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4: Y4 - Obstetrics [13] > [48] Primary Post-Partum Haemorrhage > Flashcards

[48] Primary Post-Partum Haemorrhage Flashcards

1
Q

What is primary postpartum haemorrhage?

A

Loss of >500ml of blood per vagina within 24 hours of delivery

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2
Q

What are the classifications of primary PPH?

A
  • Minor

- Major

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3
Q

What is minor primary PPH?

A

500-1000ml blood loss

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4
Q

What is major primary PPH?

A

> 1000ml blood loss

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5
Q

What is the clinical importance of primary PPH?

A

It is a major cause of morbidity and mortality worldwide

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6
Q

What can the causes of primary PPH be broadly classified into?

A
  • Tone
  • Tissue
  • Trauma
  • Thrombin
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7
Q

What does ‘tone’ refer to in primary PPH?

A

Uterine atony

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8
Q

What is the most common cause of primary PPH?

A

Uterine atony

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9
Q

What is uterine atony?

A

When the uterus fails to contact adequately following delivery due to lack of tone in uterine muscle

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10
Q

What does ‘tissue’ refer to in primary PPH?

A

Retention of placental tissue

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11
Q

What is second most common cause of primary PPH?

A

Retention of placental tissue

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12
Q

How does retention of placental tissue cause primary PPH?

A

It prevents the uterus from contracting

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13
Q

What does ‘trauma’ refer to in primary PPH?

A

Damage sustained to the reproductive tract during delivery

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14
Q

Give 2 examples of causes of trauma that can lead to primary PPH

A
  • Vaginal tears

- Cervical tears

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15
Q

What does ‘thrombin’ refer to in primary PPH?

A

Coagulopathies and vascular abnormalities

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16
Q

What vascular abnormalities can cause primary PPH?

A
  • Placental abruption
  • Hypertension
  • Pre-eclampsia
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17
Q

What coagulopathies can cause primary PPH?

A
  • Von Willebrand’s disease
  • Haemophilia A or B
  • ITP
  • Acquired coagulopathies, e.g. DIC, HELLP
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18
Q

What can the risk factors for uterine atony be divided into?

A
  • Maternal factors
  • Uterine over-distention
  • Labour factors
  • Placenta problems
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19
Q

What maternal factors increase the risk of uterine atony?

A
  • Age >40
  • BMI >35
  • Asian
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20
Q

What can cause uterine over-distention therefore increasing the risk of uterine atony?

A
  • Multiple pregnancy
  • Polyhydraminos
  • Fetal macrosomia
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21
Q

What labour factors increase the risk of uterine atony?

A
  • Induction of labour

- Prolonged labour (> 12 hours)

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22
Q

What placental problems increase the risk of uterine atony?

A
  • Placenta praevia
  • Placental abruption
  • Previous PPH
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23
Q

What are the risk factors for traumatic PPH?

A
  • Instrumental vaginal delivery
  • Episiotomy
  • C-section
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24
Q

What is the main feature of primary PPH?

A

Bleeding from the vagina

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25
Q

What symptoms may be present in primary PPH if there is substantial blood loss?

A
  • Dizziness
  • Palpitations
  • Shortness of breath
26
Q

What examinations should be done in primary PPH?

A
  • General examination
  • Abdominal examination
  • Speculum examination
  • Placenta examination
27
Q

What might be found on general examination in primary PPH?

A

Haemodynamic instability, with;

  • Tachypnoea
  • Prolonged CRT
  • Tachycardia
  • Hypotension
28
Q

What might be found on abdominal examination in primary PPH?

A

Signs of uterine rupture, e.g. palpation of fetal parts as it moves into abdomen from uterus

29
Q

What might be found on speculum examination in primary PPH?

A

May reveal sites of local trauma causing bleeding

30
Q

Why should you examine in placenta in primary PPH?

A

To ensure it is complete

31
Q

What initial laboratory tests should be done in primary PPH?

