METHODOLOGICAL INSTRUCTIONS

TO PRACTICAL LESSON FOR 5-Th YEAR STUDENTS

OF FACULTY OF FOREING STUDENTS

Content module 2.

LESSON ¹ 4 (6 hours)

 

Theme:

1. Obstetric hemorrhages in the first trimester of pregnancy. Ectopic pregnancy. (2 hours)

2. Obstetric hemorrhages in the second half of pregnancy, labor, and postpartum period. (2 hours)

 3. Intensive therapy and emergent care of obstetric hemorrhages. (2 hours)

 

Place of training: educational rooms, hospital wards.

Aim: be able to perform physical examination of the patients with uterine haemorrhage in the third trimester of pregnancy, first and second stages of labor. Learn the main causes, clinical signs and symptoms, methods of treatment in the patients with Placenta Previa and Abruptio Placentae. To learn the causes, clinical signs and features, diagnosis, prevention and treatment of the hemorrhages in the third stage of labor and postpartumto learn clinical signs and symptoms of terminal states in obstetrics, diagnostic workup of the terminal states establishment.

Professional orientation of students: Hemorrhage during the antepartum, intrapartum, or postpartum period is a life-threatening emergency for the mother and/or fetus. Early antepartum hemorrhage (before 20 weeks gestation) can be related to abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease; late antepartum hemorrhage (after 20 weeks gestation) may result from placental abruption and placenta previa. Intrapartum hemorrhage is most commonly due to placental abruption, or to uterine rupture, uterine inversion, invasive conditions of the placenta, or complications of Cesarean birth. Postpartum hemorrhage is defined as blood loss greater than 500 ml in a vaginal delivery or 1000 ml in a Cesarean birth; early postpartum hemorrhage occurs during the first 24 hours after delivery; late postpartum hemorrhage occurs after the first 24 hours after delivery. The most common cause of postpartum hemorrhage is uterine atony; however, lacerations, hematomas, and subinvolution of the uterus can also cause postpartum hemorrhage. MD who understand how to assess, plan, intervene, and evaluate outcomes for perinatal hemorrhage are in the position to prevent the major tragedies that can accompany hemorrhage in pregnancy and shortly afterward.

1. Methodology of Practical Class: 9.00-12.00.

Tasks for practical work 1.

Obtain a set of vital signs from the mother, including BP, pulse and temperature.

·         Elevated BP suggests the presence of pre-eclampsia.

·         Elevated BP may be defined as a persistently greater than 140 systolic or 90 diastolic. Usually, if one is elevated, both are elevated.

·         Elevated temperature suggests the possible presence of infection.

·         Many pregnant women normally have oral temperatures of as much as 99+. These mild elevations can also be an early sign of infection.

·         While a pregnant pulse of up to 100 BPM or greater may be normal, rapid pulse may also indicate hypovolemia.

Tasks for practical work 2.

1.     To take history.

2.     To reveal the main symptoms of Placenta Previa and Abruptio Placenta.

3.     To make plan of initial examination of the patients with uterine bleeding.

4.     To evaluate the dates which have been received during physical examination of the pregnant woman.

5.     Confirmation of diagnosis.

6.     To prescribe adequate therapy.

7.  To take history and perform physical examination in the third stage of labor and puerperium.

8.  To assess of the placental separation and removal abnormalities.

9.  To make diagnosis and differential diagnosis of postpartum hemorrhage due to different causes.

 

Tasks for practical work 3.

 

1.  To take history in this pathology.

2.  To diagnose of the gestational term of the pregnancy and labor.

3.  To evaluate dates have been received during physical and vaginal examination.

4.  Conservative and operative treatment confirmation.

5.  To make differential diagnosis with Placental Abruption and Placenta Previa.

6.  To prescribe adequate treatment which depends from obstetrics situation.

7.  To perform external maneuvers of the separated placenta removal. 

8.  To perform manual removal of the placenta and manual exploration of the uterine cavity, uterine massage.

9.  Systematic approach of the terminal states which have been occurred as a result of hemorrhage. 

 

2. Individual Students Program.

 

 

