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Domain 3 : Obstetrics > Green Top Guidelines On PPH Mx > Flashcards

Green Top Guidelines On PPH Mx Flashcards

1
Q

What are the risk factors for PPH

A 
4T :
Multiple pregnancy
Previous PPH
Pre-eclampsia
Fetal macrosomia
Failure to progress in 2nd stage
Prolonged 3rd stage
Retained placenta
Placenta accreta + previa + abruption 
Episiotomy
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2
Q

What are the 4 Ts of PPH

A

Tone: prolonged/ precipitate/ dysfunctional labour, uterine over distention(multi preg, polyhydromnios,macrosomia,) fibroids, uterine infection, drugs (tocolytics GA,MgSO4,)
Tissue : Abnormal placentation,retained products/placenta
Thrombin: drugs( aspirin, anticoagulants,) Preeclampsia, HELLP syndrome, IUFD, sepsis, amniotic fluid embolism, abruption, bleeding disorders
Trauma : c/s, assisted delivery, Cervical lacerations

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3
Q

Recommendations on risk 1

A

Risk factors for PPH may present antenatally or intrapartum; care plans must be modified as and when risk factors arise.

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4
Q
A

Clinicians must be aware of risk factors for PPH and should take these into account when counselling women about place of delivery

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5
Q

Where to deliver patients with history of PPH?

A

Women with known risk factors for PPH should only be delivered in a hospital with a blood ✓ ✓ bank on site

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6
Q

What is the most common cause of PPH

A

Uterine atony

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7
Q

How’d we minimize the risk of PPH predelivery?

A

Antenatal anaemia should be investigated and treated appropriately as this may reduce the morbidity associated with PPH.D

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8
Q

Definition of level anaemia st 1st anc visit?

A

HB <11g/dl

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9
Q

Definition of level anaemia 28weeks anc visit

A

<10.5g/dl

*< 10g/dl postpartum

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10
Q

Management of pre-natal anaemia

A
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11
Q

What is the recommendation on uterine massage on PPH prophylaxis?

A

Uterine massage is of no benefit in the prophylaxis of PPH

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12
Q

What is the recommendation on Uterotonics

A

Prophylactic uterotonics should be routinely offered in the management of the third stage of labour in all women as they reduce the risk of PPH.

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13
Q

What is the recommended dose Oxytocin in NVD

A

For women without risk factors for PPH delivering vaginally, oxytocin (10 iu by intramuscular injection) is the agent of choice for prophylaxis in the third stage of labour. A higher dose of oxytocin is unlikely to be beneficial.

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14
Q

What is the recommended dose of oxytocin in c/s

A

For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be used to encourage contraction of the uterus and to decrease blood loss.

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15
Q

What is the recommendation of ergometrine?

A

Ergometrine–oxytocin may be used in the absence of hypertension in women at increased risk of haemorrhage as it reduces the risk of minor PPH (500–1000 ml).

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16
Q

Contraindications of ergometrine?

A

Cardiac

HPT

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17
Q

SE of ergometrine

A

Hypertension
Coronary vasospasm with possible MI
Nausea and vomiting

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18
Q

SE of oxytocin

A

Decrease svr with reduced MAP and increase cardiac output

ADH like effect with hyponatramia

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19
Q

What is the recommendation for increased risk of pph

A

For women at increased risk of haemorrhage, it is possible that a combination of preventative measures might be superior to syntocinon alone to prevent PPH.

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20
Q

Tranexamic acid recommendation

A

Clinicians should consider the use of intravenous tranexamic acid (0.5–1.0 g), in addition to oxytocin, at caesarean section to reduce blood loss in women at increased risk of PPH.