A
  • FBC
  • Cross match 4-6 units of blood
  • Coagulation profile
  • U&Es
  • LFTs
32
Q

Who should be involved in the immediate management of PPH?

A
  • Midwife in charge and midwives
  • Obstetricians
  • Anaesthetists
  • Blood bank
  • Clinical haematologists
  • Porters
33
Q

What is involved in the immediate management of primary PPH?

A
  • Investigations and monitoring
  • Resuscitation using A-E approach
  • Consider catheterisation and insertion of a central venous line
34
Q

What monitoring should be done in primary PPH?

A
  • RR
  • O2 sats
  • HR
  • BP
  • Temperature

Done every 15 mins

35
Q

What does the definitive management of primary PPH depend on?

A

The underlying cause

36
Q

What is the management of primary PPH caused by uterine atony?

A
  • Bimanual compression to stimulate uterine contraction
  • Pharmacological measures to increase uterine contraction
  • Surgical measures
37
Q

How is bimanual compression to simulate uterine contraction performed?

A

A gloved hand is inserted into the vagina, and a fist formed inside the anterior fornix to compress the anterior uterine wall. The other hand should apply pressure on the abdomen at the posterior aspect of the uterus

38
Q

What do you need to ensure when doing bimanual compression to stimulate uterine contraction?

A

The bladder is emptied by catheterisation

39
Q

What surgical measures can be used in uterine atony?

A
  • Intrauterine balloon tamponade
  • Haemostatic suture around uterus
  • Bilateral uterine or iliac artery ligation
  • Hysterectomy (last resort)
40
Q

What drugs can be used primary PPH?

A
  • Syntocinon
  • Ergometrine
  • Carboprost
  • Misoprostol
41
Q

What is syntocinon?

A

A synthetic oxytocin

42
Q

What does syntocinon do?

A

Acts on oxytocin receptors in the myometrium

43
Q

What are the side effects of syntocinon?

A
  • Nausea
  • Vomiting
  • Headache
  • Rapid infusion can cause hypotension
44
Q

What are the contraindications to syntocinon?

A
  • Hypertonic uterus

- Severe CVS disease

45
Q

What is the action of ergometrine?

A

Has action at multiple receptor sites

46
Q

What are the side effects of ergometrine?

A
  • Hypertension
  • Nausea
  • Bradycardia
47
Q

What are the contraindications to ergometrine?

A
  • Hypertension
  • Eclampsia
  • Vascular disease
48
Q

What is carboprost?

A

Prostaglandin analogue

49
Q

What are the side effects of carboprost?

A
  • Bronchospasm
  • Pulmonary oedema
  • HTN
  • Cardiovascular collapse
50
Q

What are the contraindications to carboprost?

A
  • Cardiac disease
  • Pulmonary disease, i.e. asthma
  • Untreated PID
51
Q

What is misoprostol?

A

Prostaglandin analogue

52
Q

What are the side effects of misoprostol?

A

Diarrhoea

53
Q

How is primary PPH caused by trauma managed?

A

Primary repair of any laceration

54
Q

How is primary PPH caused by uterine rupture managed?

A

Laparotomy and repair, or hysterectomy

55
Q

How is primary PPH caused by placental retention managed?

A
  • Administer IV oxytocin
  • Manual removal of placenta with regional or general anaesthetic
  • Prophylactic antibiotics in theatre
56
Q

Where should the IV oxytocin infusion be started in primary PPH caused by placental retention?

A

In theatre

57
Q

How should primary PPH caused by coagulation problems be managed?

A

Correct any coagulation abnormalities with blood products under the advice of the haematology team

58
Q

How can the risk of primary PPH be reduced?

A
  • Active management in 3rd stage of labour

- Prophylactic oxytocin

59
Q

By how much does active management in the 3rd stage of labour reduce the risk of PPH?

A

60%

60
Q

How much prophylactic oxytocin should be given to women delivering vaginally?

A

5-10units IM

61
Q

How much prophylactic oxytocin should be given to women delivering by C-section?

A

5 units IV

4: Y4 - Obstetrics [13] (61 decks)

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