APH/PPH Flashcards
What % of pregnancies are effected by APH?
3-5%
Definition minor APH
<50mls settled
Definition Major APH
50-1000mls, no signs of shock
Definition Massive APH
> 1000mls and or signs of shock
Risk factor abruption after 1 abruption?
4.4%
Risk factor abruption after 2 abruption?
20-25%
Other RF for placental abruption?
PET, FGR, Non-vertex presentation, polyhydramnios, advanced mat age, multiparity, PROM, abdominal trauma, smoking/drug misuse, 1st trimester bleeding, intrauterine haematoma, maternal thrombophilia.
What % of placental abruption in low risk pregnancy?
70%
What preventative measure for APH can be suggested?
Stop smoking & drugs use (cocaine, amphetamines)
If placenta praevia, avoid vaginal and rectal examinations.
Specific Qs to ask APH
Pain ?continous
FM
Recent SI
Previous trauma to abdomen
Previous cerival smear
Rh status
How to approach examination of patient with significant APH?
A-E approach
Abdo palpation - woody/tense
Speculum Dilation/cause of APH
Assess fetus - CTG or USS
Initial Ix for APH
IV access x 2 - Hb, coag, U+E, LFT, G+S, cross match 4 units, VBG
Kleihauer test if Rh -ve
USS - placenta position
Assess foetus - CTG if mother stable
Where to care for women
1) Spotting, placenta high, no active bleeding
2) Ongoing bleeding/heavier than spotting
1) discharge
2) Admit until bleeding stops
What % of placental abruption will have abnormal CTG?
69%
When to consider steroids
If risk of preterm labour 24-34+6
Should you give tocolysis if contracting?
Not in major APH, contraindicated in abruption
How should AN care be changed after unexplained APH/APH from abruption?
High risk
Review cons ANC and serial growth USS
If fetal death confirmed what MOD?
Vaginal delivery
CS if foetus compromised but discuss with Cons
If >37 weeks with minor or major APH but patient/baby stable when should delivery be recommended?
IOL from presentation, to avoid adverse outcomes associated with APH
When should continuous CTG be considered?
Active APH
Previous major APH
Recurrent minor APH
If 1 episode minor APH, intermittent is appropriate
What delivery complication should you expect in someone with APH? How to minimise this?
PPH, active 3rd stage
If APH immediately after ARM, which cause of APH? How to manage?
Vasa praevia
Cat 1 EMCS, clamp cord immediately after delivery and leave the long part attached to neonate
If recurrent APH how often should Anti-D be given if required?
> 20 weeks 6 weekly
If APH what should be arranged post partum?
Assess VTE
Debrief
Incident report
Consider FU with Obstetric Cons within 4-6 weeks
If fetal demise consider informing GP
What 3 things to consider when estimating blood loss
- Measured blood loss
- Signs/symptoms of shock
- Patients weight
What utertonic to use
- Low risk
- High risk no BP concerns
- High risk BP concern
- Oxytocin
- Syntometrine
- Oxytocin
Oxytocin can be given 5IU or 10IU
When should oxytocin be given?
After delivery of the anterior shoulder/baby before cord is clamped
If blood loss 1000-1500mls, what could you see on the observations?
Tachycardia, Tachyponea, Fall in SBP
If blood loss >1500mls, what could you see on the observations?
SBP <80, worsening Tachycardia/Tachyponea, altered mental state
Who should be called if blood loss 500-1000mls + no sign of shock
- 1st Line obstetric + anaesthetic Dr
Who should be called if >1000mls or signs of shock or ongoing bleeding
Experienced MW + MW in charge
Obs middle grade
Anaesthetic middle grade
On call haematologist
Porters
Inform Obs/anaesthetic cons
Inform Blood lab
When should the consultants attended?
> 1500mls patient unstable
Management of minor PPH 500-1000ml
- IV access x 1 14-guage
- Urgent bloods – FBC, G+S, Coag including fibrinogen
- Obs every 15mins (HR, RR, BP)
- Commence warm crystalloid IV
What will happen if insufficient FFP and platelets are given?