1.     Ectopic pregnancy.

2.              Pathophysiology and etiology of ectopic pregnancy.

3.              Clinical Manifestations

4.     Diagnostic Evaluation

5.     Management (Conservative Therapy, Surgical Treatment).

6.     Complications.

7.     Hydatidiform mole (gestational trophoblastic disease).

8.              Pathophysiology and etiology of gestational trophoblastic disease.

9.              Clinical Manifestations

10.                        Diagnostic Evaluation

11.                        Management (Conservative Therapy, Surgical Treatment).

12.                        Complications.

13.         Placenta previa.

14.         Pathophysiology and Etiology of placenta previa.

15.         Clinical Manifestations

16.                        Diagnostic Evaluation.

17.                        Management.

18.                        Complications.

19.         Abruptio placentae.

20.         Pathophysiology and Etiology of abruptio placentae.

21.         Clinical Manifestations

22.         Diagnostic Evaluation.

23.         Management.

24.         Complications.

25.         Uterine rupture

26.         Pathophysiology and Etiology of Uterine rupture

27.         Clinical Manifestations

28.         Diagnostic Evaluation.

29.         Management.

30.         Complications.

31.                        5. Postpartum hemorrhage

32.         Early Postpartum Hemorrhage

33.         Late Postpartum Hemorrhage

34.                        Pathophysiology and Etiology of Postpartum hemorrhage.

35.              Principles for monitoring women who are at risk of postpartum haemorrhage.

36.              Clinical signs, symptoms and principles of management of the third stage of labour and early postpartum period.

37.              Uterine contractile drugs.

38.         Clinical signs and symptoms of the hemorrhage occurring during pregnancy.

39.         Causes of postpartum pathological hemorrhage.

 

 

 

3. Seminar discussion of theoretical issues 12.30-14.00.

1.     3. Spontaneous abortion.

2.              Pathophysiology and etiology of spontaneous abortion.

3.     Types of spontaneous Abortions

4.              Clinical Manifestations

5.     Diagnostic Evaluation

6.     Management (Conservative Therapy, Surgical Treatment).

7.     Complications.

8.                   Physical and vaginal examination of the puerpera in the early puerperium.

9.                    External manoeuvres of the separated placenta removal.

10.              Causes of the pathological postpartum hemorrhage in the third stage of labor and early puerperium.

11.              Clinical signs of Placenta accreta, increta and percreta.

12.              Clinics of the placental separation and removal abnormalities.

13.              Postpartum hemorrhage due to uterine atony and hypotony.

14.              Peripartum coagulation disorders – high risk factors for postpartum hemorhage. Coagulopathy in obstetrics.

15.              Drugs indications and operative intervention in the patients with puerperium hemorrhage.

16.         Main terminal states in obstetrics:

17.         Hemorrhagic shock;

18.         Septic shock;

19.         Thrombohemorrhagic syndrome;

20.         Acute renal failure;

21.         Anaphylactic shock;

22.         Amniotic fluid embolism.

23.         Management of terminal states.

24.         Blood transfusion in obstetrics.

 

 

4.Test evaluation and situational tasks.

1. All of the following are associated with massive placental abruption EXCEPT:

A – Painless vaginal bleeding;

B – Uterine rigidity;

C – Uterine pain;

D – Maternal cardiovascular collapse;

E – Absent fetal heart sound.

 

2. Vasa previa diagnosed in early labor is best treated with:

A – Voorhees’ bag;

B – Forceps delivery;

C – Spontaneous delivery;

D – Cesarean section;

E – Willett clamp.

 

3. Which form of therapy is often most effective for patients with “ Couvellaire uterus”?

A – Bedrest;

B – Cervical cerclage;

C – Total abdominal hysterectomy;

D – Intravenous ampicillin;

E – Cesarean section.

Real - life situations to be solved.

4. An 18 year-old primigravida at term, not in labor, has sudden onset of the severe continuous lower abdominal pain with a rapid pulse, low blood pressure, fetal bradycardia, and a tender abdomen.  Which is the most likely diagnosis?

5. A primigravida at term has profuse vaginal bleeding. Fetal heart tones are normal. The cervix is 2-3 cm dilated with an edge of placenta palpable. Which is the most appropriate treatment?

 6. A 26-year-old G6 P5005 presents for her routine antepartum visit at 18 weeks’ gestational age. She is distressed because at her ultrasound visit the day before she was told by the technician that her placenta was partly over the opening of her womb. Which would you tell the patient?

 

5. Student's individual work from 14.15 till 15.00 hrs.

Students, who have not passed control in «MOODLE» system, should stay for individual work and write test control. Students work with thematic training tables, train in computer class, work with license examination test "KROK" and the department database tests, in-depth study of topics according to an individual study program, etc.

