Haemorrhage in pregnancy Flashcards
Define postpartum haemorrhage? categories?
Blood loss of >500ml from the genital tract within 24hrs after delivery - Minor = 500-1000ml - Major >1000ml o Moderate 1000-2000ml o Massive >2000ml or 150ml/min
Antepartum, intrapartum and postpartum causes of haemorrhage?
Antepartum: previous PPH, placental abruption/praevia/accreta, grand multiparity (6 or more previous babies) anaemia, OC, PET, HELLP Overdistended uterus
Intrapartum: Prolonged 1st, 2nd stage oxytocin use precipitate labour (combined 1st stage and second stage duration is under two hours) operative vaginal delivery - episiotomy 2nd stage CS
Postpartum: uterine atony, RPOC, trauma (episiotomy or perineal trauma), thrombin (tone, tissue, trauma, thrombin)
define placenta praevia?
low lying placenta, partially or completely covering the cervical os.
How to reduce risk of PPH?
Treat antenatal anaemia
reduce blood loss at delivery - using prophylactic uterotonics, oxytocin (10iu IM) in 3rd stage of labour, oxytocin (5iu) slow IV infusion) for CS, ergometrine-oxytocin (in non-HTN women)
Ix and Mx of minor PPH?
IV access with 1 14gauge 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
Fluid Mx of major PPH?
ABC position patient flat keep woman warm blood transfusion asap until blood is available - infuse up to 3.5 l of warmed clear fluids, initially 2l of warmed isotonic crystalloid. Further fluid resuscitation can continue with additional isotonic crystalloid or colloid
WHen to use FFP?
If no haemostatic results are available and bleeding is continuing, then, after 4 units of red blood cells, FFP should be infused
If no haemostatic tests are available, early FFP should be considered for conditions with a suspected coagulopathy, such as placental abruption or amniotic fluid embolism, or where detection of PPH has been delayed
If prothrombin time/activated partial thromboplastin time is more than 1.5 times normal andhaemorrhage is ongoing
What level should fibrinogen be maintained at during ongoing PPH? How to replace it?
2g/L
cryoprecipitate
When to transfer platelets during PPH?
when platelet count <75
Mx and Ix in major PPH?
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
consider transfer to ITU
Surgical measure to arrest PPH?
1st line: Intrauterine balloon tamponade (where uterine atony is the main cause)
B-lynch or vertical compression suture
internal iliac or uterine artery ligation
Hysterectomy
Mx of uterine atony?
Bimanual compression - to stimulate uterine contraction
Pharma:
- Syntocinon
- ergometrine
- Carboprost
- Misoprost
Management of primary PPH caused by RPOC?
IV oxytocin then manual removal of placenta.
after removal, start IV oxytocin infusion
MOA, SEs, CIs of ergometrine?
Synthetic oxytocin - acts at oxytocin receptors in myometrium
SEs: N+V, headache, rapid infusion –> hypotension
CIs: Severe CVS disease, hypertonic uterus
MOA, SEs, CIs of ergometrine?
it acts at Multiple receptors sites
SEs: hypertension, nausea, bradycardia
CIs: hypertension, ecclampsia, vascular disease