Dilutional coagulopathy
Major PPH >1000mls, ongoing bleeding, shock
- ABC
- Position patient flat, keep woman warm
- Transfuse blood, until blood available infuse up to 3.5 L warmed clear fluids, initially 2 L warmed isotonic crystalloid, then isotonic crystalloid colloid
- Bloods X-Match 4 units, FBC, Coag including fibrinogen, U+E, LFT
- Continous BP, HR, RR
- Temp every 15mins
- Give high flow oxygen
- Foley catheter to monitor UO
- 2 x 14 gauge cannula
- MOEWs chart
- Document fluid balance, blood, blood products and procedures
- Consider: Arterial line, ITU once bleeding controlled
What pharmacological methods can be given to control PPH?
Rub fundus
Empty bladder
Oxytocin 5IU IV - can repeat
Erymetrine 0.5mg IV (caution HTN)
Oxytocin infusion 40 IU in 500mls saline (unless fluid restriction)
Carboprost 0.25mg IM every 15 mins, max 8 dosa (caution asthma)
Misoprostol 800mcg (1-2.5hrs)
What is the maximum amount of fluid that can be given before RBCs?
Max 3.5 litres clear fluids (2L warmed isotonic crystalloid, 1.5 warmed colloid)
What can hypothermia (from cold fluids) do?
Exacerbate acidosis
When transfusing what are we aiming for:
Hb
> 80
When transfusing what are we aiming for:
Platelets
- Platelet > 50 x 10-9
When transfusing what are we aiming for:
PT
- PT < 1.5 x normal
When transfusing what are we aiming for:
APTT
- APTT < 1.5 normal
When transfusing what are we aiming for:
Fibrinogen
- Fibrinogen > 2g/l
Which blood should be given in an emergency setting?
Start with O -ve, K-ve blood
Switch to ‘Group specific blood’ as soon as possible
CMV negative if AN
How much does intra-operative cell salvage reduce risk of blood transfusion?
38→21%
How regularly should bloods be sent in uncontrolled MOH, to asses blood products?
Every 30 mins
What blood often becomes abnormal first in MOH?
Fibrinogen
If no blood results when should FFP be given? At what rate?
After 4 units RBCs
15ml/kg/hr
Consider earlier if suspected coagulopathy
Given in ration 6:4
Order ASAP as need to be thawed
If PPH stopped, do you need to give FFP? (if not suspecting coagulopathy)
No
If ongoing bleeding, PT/APTT < 1.5 greater than normal
Give FFP 12-15 ml/kg aiming to maintain <1.5 PT/APTT
If ongoing bleeding, PT/APTT >1.5 normal
Higher dose FFP, increased risk TACO
Would you give FFP if ongoing bleeding and PT/APTT normal?
No, ongoing testing
If no blood results, when should Cryopreciptates and platelets be given?
How much?
If > 8 units
2 pools cryoprecipitate
1 pool platelets
At which blood level should fibrinogen be given?
If falls <2
2 pools will increase by 1
At which blood level should platelets be given?
If <75
If using 1st line surgical - uterine balloon tamponade, how long should it be left in for?
What is the maximum amount of saline needed?
4-6 hours, remove in daylight hours
Mx 500mls
What are contraindications to uterine balloon tamponade?
Uterine malformations
Uterine rupture
Placenta retention
Endometrial infection
Which haemostatic suture required a hysterotomy?
B-Lynch
What % of haemostatic sutras will require hysterectomy? What is the biggest RF?
25% will require hysterectomy
Biggest RF is prolonged delay between delivery and uterine compression
Describe stepwise uterine devascularisation
Succssive ligation of
1) 1 uterine artery
2) both uterine arteries
3) Low uterine arteries
4) 1 ovarian artery
5) Both ovarian artiees
6) Internal iliac (vascular surgeon must be present)
How successful is selective arterial occlusion/embolisation by IR at controlling bleeding?
86.5% success
In which cases should hysterectomy be considered sooner?
Bleeding associated with placenta accreta/uterine rupture
Decision by experienced Cons
Which patients should be considered for ITU
> 2500mls
5units transfused
Tx coagulopathy
How to assess 2nd PPH
Vaginal swab (HVS and endocervical)
Abx for endometritis
Pelvic USS ?RPOC
