Haemorrhage

Question 1

Causes of haemorrhage

Answer 1

Question 2

Definition and causes of Antepartum Haemorrhage (APH)

Answer 2

• Any bleeding from or in to the genital tract from 24+0 weeks gestation to delivery
• Causes
  
  • Placenta praevia (placenta sited in lower uterine segment - important but not most common)
  • Vasa praevia
  • Abruption (important but not most common)
  • Uterine rupture
  • Vulval (trauma, infection, dermatosis)
  • Vaginal (trauma, infection)
  • Cervical (polyp, ectropion, cancer, infection
  • Urinary/bowel

Question 3

Definition and causes of Post Partum Haemorrhage (PPH)

Answer 3

• Any bleeding from or in the genital tract following delivery of the infant
• Primary - occuring within 24 hours of delivery
  
  • Caused by the 4T’s
    
    • Throbmin
    • Tissue
    • Tone
    • Trauma
• Secondary - occurring between 24 hours and 12 weeks postnatally
• Minor (500-1000mls), moderate (1000-2000mls) and severe (>2000mls)
• Uterus needs to contract after birth to constrict the vasculature

Question 4

Risk factors for PPH

Answer 4

• Antenatal
  
  • Suspected or proven placental abruption
  • Known placenta previa
  • Multiple pregnancy
  • Pre-eclampsia/gestational HTN
  • Previous PPH
  • Asian ethnicity
  • Obesity
  • Anaemia (<9g/L)
• Intrapartum
  
  • Caesarean section
  • Induction of labour
  • Retained placenta
  • Mediolateral episiotomy
  • Operative vaginal delivery
  • Prolonged labour (>12 hours)
  • Big baby (>4kg)
  • Pyrexia in labour
  • Age (>40 years)

Question 5

Management of PPH

Answer 5

• Activate major haemorrhage
• ABCDE
• Bimanual compression
• Medications
  
  • Oxytocin (syntocinon)
  • Carboprost
  • Misoprostol
  • Ergometrine
• If in theatre can use intrauterine balloon, uterine artery ligation, hysterectomy, B lynch suture, interventional radiology

NB - Promoting uterine contractility

Question 6

Diagnosis and management of PP in APH

Answer 6

• Suspect and exclude PP
• Detailed history
• Examination
  
  • Usually not shocked
  • Abdomen soft
• US
• If light bleeding and not shocked then expectant management
• If bleeding heave or shocked then resuscitate and deliver immediately if maternal or fetal risks

Question 7

Diagnosis and management of placental abruption

Answer 7

• Separation of a normally located placenta after 24 weeks
• History revealed bleeding, abdomimnal pain and contractions
• Examination
  
  • Shock, tender and firm uterus, may be in labour
• FBC, coagulation screen, crossmatch, US and fetal monitoring
• Resuscitate mother, expedite delivery