in different speciality and hospitals. This has interrupted her opportunity to establish proper breast feeding and bonding with her child. http://dx.doi.org/10.1016/j.ejogrb.2016.07.391
