Obstetric Emergencies: Massive PPH

Question 1

Define primary PPH

Answer 1

Loss >500mls from genital tract <24hrs after delivery

• Minor PPH = 500-1000ml, with no signs of shock
• Major PPH >1000ml, or signs of shock

Question 2

Define secondary PPH

Answer 2

Excessive bleeding from genital tract from 24hrs to 6wks post delivery

Question 3

What is the incidence of PPH?

Answer 3

10% - major cause of maternal mortality

Question 4

What guideline is used for the management of PPH?

Answer 4

HSE CPG 17 2012 - Prevention and Management of Primary Post-Partum Haemorrhage

Question 5

List the causes of PPH

Answer 5

1. Tone - Uterine atony = 80%
2. Trauma - Tears = 20% (perineal, episiotomy, high vaginal, cervical)
3. Tissue - retained placental tissue = 2.5%
4. Thrombin - coagulopathy (rare)

Question 6

List the risk factors for PPH

Answer 6

1. Previous hx PPH
2. Delivery after APH
3. Multiple pregnancy/polyhydramnios
4. Prolonged or induced labour
5. Grand multiparity (>/=5)
6. Coagulation disorders

Question 7

How can we prevent PPH?

Answer 7

• Oxytocin in 3rd stage of labour
• Reduces risk of PPH by 60%
• Given IM once shoulders delivered

Question 8

What are the clinical features of PPH?

Answer 8

1. Blood loss
2. Enlarged uterus above level of umbilicus (suggest uterine cause)
3. Check for tears in the vaginal wall, perineum or cervix
4. Collapse

Question 9

What are the 4 components of management in the Irish guidelines?

Answer 9

1. Communication
2. Resuscitation
3. Monitoring and investigation
4. Arresting the bleeding

*These components need to be done at the same time

Question 10

Describe the communication aspect of management

Answer 10

Major PPH:

• Inform midwife in charge
• Inform anaesthetics
• Inform obstetric team
• Inform blood transfusion lab
• Inform Haematologist
• Inform porters
• Have one team member documenting everything

Question 11

What resuscitation should be carried out?

Answer 11

• ABC
• O2 10-15L per min
• IV access = 2x14G cannula
• Lie flat
• Keep patient warm
• Fluids = up to 3L warm (crystalloid 2L, Colloid 1-2L)
• +/- recombinant factor VIIa
• BLOOD PRODUCTS:
  
  • RBC X-matched
  • Consider plasma, platelets, and fibrinogen

Question 12

What monitoring and investigation should be done?

Answer 12

1. Bloods - FBC, coag, G+X-match 4iu, U&E, LFTS (baseline)
2. Monitor:
   - Use iMEWS chart
   - Obs = HR, BP, RR
   - Urinary output (place a catheter in)
   - Documentation of all fluids given , obs

Question 13

What non-pharmacological treatments can be used to arrest the bleeding?

Answer 13

• Bimanual compression of the uterus and rubing up the fundus to stimulate uterine contractions
• Insert catheter
• Remove placenta manually of bleeding or if not expelled within 60mins of delivery
• VE to exclude rare causes (uterine inversion and vaginal lacerations)

Question 14

What is the pharmacological treatment for massive PPH?

Answer 14

mnemonic = “Oh Emergency Medical Call Team”

1. (Oxytocin) Syntocinin 5units by slow IV
2. Ergometrine 0.5mg by slow IV or IM (CI HTN)
3. Syntocinin infusion
4. Carboprost 0.25mg by IM injection every 15mins to max 8 doses
5. Direct intramyometrial injection of Carboprost
6. Misoprostal 600mcg PO or SL
7. Tranexamic acid (WOMAN trial)

Question 15

What do we do if medical and non-pharmacological management does not work?

Answer 15

Examination under anaesthetic (EUA)

Question 16

What surgical procedures can be used to manage the bleeding?

Answer 16

1. Balloon tamponade - Rusch balloon
2. Haemostatic brace suture - B Lynch approach
3. Bilateral ligation of uterine of internal iliac arteries
4. Uterine artery embolization
5. Hysterectomy (sooner rather than later)