 

6. Student should know:

1.     Etiology of Placenta Previa.

2.     Classification of Placenta Previa.

3.     Diagnosis of Placenta Previa.

4.     General principles of the management of the women with Placenta Previa according to the types of placenta previa.

5.     Causes of the Placental Abruptio.

6.     Clinical; signs and symptoms of the Placental Abruptio.

7.     Management of the patients with Placental Abruptio.

8.     Definition of the “Couvelaire uterus” term.

9.        Etiology and pathogenesis of postpartum hemorrhage.

10.   Signs of placental separation abnormalities.

11.   Signs of the placental removal from the uterine cavity abnormalities.

12.   Clinical symptoms of the uterine atony hemorrhage.

13.                  Factors predisposing to developed of the hemorrhage during pregnancy and labor.

14.                  Signs of placental separation.

15.                  Confirmation of the diagnosis and methods of treatment hemorrhage due to atony and coagulopathy.

16.                  Systematic urgent approach during obstetrics terminal states.  

 

7. Student should be able to:

1.     To reveal the main symptoms of Placenta Previa and Abruptio Placenta.

2.     To make plan of initial examination of the patients with uterine bleeding.

3.     To evaluate the dates which have been received during physical examination of the pregnant woman.

4.     Confirmation of diagnosis.

5.     To prescribe adequate therapy.

6.  To take history and perform physical examination in the third stage of labor and puerperium.

7.  To assess of the placental separation and removal abnormalities.

8.  To make diagnosis and differential diagnosis of postpartum hemorrhage due to different causes.

9.  To diagnose of the gestational term of the pregnancy and labor.

10.                 To evaluate dates have been received during physical and vaginal examination.

11.                 Conservative and operative treatment confirmation.

12.                 To make differential diagnosis with Placental Abruption and Placenta Previa.

13.                 To prescribe adequate treatment which depends from obstetrics situation.

14.                 To perform external maneuvers of the separated placenta removal. 

15.                 To perform manual removal of the placenta and manual exploration of the uterine cavity, uterine massage.

16.                 Systematic approach of the terminal states which have been occurred as a result of hemorrhage. 

 

 

8. Correct answers of test evaluations and situational tasks:

1. A.

2. D.

3. C. D.

4. Abruptio placentae.

 5. Cesarean section.

6. She has a placenta previa and will definitely require cesarean section. The ultrasound is consistent with a partial placenta previa. Because the growth of the upper and lower uterine segments may results in the placenta “migrating away” from the cervical os, it is too early to be certain that cesarean section will be required. 

 

 9. References:

The main:

1.     Obstetrics and gynaecology. Williams & Wilkins Waverly Company. – Third Edition.- 1998. – P. 237 - 246.

2.     Danforth’s Obstetrics and gynaecology. - Seventh edition.- 1994. – P. 351 – 464.

3.     Basic Gynecology and Obstetrics. – Norman F. Gant, F. Gary Cunningham. – 1993. – P. 444 - 456.

4.     Obstetrics and gynecology. – Pamela S.Miles, William F.Rayburn, J.Christopher Carey. – Springer-Verlag New York, 1994. – P. 74 - 77.

5.     Obstetric hemorrhages in the first term of pregnancy

 

Additional:

1.     Order ¹ 503 from 28.12.2002 «Improvement of ambulatory obstetric-gynecological help».

2.     Order ¹ 582 from 15.12.2003 «Clinical protocols from the obstetric and gynecological help».

3.     Order ¹ 620 from 29.12.2003 «Organization of grant of stationary obstetric-gynecological and neonatal manuals».

4.     Order ¹ 676 from 31.12.2004 «Clinical protocols from the obstetric and gynecological help».

5.     Order ¹ 782 from 29.12.2005 «Clinical protocols from the obstetric and gynecological help».

 

 

Methodical instruction has been worked out by: Korda I.V.

 

Methodical instruction was discussed and adopted at the Department sitting

27.05.2011. Minute ¹ 13

Methodical instruction was reviewed and adopted at the Department sitting

24.05.2012. Minute ¹ 13

Methodical instruction was discussed and adopted at the Department sitting

23.05.2013. Minute ¹ 10

Methodical instruction was adopted and reviewed at the Department sitting

__________20__. Minute ¹ __

Methodical instruction was adopted and reviewed at the Department sitting

__________20__. Minute ¹ __

Methodical instruction was adopted and reviewed at the Department sitting

__________20__. Minute ¹ __

Methodical instruction was adopted and reviewed at the Department sitting

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