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Gaby’s Green Top Guidelines > 2016 52 PPH > Flashcards

2016 52 PPH Flashcards

1
Q

** How can risk factors for PPH be minimised? **

A
  1. Investigate & treat antenatal anaemia
  2. Offer prophylactic uterotonics to all women for the 3rd stage
  3. Uterine massage is of no benefit
  4. Consider IV TXA 0.5-1g
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2
Q

** What uterotonics should be used for 3rd stage? **

A
  1. NVB no RFs: Oxytocin 10 units IM
  2. CS: Oxytocin 5 units slow IV
  3. Increased risk with no HTN: Syntometrine
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3
Q

** What are the definitions of PPH? **

A
  1. Minor: 500-1000ml
  2. Major: >1000ml
  3. Massive: >2000ml or >30% blood volume
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4
Q

** What resuscitation measures should be employed for a minor PPH? **

A
  1. Midwife in charge, obstetrician, anaesthetist
  2. 14G cannula (orange, >grey)
  3. Bloods: G&S, FBC, clotting inc fibrinogen
  4. Obs: RR, HR, BP every 15 mins
  5. Fluids: warmed crystalloid
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5
Q

** What resuscitate measures should be employed for a major PPH? **

A
  1. MDT including senior staff
  2. Evaluate ABC
  3. Position flat
  4. Warming
  5. Transfuse ASAP if clinically required
  6. Fluids: up to 3.5L warmed clear; initially crystalloid, not hydroxyethyl starch
  7. Rapid warmed infusion, no filters
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6
Q

** What features should emergency blood have? **

A
  1. Group O
  2. D-negative
  3. K-negative
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7
Q

** How should FFP be transfused in PPH? **

A

If no haemostatic results & bleeding continuing:
1. After 4 units of RBCs
2. At a dose of 12-15ml/kg
3. Earlier if abruption, AFE, delayed detection
If known:
4. PT/APTT >1.5 x normal
5. Give >15ml/kg

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8
Q

** How should cryoprecipitate be used in PPH? **

A

To maintain fibrinogen > 2g/L

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9
Q

** When should platelets be transfused in PPH? **

A

When platelet count < 75

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10
Q

** What surgical methods can be used in PPH? **

A
  1. 1st line: intrauterine balloon tamponade
  2. Brace suture
  3. Hysterectomy sooner rather than later, esp for placenta accreta or uterine rupture
  4. Involve consultant & 2nd opinion for hysterectomy decision
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11
Q

** How should secondary PPH be managed? **

A
  1. Swabs: HVS & endocervical
  2. Abx if endometritis suspected
  3. Pelvis USS to exclude RPOC
  4. Surgical ERPC under experienced clinician
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12
Q

What are the 4 Ts of PPH causes?

A

Tone: abnormalities of uterine contraction
Tissue: retained products of conception
Trauma: genital tract injury
Thrombin: abnormalities of coagulation

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13
Q

What are the risk factors for PPH due to tone

A
  1. Overdistension of uterus: polyhydramnios, multiple gestation, macrosomia
  2. Intra-amniotic infection: fever, prolonged ROM
  3. Uterine distortion: rapid or prolonged labour, fibroids, placenta praevia, uterine anomalies
  4. Bladder distension
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14
Q

What are the tissue causes of PPH?

A
  1. Retained cotyledon or succenturiate lobe
  2. Retained blood clots
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15
Q

What are the risk factors for traumatic causes of PPH?

A
  1. Lacerations of cervix, vagina or perineum: OVB, precipitous delivery
  2. Extensions or lacerations at CS: malposition, deep engagement
  3. Uterine rupture: previous uterine surgery
  4. Uterine inversion: high parity with excessive cord traction
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16
Q

What are the 4 categories of abnormalities of coagulation that can cause PPH?

A
  1. Pre-existing states
  2. Conditions acquired in pregnancy
  3. DIC
  4. Therapeutic anticoagulation
17
Q

What pre-existing abnormalities of coagulation can cause PPH?

A
  1. Haemophilia A
  2. Idiopathic thrombocytopenic purpura
  3. Von Willebrand’s disease
  4. History of previous PPH
18
Q

What conditions acquired in pregnancy can cause PPH due to abnormal clotting?

A
  1. Gestational thrombocytopenia
  2. Pre-eclampsia with thrombocytopenia inc HELLP
19
Q

What are the causes of DIC?