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21
Q

What is tranexamic acid

A

Antifibrinolytic

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22
Q

What are the commonly used Uterotonics

A

Oxytocin
Oxytocin + ergometrine
Prostaglandins
Carbetocine

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23
Q

WOMAN trial

A

6 years
20000 women vs placebo
Very low risk reduction was 0.004 meaning number to treat 137 to 24123 to save 1 life

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24
Q

Problem with visual estimation of blood loss

A

Clinicians should be aware that the visual estimation of peripartum blood loss is inaccurate and that clinical signs and symptoms should be included in the assessment of PPH.

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25
Q

How is PPH measured

A

Swab weigh

Collecting bag measure

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26
Q

Clinical signs of PPH

A

A systolic blood pressure below 80 mmHg usually indicates a PPH in excess of 1500 ml
* Use shock index

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27
Q

What is the shock index?

A

HR/BP

Pregnancy <0.9

28
Q

Who should be notified when PPH occurs?

A

Relevant staff with an appropriate level of expertise should be alerted of PPH. The midwife in charge and the first-line obstetric and anaesthetic staff should be alerted when women present with minor PPH (blood loss 500–1000 ml) without clinical shock. A multidisciplinary team involving senior members of staff should be summoned to attend to women with major PPH (blood loss of more than 1000 ml) and ongoing bleeding or clinical shock.

29
Q

Measures for management of minor PPH?

A

Measures for minor PPH minor PPH (blood loss 500–1000 ml) without clinical shock: intravenous access (one 14-gauge cannula) urgent venepuncture (20 ml) for:– group and screen– full blood count– coagulation screen, including fibrinogen pulse, respiratory rate and blood pressure recording every 15 minutes commence warmed crystalloid infusion.

30
Q

Measures for management of major PPH?

A

A and B– assess airway and breathing C– evaluate circulation position the patient flat keep the woman warm using appropriate available measures transfuse blood as soon as possible, if clinically required until blood is available, infuse up to 3.5 l of warmed clear fluids, initially 2 l of warmed isotonic crystalloid. Further fluid resuscitation can continue with additional isotonic crystalloid or colloid (succinylated gelatin). Hydroxyethyl starch should not be used. the best equipment available should be used to achieve rapid warmed infusion of fluids special blood filters should not be used, as they slow infusions.

31
Q

Fluid and blood products

A

Fixed ratio : RBC:FFP 1:1 OR 3:2

Goal directed: ROTEM guided

32
Q

ACOG PPH protocol

A
33
Q

Airway management

A

^ [] FiO2 10-15L/min

Intubate if indicated

34
Q

Cardiovascular management

A

X2 14g ivl

20m blood sample : coagulation, fbc, u+e, crossmatch, abg, teg crossmatch

35
Q

What are the haematological resus goals

A

HB > 80g/l
platelet count >50×109/l (PT)less < 1.5x normal
(APTT)> 1.5x normal
fibrinogen > 2g/l.

36
Q

Fluid resus who guidelines

A

Isotonic crystalloid > colloid

Colloid has no added improvements in survival

37
Q

Volume of crystalloid

A

Max 3,5l if rcc delay

38
Q

What are the indications for transfusion

A

There are no firm criteria on green top
Clinical assessment should guide
HB <7g/dl needs t/f

39
Q

Redcell

A

group O, rhesus D (RhD)-negative and K-negative units, with a switch to group-specific blood as soon as feasible.
clinically significant red cell antibodies are present, close liaison with the transfusion laboratory is essential to avoid delay in transfusion in life-threatening haemorrhage. D All delivery units, especially small units without a blood bank on site, should maintain a supply of group O, RhD-negative blood.

40
Q

Cell salvage and pregnancy

A

Intraoperative cell salvage should be considered for emergency use in PPH associated with ✓ caesarean section and with vaginal delivery

  • liumbruno et Al review o. Use of cell saved blood, no risk of complications or amniotic fluid emboli
  • Use separate suctions
  • Use leukocyte depletion *pressurise blood
  • RH neg dose adjustment of RhoGAM
41
Q

Blood component

A

Guided by clinical assessment and coagulation tests

42
Q

FFP

A

If no haemostatic results are available and bleeding is continuing, then, after 4 units of RBCs, FFP should be infused at a dose of 12–15 ml/kg until haemostatic test results are known.

