9.13 Postpartum Haemorrhage Flashcards
How much blood loss counts as PPH?
500ml after vaginal delivery
1000ml after c-section
PPH can be minor or major and moderate or severe: how much blood is lost in each?
Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss
Major can then be:
Moderate PPH – 1000-2000ml blood loss
Severe PPH – over 2000ml blood loss
(and massive is >1500ml) lol so many categories
What mnemonic can help you think of the causes of PPH?
the “4 Ts”
What are the 4 Ts for PPH causes?
Tone (uterine atony)
Trauma (perineal tear)
Tissue (retained placenta)
Thrombin (bleeding disorder)
What are several risk factors for PPH?
- Previous PPH
- Multiple pregnancy
- Obesity
- Large baby
- Failure to progress in the second stage of labour
- Prolonged third stage
- Pre-eclampsia
- Placenta accreta
- Retained placenta
- Instrumental delivery
- General anaesthesia
- Episiotomy or perineal tear
What can be done to reduce the risk of PPH?
- treat antenatal ANAEMIA
- empty BLADDER (a full bladder reduces uterine contraction)
- active management of the third stage (IM OXYTOCIN)
- IV TRANEXAMIC acid can be used during c-section (in the third stage) in higher-risk patients
What can you activate in severe cases of PPH?
major haemorrhage protocol
gives:
- rapid access to 4 units of crossmatched or O-ve blood
What initial management do you do in PPH?
- get help
- ABCDE approach
- oxygen
- two large-bore cannulas 14/grey
- FBC, U&E and clotting screen
- warm 1L Hartmanns stat and blood resuscitation
- FFP if clotting abnormal or 4 units of blood
- catheterise
- massage uterus early on
- deliver placenta
- drugs to contract
- repair tears
What 3 categories of treatment options for stopping PPH are there?
- mechanical
- medical
- surgical
What are the mechanical treatment options for PPH?
- Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
- Catheterisation (bladder distention prevents uterus contractions)
What are the medical / drugs treatment options for PPH?
Sequentially:
- IM syntometrine 1 ampoule (oxytocin’s and ergometrine)
- oxytocin 40 units in 500ml over 4hrs
- ergometrine 500microgram IM or IV
- carboprost 250micrograms every 15mins up to 8 times
(misoprostol and tranexamic acid too)
What are the surgical treatment options for PPH?
INTRAUTERINE BALLON TAMPONADE – inserting an inflatable balloon into the uterus to press against the bleeding
B-LYNCH SUTURE – putting a suture around the uterus to compress it
UTERINE ARTERY LIGATION – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
HYSTERECTOMY is the “last resort” but will stop the bleeding and may save the woman’s life
What is classed as secondary PPH?
bleeding between 24hrs - 12weeks post partum
What tends to cause secondary PPH?
- retained products of conception (RPOC)
- infection (endometritis)
What are you Ix and Mx for secondary PPH?
Ix:
- Ultrasound for retained products of conception
- Endocervical and high vaginal swabs for infection
Mx depends:
- Surgical evaluation of retained products of conception
- Antibiotics for infection
