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A - MSRA Obstetrics [16] > [49] Secondary Post-Partum Haemorrhage > Flashcards

[49] Secondary Post-Partum Haemorrhage Flashcards

1
Q

What is secondary postpartum haemorrhage?

A

Excessive vaginal bleeding in the period from 24 hours - 12 weeks postpartum

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2
Q

What is the overall incidence of postpartum haemorrhage in the developed world?

A

0.47-1.44%

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3
Q

What are the causes of secondary postpartum haemorrhage?

A
  • Endometritis
  • Retained placental fragments or tissue
  • Abnormal involution of placental site
  • Trophoblastic disease
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4
Q

What is meant by abnormal involution of the placental site?

A

Inadequate closure and sloughing of spiral arteries at the placental attachment site

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5
Q

Is trophoblastic disease common?

A

No, it is very rare

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6
Q

What is the main symptom of secondary PPH?

A

Excessive vaginal bleeding

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7
Q

How does the severity of secondary PPH compare to primary?

A

It is usually not as severe as primary

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8
Q

How might the patient describe the vaginal bleeding in secondary PPH?

A

May complain of spotting on-and-off for days after delivery, with occasional gush or fresh blood

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9
Q

What % of cases of secondary PPH will present with massive haemorrhage?

A

10%

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10
Q

What do the additional clinical features of secondary PPH depend on?

A

The underlying cause

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11
Q

What symptoms might be present with endometritis?

A
  • Fever/rigors
  • Lower abdominal pain
  • Foul smelling lochia
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12
Q

What is lochia?

A

The normal discharge from the uterus following childbirth

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13
Q

What may be found on abdominal examination in secondary PPH?

A
  • Lower abdominal tenderness

- Uterus may still be high

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14
Q

What is lower abdominal tenderness a sign of?

A

Endometritis

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15
Q

What is the uterus being high a sign of?

A

Retained placenta

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16
Q

Why is speculum examination important in secondary PPH?

A

To assess amount of bleeding

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17
Q

What should be done during speculum examination in secondary PPH?

A

High vaginal swab

18
Q

How should secondary PPH be managed if the patient is haemodynamically unstable or bleeding heavily?

A

Call for help and follow resuscitation algorithm

19
Q

Should you establish a cause before resuscitation is commenced in secondary PPH where the patient is haemodynamically unstable or bleeding heavily?

A

No

20
Q

What laboratory tests should be done in secondary PPH?

A
  • FBC
  • Urea and electrolytes
  • C-reactive protein
  • Coagulation profile
  • Group and save
  • Blood cultures (if pyrexial)
21
Q

How might a pelvic ultrasound be helpful in secondary PPH?

A

Can assist in diagnosis of retained placental tissue

22
Q

What is the problem with diagnosing retained placental tissue on ultrasound in secondary PPH?

A

The over-diagnosis of retained placental tissue on ultrasound can lea to unnecessary surgical intervention

23
Q

What is a pelvic ultrasound good regarding retained placental tissue?

A

It has a good negative predictive value, and so is helpful in excluding the diagnosis

24
Q

What is the mainstay of treatment for secondary PPH?

A
  • Antibiotics

- Uterotonics

25
Q

What antibiotics are given in secondary PPH?

A

Combination of ampicillin and metronidazole

26
Q

What antibiotic can be used as an alternative to ampicillin in secondary PPH if the patient is penicillin allergic?

A

Clindamycin

27
Q

What antibiotic may be added to the regime in secondary PPH?

A

Gentamicin

28
Q

When might gentamicin be added to the antibiotic regime in secondary PPH?

A

In cases of endomyometritis (tender uterus) or overt sepsis

29
Q

Give 4 examples of uterotonics that can be used in secondary PPH

A
  • Syntocinon
  • Syntometrine
  • Carboprost
  • Misoprostol
30
Q

What is syntocinon?

A

Oxytocin

31
Q

What is syntometrine?

A

Oxytocin and ergometrine

32
Q

What is carboprost?

A

Prostaglandin F2

33
Q

What is misoprostol?

A

Prostaglandin E1

34
Q

When might surgical measures be taken in secondary PPH?

A

In excessive or continuous bleeding

35
Q

What surgical measure may be effective in secondary PPH in continuing haemorrhage?

A

Insertion of balloon catheter into uterus

36
Q

What are the components of management of massive secondary PPH?

A
  • Communication
  • Resuscitation
  • Monitoring and investigation
  • Arresting the bleeding
37
Q

How should the bleeding be stopped in massive secondary PPH?

A

Using ureterotonics/surgical measures, depending on suspected cause

38
Q

What does any surgical evacuation of retained products of conception carry a high risk of?

A

Uterine perforation

39
Q

Why does surgical evacuation of retained products of conception carry a high risk of uterine perforation?

A

Because the uterus is softer and thinner postpartum

40
Q

Who should the surgical evacuation of retained products fo conception involve?

A

A senior obstetrician for planning and delivery of surgery

A - MSRA Obstetrics [16] (61 decks)

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