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obstetric haemorrhage Flashcards

1
Q

define PPH

A 
BLOOD LOSS OF 500MLS OR MORE  FROM THE GENITAL TRACT WITHIN 24HRS AFTER DELIVERY
MINOR 500-1000MLS
MAJOR  (>1000MLS)
MODERATE  (1000-2000MLS)
MASSIVE  (>2000MLS  OR 150MLS/MIN)
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2
Q

most common form of obstertic haemorrhage

A

PPH

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3
Q

causes of antepartum haemorrhage

A 
- Previous PPH
Placenta-Abruption praevia/accreta
Grand multiparity
Anaemia,medical
Obstetric Cholestasis,PET,HELLP
Over distended uterus due to polyhydraminos, multiple pregnancies, fibroids effect contractility of delivery baby and placenta
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4
Q

intrapartum causes of heamorrhage

A 
Prolonged 1st, 2nd stage
Oxytocin use
Precipitate labour
Operative vaginal delivery-Episiotomy
Second stage caesarean section - c section after full dilatation
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5
Q

postpartum causes of haemorrhage

A

Uterine atony MOST COMMON CAUSE
Retained products
Trauma
Thrombin

secondary

  • retained POC
  • endometritis
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6
Q

what is placenta praevia

types

A

placenta attaches low down on the uterus and may cover all or part of the cervix

low lying placenta -> >16w placental edge <20mm from the internal os via transabdominal/transvaginal scanning

if this is found at the fetal anomaly scan a follow-up ultrasound examination
including a TVS is recommended at 32 weeks

low lying
marginal
partial
complete

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7
Q

Complications forms placenta praevia

A

hypovolaemic shock

VTE

Placenta accreta - placenta into endometrial part

increta into the myometrial part

Percreta - outside of the uterus outside of serosa into bladder or other organs

Fetal haemorrhage, prematurity, intrauterine asphyxia or birth injury.

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8
Q

what is vasa praevia

A

presentation of umbilical vessels lacking Wharton’s Jelly below the presenting part. Rupture of a vessel causes bleeding from the baby.

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9
Q

what is placental abruption

A 
separation of placenta
concealed or visible bleeding
Painful Bleeding - due to separation and contractility
Reduced/absent FM
Tense tender abdomen uterus like wood
Coagulopathy - DIC
PPH
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10
Q

antentatal haemorrhage Mx

A
  • OPTIMISE HAEMOGLOBIN ANTENATALLY
  • TREAT w iron IF HB<10.5 (EXCLUDE HAEMOGLOBINOPTHIES)
  • RISK OF HAEMORRHAGE – HOSPITAL DELIVERY
  • HB CHECK AT BOOKING THEN 28/40 +/- 36 weeks
  • CROSSMATCHING ( ESPECIALLY THOSE WITH ATYPICAL ANTIBODIES)
  • PATIENT’S WHO DECLINE BLOOD PRODUCTS
    Prophylactic 10 Units oxytocin i/m at delivery
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11
Q

intrapartum haemorrhage Mx

A

CANNULATION

  • FULL BLOOD COUNT
  • Coagulation screen- fibrinogen
  • GROUP AND SAVE
  • pulse, respiratory rate and blood pressure - every 15 minutes
  • commence warmed crystalloid infusion.

between 24 and 34 +6 weeks - administer steroids

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12
Q

Mx of PPH

A
  • ABC including two peripheral cannulae, 14 gauge
  • IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
  • IM carboprost
  • if medical options failure to control the bleeding then surgical options will need to be urgently considered
  • the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
  • other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
    if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
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13
Q

Mx of placental abruption

A

Fetus alive and < 36 weeks

  • fetal distress: immediate caesarean
  • no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Fetus alive and > 36 weeks

  • fetal distress: immediate caesarean
  • no fetal distress: deliver vaginally

Fetus dead
- induce vaginal delivery

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14
Q

dose
mode
MOA
oxytocin

A

5 units IV
10 units IM
40 units in 36mls infusion

15-30 mins

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15
Q

dose
mode
MOA
ergomtrine

A

0.25 mg (0.5mg) IV or IM

1-2 hours

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16
Q

dose
mode
MOA
syntometrine combination of oxytocin and syntometrine

A

1 amp IM

1-2 hours

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17
Q

dose
mode
MOA
misoprostol

A

PGs analogue

400-600mcg oral
800 – 1000mcg rectal

1-2 hours

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18
Q

dose
mode
MOA
carboprost

A

PG alpha analogue

0.25mg IM or IMM
IMM not licensed and not recommended
4-6 hours

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19
Q

adverse effects and CI of oxytocin

A

Hypotension, flushing, water intoxication, nausea, vomiting, hypertension, vasospasm

none

20
Q

adverse effects and CI of ergomtrine

A

Nausea, vomiting, hypertension, vasospasm

PET, Hypertension, Cardiovascular disease

21
Q

adverse effects and CI of syntometrine

A

Nausea, vomiting, hypertension, vasospasm

PET, Hypertension, Cardiovascular disease

22
Q

adverse effects and CI of misoprostol

A

Nausea, diarrhoea, shivering, pyrexia

None

23
Q

adverse effects and CI of carboprost

A

Vomiting, diarrhoea, flushing, shivering, vasospasm, bronchospasm

Cardiovascular disease, asthma

24
Q

if immediate transfusion required what do u do

A

give emergency group O
RhD-
K negative red cell units
switch to group-specific red cells ASAP