PT or APTT > 1,5X normal and haemorrhage is ongoing, volumes of FFP in excess of 15 ml/kg are likely to be needed to correct coagulopathy

43
Q

Indication/ risk factors with highest Incidence for PPH

A

Amniotic fluid embolism
Delayed pph
Abruption

44
Q

Fibrinogen level

A

A plasma fibrinogen level of greater than 2 g/l should be maintained during ongoing PPH. C Cryoprecipitate should be used for fibrinogen replacement.

  • <2 g/l 100% predictive value of having major pph
  • FibTem A5, MA fibrin contribution 12mm at 5min is fibrinogen of 2,2
45
Q

Platelets

A

During PPH, platelets should be transfused when the platelet count is less than 75 and matained above 50

Evidence level 2+ Evidence level 1 Evidence level 3 based on laboratory monitoring

46
Q

Recombinant Factor IVa

A

The routine use of rFVIIa is not recommended in the management of major PPH unless as part of a clinical trial.

The use of rFVIIa may be considered as a treatment for life-threatening PPH, but should not delay or be considered a substitute for a life-saving procedure, such as embolisation or surgery, or transfer to a referral centre.

47
Q

Full protocol for monitoring and investigation in and ongoing haemorrhage major PPH (blood loss greater than 1000 ml) or clinical shock:

A 
immediate venepuncture (20 ml) for:– cross-match (4 units minimum)– full blood count– coagulation screen, including fibrinogen– renal and liver function for baseline ° monitor temperature every 15 minutes continuous pulse, blood pressure recording and respiratory rate (using oximeter, electrocardiogram and automated blood pressure recording) ° Foley catheter to monitor urine output 
° two peripheral cannulae, 14 gauge consider arterial line monitoring (once appropriately experienced staff available for insertion) consider transfer to intensive therapy unit once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate recording of parameters on a modified early obstetric warning score (MEOWS) chart (see Appendix IV) acting and escalating promptly when abnormal scores from a MEOWS chart are observed documentation of fluid balance, blood, blood products and procedures.
48
Q

Surgical management of PPH

A
49
Q

Mechanical and pharmacological

A
  1. palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’) ensure that the bladder is empty (Foley catheter, leave in place) 2. oxytocin 5 iu by slow intravenous injection (may have repeat dose) 3. ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension)
  2. oxytocin infusion (40 iu in 500 ml isotonic crystalloids at 125 ml/hour) unless fluid restriction is necessary 5. carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of eight doses (use with caution in women with asthma)
  3. misoprostol 800 micrograms sublingually
50
Q

Surgical & mechanical management?

A

Intrauterine balloon tamponade is an appropriate
B lynch
Hysterectomy

51
Q

Balloon tamponade

A

The successful outcome of balloon tamponade is reported to be 80–100 %

Recommended by FIGO & WHO 2nd line treatment.

52
Q

B-Lynch

A
53
Q

Uterine deva secularization

A
54
Q

Internal iliac artery ligation

A
55
Q

Radiological intervention

A
56
Q

Hysterectomy

A
57
Q

Vaginal swab

A
58
Q

U/S

A
59
Q

EVAC

A
60
Q

Risk management

A
61
Q

Documentation of delivery with pph

A
62
Q

Debriefing

A
63
Q

Shock index

A
64
Q

Fibrinogen replacement

A

° 1ffp 280ml = 200mg 30ml/kg to increase by 1g/l
° 1cryo 150ml = 1500-2500mg 3ml/kg to get 1g/l
° Fibrinogen concentrate 1g/50ml 60mg/kg to increase 1g/l

65
Q

What is the consensus statement on use of Uterotonics?

A

Domain 3 : Obstetrics (30 decks)

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