[48] Primary Post-Partum Haemorrhage Flashcards
What is primary postpartum haemorrhage?
Loss of >500ml of blood per vagina within 24 hours of delivery
What are the classifications of primary PPH?
- Minor
- Major
What is minor primary PPH?
500-1000ml blood loss
What is major primary PPH?
> 1000ml blood loss
What is the clinical importance of primary PPH?
It is a major cause of morbidity and mortality worldwide
What can the causes of primary PPH be broadly classified into?
- Tone
- Tissue
- Trauma
- Thrombin
What does ‘tone’ refer to in primary PPH?
Uterine atony
What is the most common cause of primary PPH?
Uterine atony
What is uterine atony?
When the uterus fails to contact adequately following delivery due to lack of tone in uterine muscle
What does ‘tissue’ refer to in primary PPH?
Retention of placental tissue
What is second most common cause of primary PPH?
Retention of placental tissue
How does retention of placental tissue cause primary PPH?
It prevents the uterus from contracting
What does ‘trauma’ refer to in primary PPH?
Damage sustained to the reproductive tract during delivery
Give 2 examples of causes of trauma that can lead to primary PPH
- Vaginal tears
- Cervical tears
What does ‘thrombin’ refer to in primary PPH?
Coagulopathies and vascular abnormalities
What vascular abnormalities can cause primary PPH?
- Placental abruption
- Hypertension
- Pre-eclampsia
What coagulopathies can cause primary PPH?
- Von Willebrand’s disease
- Haemophilia A or B
- ITP
- Acquired coagulopathies, e.g. DIC, HELLP
What can the risk factors for uterine atony be divided into?
- Maternal factors
- Uterine over-distention
- Labour factors
- Placenta problems
What maternal factors increase the risk of uterine atony?
- Age >40
- BMI >35
- Asian
What can cause uterine over-distention therefore increasing the risk of uterine atony?
- Multiple pregnancy
- Polyhydraminos
- Fetal macrosomia
What labour factors increase the risk of uterine atony?
- Induction of labour
- Prolonged labour (> 12 hours)
What placental problems increase the risk of uterine atony?
- Placenta praevia
- Placental abruption
- Previous PPH
What are the risk factors for traumatic PPH?
- Instrumental vaginal delivery
- Episiotomy
- C-section
What is the main feature of primary PPH?
Bleeding from the vagina
What symptoms may be present in primary PPH if there is substantial blood loss?
- Dizziness
- Palpitations
- Shortness of breath
What examinations should be done in primary PPH?
- General examination
- Abdominal examination
- Speculum examination
- Placenta examination
What might be found on general examination in primary PPH?
Haemodynamic instability, with;
- Tachypnoea
- Prolonged CRT
- Tachycardia
- Hypotension
What might be found on abdominal examination in primary PPH?
Signs of uterine rupture, e.g. palpation of fetal parts as it moves into abdomen from uterus
What might be found on speculum examination in primary PPH?
May reveal sites of local trauma causing bleeding
Why should you examine in placenta in primary PPH?
To ensure it is complete
What initial laboratory tests should be done in primary PPH?
- FBC
- Cross match 4-6 units of blood
- Coagulation profile
- U&Es
- LFTs
Who should be involved in the immediate management of PPH?
- Midwife in charge and midwives
- Obstetricians
- Anaesthetists
- Blood bank
- Clinical haematologists
- Porters
What is involved in the immediate management of primary PPH?
- Investigations and monitoring
- Resuscitation using A-E approach
- Consider catheterisation and insertion of a central venous line
What monitoring should be done in primary PPH?
- RR
- O2 sats
- HR
- BP
- Temperature
Done every 15 mins
What does the definitive management of primary PPH depend on?
The underlying cause
What is the management of primary PPH caused by uterine atony?
- Bimanual compression to stimulate uterine contraction
- Pharmacological measures to increase uterine contraction
- Surgical measures
How is bimanual compression to simulate uterine contraction performed?
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
What do you need to ensure when doing bimanual compression to stimulate uterine contraction?
The bladder is emptied by catheterisation
What surgical measures can be used in uterine atony?
- Intrauterine balloon tamponade
- Haemostatic suture around uterus
- Bilateral uterine or iliac artery ligation
- Hysterectomy (last resort)
What drugs can be used primary PPH?
- Syntocinon
- Ergometrine
- Carboprost
- Misoprostol
What is syntocinon?
A synthetic oxytocin
What does syntocinon do?
Acts on oxytocin receptors in the myometrium
What are the side effects of syntocinon?
- Nausea
- Vomiting
- Headache
- Rapid infusion can cause hypotension
What are the contraindications to syntocinon?
- Hypertonic uterus
- Severe CVS disease
What is the action of ergometrine?
Has action at multiple receptor sites
What are the side effects of ergometrine?
- Hypertension
- Nausea
- Bradycardia
What are the contraindications to ergometrine?
- Hypertension
- Eclampsia
- Vascular disease
What is carboprost?
Prostaglandin analogue
What are the side effects of carboprost?
- Bronchospasm
- Pulmonary oedema
- HTN
- Cardiovascular collapse
What are the contraindications to carboprost?
- Cardiac disease
- Pulmonary disease, i.e. asthma
- Untreated PID
What is misoprostol?
Prostaglandin analogue
What are the side effects of misoprostol?
Diarrhoea
How is primary PPH caused by trauma managed?
Primary repair of any laceration
How is primary PPH caused by uterine rupture managed?
Laparotomy and repair, or hysterectomy
How is primary PPH caused by placental retention managed?
- Administer IV oxytocin
- Manual removal of placenta with regional or general anaesthetic
- Prophylactic antibiotics in theatre
Where should the IV oxytocin infusion be started in primary PPH caused by placental retention?
In theatre
How should primary PPH caused by coagulation problems be managed?
Correct any coagulation abnormalities with blood products under the advice of the haematology team
How can the risk of primary PPH be reduced?
- Active management in 3rd stage of labour
- Prophylactic oxytocin
By how much does active management in the 3rd stage of labour reduce the risk of PPH?
60%
How much prophylactic oxytocin should be given to women delivering vaginally?
5-10units IM
How much prophylactic oxytocin should be given to women delivering by C-section?
5 units IV