25
Q

how much crystalloid do u give

A

up to 2 isotonic crystalloid

26
Q

how much colloid do u give

A

upto 1.5 colloid until blood arrives

27
Q

when do u administer FFP

A

If PT or APTT are prolonged and haemorrhage is ongoing administer 12-15ml/kg of FFP

if haemorrhage continues after 4 units of RBCs adn haemostatic tests are unavailable, administer 4 units of FFP

28
Q

when do you administer platelet concentrates

A

administer 1 pool of platelets if haemorrhage is ongoing and platelet count less than 75x10^9/L

29
Q

when do you administer cryoprecipitate

A

administer 2 pools of cryoprecipitate if haemorrahge is ongoing and fibrinogen less than 2g/l

30
Q

Mx of massive obstetric haemorrhage

A
  • ACTIVATION OF MOH PROTOCOL
    MDT - senior anaesthetist, midwife, obstetrician, blood banks, porter, coordinators
  • TRANSFER TO THEATRE

Think of 4 Ts
Tone - uterine massage, bimanual compression

Trauma - repair 
Tissue
Thrombin
CORRECT COAGULOPATHY
HAEMOCUE
TEG
31
Q

continual Haemorrhage regardless of initial Mx

A 
no Tissue
no Trauma
Atony
UTERINE TAMPONADE
BAKRI BALLOON
REMOVAL OF PACK

last 6-8 hours of even next morning

32
Q

if balloon fails what do u do

A
  • UTERINE HAEMOSTATIC SUTURES
  • INTERNAL ILIAC LIGATION

if nothing available do this
SELECTIVE ARTERIAL OCCLUSION OR EMBOLIZATION BY INTERVENTIONAL RADIOLOGY

If haemorrhage is too extensive skip first two steps
HYSTERECTOMY
** HAEMOSTATIC DRUGS
TRANEXAMIC ACID/RECOMBINANT FACTOR VII
***CELL SALVAGE

ONCE PATIENT STABLE INFORM BLOOD BANK

33
Q

Risk factors of placenta praevia

A
  1. previous placenta praevia
  2. previous C sections
  3. previous termination of pregnancy
  4. multiparity
  5. advanced maternal age >40 years
  6. multiple pregnancy
  7. smoking
  8. deficient endometrium
    - uterine scar
    - endometritis
    - manual removal of placenta
    - curettage
    - submucous fibroid
  9. assisted conception
34
Q

RFs for palcental abruption

A
  1. previous abruption
  2. pre-eclampsia
  3. fetal growth restriction
    - first trimester bleeding
    - maternal thrombiphilias
  4. breech
  5. polyhydraminos
  6. advanced maternal age
  7. multiparity
  8. low BMI
  9. pregnancy following assited techniwues
  10. intrauterine infection
  11. PROM
  12. abdominal trauma
  13. smoking and drug use
35
Q

maternal complicaitons of APH

A
  • anaemia
  • infection
  • maternal shock
  • renal tubular necrosis
  • consumptive coagulopathy
  • postpartum haemorrhage
  • prolonged hospital stay
    psycholoigcal sequeale
  • complications of blood transfusion
36
Q

RFs of primary postpartum haemorrhage

A
  • previous PPH
  • prolonged labour
  • pre-eclampsia
  • increased maternal age
  • polyhydraminos
  • emergency C-section
  • placenta praevia, placenta accreta
  • macrosomia
  • ritodrine (beta 2 adrenergic receptor agonist)
37
Q

Mx of minor PPH

A
  1. IV access (one 14 gauge cannula)
  2. urgent venepuncture (20ml ) for:
    - group and screen
    - FBC
    - coagulation screen, including fibrinogen
  3. pulse, resp rate, and BP every 15 minutes
  4. commence warmed crystalloid infusion
38
Q

Mx of major PPH

A

 A and B – assess airway and breathing
 C – evaluate circulation
 position the patient flat
 keep the woman warm
 transfuse blood as soon as possible, if clinically required
 until blood is available, infuse up to 3.5 l of warmed clear fuids, 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

39
Q

what measures are taken to reduce blood loss at delivery

A
  • oxytocin
  • — deliverign vaginally - in the 3rd stage of labour
  • — C section
40
Q

Mechanical and pharmcological measure sto manage PPH

A
  • palpate fundus to stimulate contraction
  • bladder empty - foley
  • oxytocin 5 iu sloe IV
  • ergometrine 0.5mg by slow IV or IM
  • oxytocin infusion unless fluid restriction is necessary
  • carboprost 0.25mg by IM max 8 doses repeated at intervals
  • misoprostol 800 micrograms sublingually
41
Q

Surgical measures to arrest the bleeding

A

intrauterine balloon tamponade - uterine atone FIRST line

haemostatic brace sutures

uterine devascularisation and internal iliac artery ligation

hysterectomy

42
Q

Mx of secondary PPH be managed

A
  • high vaginal and endocervical swabs

pelvic US - exclude retained products of conception

surgical evacuation of reaitend placental tissue

43
Q

fetal complications of placental abruption

A 
IUGR
hypoxia
death
small for gestational age and fetal growth restriction
prematuritiy
44
Q

clinical features of placental abruption

A 
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria

extreme pain and cold to touch

45
Q

RFs of placental abruption

A 
proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age
46
Q

Maternal Ix of APH

fetal Ix during a APH

A

FBC - coag screen only if platelets are abnormal
U&Es
LFTs
group and save

kleihauer test in rhesus D negative women

US for praevia

CTG, US if fetal viability cannot be detected

47
Q

Mx of placenta praevia

A

antenatal sterodis 34-35+6 weeks

Tocolysis for women presenting with symptomatic placenta praevia or a low-lying placenta may
be considered for 48 hours to facilitate administration of antenatal corticosteroids.

cross-match
c sections between 36-37 weeks

repro (28 decks)

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