Antepartum + Postpartum Haemorrhage Flashcards
Dose of oxytocin post vaginal delivery
10iu intrasmuscularly
Dose of oxytocin after cesarean section
5iu intravenous slow push
What is the definition of minor PPH
EBL 500- 1000L without clinical shock
Management of minor PPH (5)
- one 14G iva
- 20ml blood for cbc, gxm, coagulation, fibrinogen
- vitals every 15minutes
- warmed crystalloids
- uterotonics
Definition of major PPH
- EBL >1L
- ongoing bleeding
- or clinical shock
Management of Major PPH (10)
- HELP
- ABC
- 2 large bore iva - cbc,u+e,pt/ptt,fibrinogen,gxm
- Temperature q 15mins, continuous pulse,resp,bp monitoring charted on MEOWS
- Foley catheter for I/O
- Flat position
- Warm
- Transfuse ASAP(clinically determined)
- rapid 3.5L warmes clear fluids until blood available
- HDU level care
When and how is FFP administered
-If no coagulation panel available
- after each 4 units of blood
Rate: 12-15ml/kg until results available
Target fibrinogen level
> 2g/l
What should be used to replace fibrinogen?
Cryoprecipitate or FFP
Cryoprecipitate
What value of platelets require transfusion
<75 × 10e9/l
Definition of secondary PPH
Significant uterine bleeding between 24hrs and 12 weeks postpartum.
Initial evaluation of secondary PPH
- HVS and endocervical swab
- Ultrasound if patient haemodynamicallt stable
What is the further classification of Major PPH
Moderate 1001- 2000ml
Severe >2000ml
Therapeutic target in PPH (4)
- Hb >8g/l
- Platelet >50 x 10e9
- PT/PTT less than 1.5 times normal
- Fibrinogen >2g/l
Obstetric shock index
Tool used to clinically asses patients with obstetric hemorrhage and the risk of adverse outcomes
HR/SBP
score >/=1 associated with adverse outcomes
What is the rule of 30 (6)
Clinical red flag signs associated with severe hemorrhage
- respiratory rate >30
- pulse rate increase by 30bpm
- fall in systolic bp of 30mmhg
- hct fall >30%
- urine output <30ml/hr
- EBl 30% blood volume
Mechanical measures for management of PPH (2)
- fundal massage
- Foley catheter
Pharmacological management of initial pph (5)
- 5uiv slow push oxytocin
- ergometrine 5iu slow iv/I’m (htn)
- oxytocin infusion 40iu in 500ml at 125ml/hr
- carboprost 0.25mg I’m q 15mins max 8 doses (asthma)
- misoprostol 800mcg sublingual
Surgical interventions for pph
- first line
Intrauterine balloon
What surgical measures to attempt post Balloon failure (5)
Laparotomy
Brace sutures- b lynch
Uterine artery ligation
Internal Iliac ligation
Hysterectomy
Failure rate of BLYnch
25%
Risk factors for B Lynch failure (3)
- increased maternal age
- vaginal delivery
- delay if 2-6hrs between delivery and placement
How many pregnancies are complicated by APH
3-5%
Most predictive risk factor for placental abruption
Previous abruption
What is the recurrence rate of placental abruption
4% after 1 abruption
25% after 2 previous abruptions
What are other risk factors for placental abruption (maternal)
(6)
- pre eclampsia
- AMA
- multiparity
- ART
- low bmi
- smoking and cocaine
- domestic abuse and trauma
What are fetal causes of abruption(3)
- malpresentation
- polyhydramnios
- FGR
What are other risk factors beside maternal and fetal for placental abruption (2)
- PPROM
- intrauterine infection
Risk factors for placental praevia (10)
- previous placenta previa
- previous cesarean section
- previous top
- uterine surgery
- endometritis
- AMA >40 yrs
- ART
- multiple pregnancy
- smoking
- multiparty
Management of suspected DIC(pending coagulation screen)
- up to 4units/1L FFP
- up to 10 units/2 packs cryoprecipitate
What is the odds ratio of recurrent placenta praevia
9.7
Incidence of placenta praevia at term
1:200
What is the rank of antepartum hemorrhage interms of direct maternal death
Sixth
Diagnosis of vasa praevia
- combination transabdominal and transvaginal colour doppler has best diagnostic accuracy
- done at time of anomaly scan
- may be diagnosed in labour after arom
At what gestational age should patients with vasa praevia ve delivered
- planned csection at 34-36 weeks I’d asymptomatic
Admit for corticosteroids at 32 weeks
How is vasa praevia classified
Type 1 - velamentous attachment
Type 2- succenturiate or accessory lobe attachment
What is the fetal mortality rate with ruptured vasa praevia
60%
What is the survival rate of vasa praevia with antenatal diagnosis
95%
What is the reported prevalence of vasa praevia
1: 1200 to 1: 5000
What is the prevalence of vasa praevia following ivf
1:300
What is the fetal blood volume at term
80 -100ml/kg
Can vasa praevia resolve pre delivery?
Yes
20% of 2nd trimester vasa praevia resolve by t3 hence repeat ultrasound d at 32 weeks recommended
What is the risk of placenta praevia after …
1 section
2 sections
3 sections
4 sections
1- 1:160 0.6% RR(nice) 4.5
2- 1:60 1.6% 7.4
3- 1:30 3.3% 6.5
4- 1:10 10% 44.9
