Obs Emergencies - Postpartum Haemorrhage

Question 1

What is PPH?

Answer 1

Blood loss >500mls at VD and >1000ml at CS

Question 2

How do you classify PPH?

Answer 2

Primary PPH: <24hr of delivery
Secondary PPH: 24hrs-6 weeks
Massive: >2500ml or needing >5units of blood transfusion or coagulopathy secondary
blood loss

Question 3

What are the causes of primary vs secondary PPH?

Answer 3

Primary PPH: <24hr of delivery
* Tone –Uterine atony
* Tissue –Placental tissue, placenta accreta
* Trauma –perineal lacerations, uterine rupture
* Thrombin –DIC

Secondary PPH: 24hrs-6 weeks
* Infection
* Retained placental tissue

Question 4

What are the risk factors for getting a PPH?

Answer 4

PET, Nulliparity, Multiple gestation, Hx PPH, Hx CS, prolonged stage 3, episiotomy, arrest of descent, lacerations, assisted delivery, augmented or induced delivery

Question 5

How do you prevent PPH?

Answer 5

• Active management of 3rd stage –oxytocin IM, controlled cord tractionActive management of the 3rd stage of labour routinely reduces PPH risk by 60%:

Women delivering vaginally should be administered 5-10 units of IM Oxytocin prophylactically.
Women delivering via C-section should be administered 5 units of IV Oxytocin

• Rub up contraction
• Bimanual compression
• Uterotonic drugs –syntocinon (bolus and infusion IV), ergometrine (not if hypertensive), misoprostol (PR), carboprost (IM)
• Rapid diagnosis
• Teamwork

Question 6

What are the clinical features of PPH?

Answer 6

The main feature of a post-partum haemorrhage is bleeding from the vagina.

If there is substantial blood loss, the patient may complain of dizziness, palpitations, and shortness of breath.

On Examination:

General examination may reveal haemodynamic instability with tachypnoea, prolonged capillary refill time, tachycardia, and hypotension.

Abdominal examination may show signs of uterine rupture i.e. palpation of fetal parts as it moves into the abdomen from the uterus.

Speculum examination may reveal sites of local trauma causing bleeding.

Examine the placenta to ensure that the placenta is complete (a missing cotyledon or ragged membranes could both cause a PPH).

Question 7

The initial laboratory tests in primary post-partum haemorrhage include:

Answer 7

Full blood count
Cross match 4-6 units of blood
Coagulation profile
Urea and Electrolytes
Liver function tests

Question 8

The management of primary post-partum haemorrhage should include the simultaneous delivery of TRIM:

Answer 8

Teamwork (Immediate Management)
Resuscitation (Immediate Management)
Investigations and Monitoring (Immediate Management)
Measures to arrest bleeding (Definitive Management)

Question 9

What is the definitive management of PPH?

Answer 9

The definitive treatment for primary post-partum haemorrhage is largely dependent on the underlying cause:

Uterine Atony

Bimanual compression to stimulate uterine contraction – insert a gloved hand into the vagina, then form a fist insider the anterior fornix to compress the anterior uterine wall and the other hand applies pressure on the abdomen at the posterior aspect of the uterus (ensure the bladder is emptied by catheterisation).

Pharmacological measures (Table 1) – act to increase uterine myometrial contraction.

Surgical measures – intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).

Trauma

Primary repair of laceration, if uterine rupture: laparotomy and repair or hysterectomy.

Tissue

Administer IV Oxytocin, manual removal of placenta with regional or general anaesthetic, and prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal.

Thrombin

Correct any coagulation abnormalities with blood products under the advice of the haematology team.

Question 10

Drugs used in Primary Post-Partum Haemorrhage

Answer 10

1. can give another 5 unites of oxytocin Syntocinon = Synthetic oxytocin, act on oxytocin receptors in the myometrium Nausea, vomiting, headache, rapid infusion à hypotension Hypertonic uterus, severe CVS disease

+ tranexemic acid
then can give an infusion of oxytocin 4 hour

if still bleeding
2. Ergometrine (250 twice) = Multiple receptor sites action Hypertension, nausea, bradycardia Hypertension, eclampsia, vascular disease
NB the mother will vomit after getting it

3. Misoprostol (1000mg Pv/PO/rectal = Prostaglandin analogue Diarrhoea, hyperthermia, shivering
4. Carboprost (not if asthmatic = Prostaglandin analogue Bronchospasm, pulmonary oedema, HTN, cardiovascular collapse Cardiac disease, pulmonary disease i.e. asthma, untreated PID

if still bleeding give blood