A
  1. Gestational hypertensive disorder
  2. In utero fetal demise
  3. Severe infection
  4. Placental abruption
  5. Amniotic fluid embolus
20
Q

What are the thresholds for anaemia in pregnancy?

A
  1. 110 in 1st trimester
  2. 105 in 2nd/3rd trimester
  3. 100 postpartum
21
Q

What impact can early cord clamping have on the neonate?

A

Lower blood volume, leading to
Lower birth weight

22
Q

How does syntometrine compare to oxytocin in PPH prophylaxis?

A
  1. Similar efficacy oxytocin 5 or 10 units vs syntometrine
  2. Syntometrine increases N&V & raises blood pressure
23
Q

What prostaglandins can be used in PPH management?

A

Carboprost IM
Misoprostol SL or other routes

24
Q

Why is carbetocin often chosen for PPH prophylaxis at CS?

A
  1. Longer-acting oxytocin derivative
  2. Reduces need for further uterotonics
25
Q

At what keeps of blood loss do signs of hypovolaemic shock usually show in PPH?

A
  1. 1000ml: tachycardia, tachypnoea, slightly reduced systolic BP
  2. 1500ml: systolic BP <80, altered mental state, worsening HR & RR
26
Q

What fluids can be used in PPH?

A
  1. Crystalloid: up to 2L isotonic
  2. Colloid: up to 1.5L awaiting blood
  3. Blood: emergency group O, D-negative, K-negative
  4. FFP: 4 units after 4 units RBCs, or 12-15mg/kg if PT or APTT prolonged
27
Q

What fluids can be used in PPH?

A
  1. Crystalloid: up to 2L isotonic
  2. Colloid: up to 1.5L awaiting blood
  3. Blood: emergency group O, D-negative, K-negative
  4. FFP: 4 units after 4 units RBCs, or 12-15mg/kg if PT or APTT prolonged
  5. Platelets: 1 pool if <75
  6. Cryoprecipitate: 2 pools if fibrinogen <2
28
Q

What blood component targets are we aiming to maintain in PPH?

A
  1. Hb>80
  2. Platelets >50
  3. PT < 1.5x normal
  4. APTT < 1.5 x normal
  5. Fibrinogen > 2
29
Q

What point of care tests can be used to assess coagulation?

A
  1. TEG: thromboelastography
  2. ROTEM: rotational thromboelastometry
30
Q

What are the risks of FFP?

A
  1. Majority have normal coagulation at time of administration
  2. TACO: transfusion-associated circulatory overload
  3. Transfusion-related lung injury
  4. Small increase so often need cryoprecipitate or fibrinogen as well
31
Q

How much does cryoprecipitate increase fibrinogen level?

A

2 pools (10 donors) increase fibrinogen by 1

32
Q

What doses of TXA are recommended in PPH?

A

1g IV
2nd dose can be given after 30 mins

33
Q

What are the recommendations for recombinant factor VIIa therapy in PPH?

A

Do not use routinely
Can use in clinical trials
Increases arterial & venous thromboembolism

34
Q

What actions should be taken, in order, for PPH due to atony?

A
  1. Rub up the fundus
  2. Indwelling catheter
  3. Oxytocin 5 units slow IV, can repeat
  4. Ergometrine 0.5mg IM or slow IV, unless HTN
  5. Oxytocin infusion 40 units in 500ml saline at 125ml/hr unless fluid restricted
  6. Carboprost 0.25mg IM can be repeated every 25 mins up to 8 doses (caution in asthma), theatre after 3rd
  7. Misoprostol 800 micrograms SL
35
Q

What surgical methods can be used in PPH if skills & equipment allow?

A
  1. Compression of aorta to allow time for resuscitation
  2. Intrauterine balloon tamponade, 4-6 hours, remove in daytime
  3. Haemostatic suturing eg B-lynch
  4. Stepwise uterine devasularisation
  5. Internal iliac artery ligation
  6. IR: Selective arterial occlusion or embolisation
  7. Hysterectomy
36
Q

What antibiotics are recommended for postpartum endometritis?

A

Clindamycin & gentamicin

37
Q

What ultrasound findings indicate postpartum RPOC?

A
  1. Echogenic mass
  2. Thickened endometrium
  3. AP diameter of cavity > 25mm d1-7
38
Q

What should debrief focus on following PPH?

A
  1. Events surrounding birth
  2. Postnatal depression
  3. Fears of future births
  4. Investigations for coagulopathies
  5. Screening for Sheehan syndrome: postpartum hypopituitarism

Gaby’s Green Top Guidelines (27 decks)

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