obstetric haemorrhage Flashcards
define PPH
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)
most common form of obstertic haemorrhage
PPH
causes of antepartum haemorrhage
- 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
intrapartum causes of heamorrhage
Prolonged 1st, 2nd stage Oxytocin use Precipitate labour Operative vaginal delivery-Episiotomy Second stage caesarean section - c section after full dilatation
postpartum causes of haemorrhage
Uterine atony MOST COMMON CAUSE
Retained products
Trauma
Thrombin
secondary
- retained POC
- endometritis
what is placenta praevia
types
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
Complications forms placenta praevia
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.
what is vasa praevia
presentation of umbilical vessels lacking Wharton’s Jelly below the presenting part. Rupture of a vessel causes bleeding from the baby.
what is placental abruption
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
antentatal haemorrhage Mx
- 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
intrapartum haemorrhage Mx
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
Mx of PPH
- 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
Mx of placental abruption
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
dose
mode
MOA
oxytocin
5 units IV
10 units IM
40 units in 36mls infusion
15-30 mins
dose
mode
MOA
ergomtrine
0.25 mg (0.5mg) IV or IM
1-2 hours
dose
mode
MOA
syntometrine combination of oxytocin and syntometrine
1 amp IM
1-2 hours
dose
mode
MOA
misoprostol
PGs analogue
400-600mcg oral
800 – 1000mcg rectal
1-2 hours
dose
mode
MOA
carboprost
PG alpha analogue
0.25mg IM or IMM
IMM not licensed and not recommended
4-6 hours
adverse effects and CI of oxytocin
Hypotension, flushing, water intoxication, nausea, vomiting, hypertension, vasospasm
none
adverse effects and CI of ergomtrine
Nausea, vomiting, hypertension, vasospasm
PET, Hypertension, Cardiovascular disease
adverse effects and CI of syntometrine
Nausea, vomiting, hypertension, vasospasm
PET, Hypertension, Cardiovascular disease
adverse effects and CI of misoprostol
Nausea, diarrhoea, shivering, pyrexia
None
adverse effects and CI of carboprost
Vomiting, diarrhoea, flushing, shivering, vasospasm, bronchospasm
Cardiovascular disease, asthma
if immediate transfusion required what do u do
give emergency group O
RhD-
K negative red cell units
switch to group-specific red cells ASAP
how much crystalloid do u give
up to 2 isotonic crystalloid
how much colloid do u give
upto 1.5 colloid until blood arrives
when do u administer FFP
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
when do you administer platelet concentrates
administer 1 pool of platelets if haemorrhage is ongoing and platelet count less than 75x10^9/L
when do you administer cryoprecipitate
administer 2 pools of cryoprecipitate if haemorrahge is ongoing and fibrinogen less than 2g/l
Mx of massive obstetric haemorrhage
- 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
continual Haemorrhage regardless of initial Mx
no Tissue no Trauma Atony UTERINE TAMPONADE BAKRI BALLOON REMOVAL OF PACK
last 6-8 hours of even next morning
if balloon fails what do u do
- 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
Risk factors of placenta praevia
- previous placenta praevia
- previous C sections
- previous termination of pregnancy
- multiparity
- advanced maternal age >40 years
- multiple pregnancy
- smoking
- deficient endometrium
- uterine scar
- endometritis
- manual removal of placenta
- curettage
- submucous fibroid - assisted conception
RFs for palcental abruption
- previous abruption
- pre-eclampsia
- fetal growth restriction
- first trimester bleeding
- maternal thrombiphilias - breech
- polyhydraminos
- advanced maternal age
- multiparity
- low BMI
- pregnancy following assited techniwues
- intrauterine infection
- PROM
- abdominal trauma
- smoking and drug use
maternal complicaitons of APH
- anaemia
- infection
- maternal shock
- renal tubular necrosis
- consumptive coagulopathy
- postpartum haemorrhage
- prolonged hospital stay
psycholoigcal sequeale - complications of blood transfusion
RFs of primary postpartum haemorrhage
- previous PPH
- prolonged labour
- pre-eclampsia
- increased maternal age
- polyhydraminos
- emergency C-section
- placenta praevia, placenta accreta
- macrosomia
- ritodrine (beta 2 adrenergic receptor agonist)
Mx of minor PPH
- IV access (one 14 gauge cannula)
- urgent venepuncture (20ml ) for:
- group and screen
- FBC
- coagulation screen, including fibrinogen - pulse, resp rate, and BP every 15 minutes
- commence warmed crystalloid infusion
Mx of major PPH
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
what measures are taken to reduce blood loss at delivery
- oxytocin
- — deliverign vaginally - in the 3rd stage of labour
- — C section
Mechanical and pharmcological measure sto manage PPH
- 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
Surgical measures to arrest the bleeding
intrauterine balloon tamponade - uterine atone FIRST line
haemostatic brace sutures
uterine devascularisation and internal iliac artery ligation
hysterectomy
Mx of secondary PPH be managed
- high vaginal and endocervical swabs
pelvic US - exclude retained products of conception
surgical evacuation of reaitend placental tissue
fetal complications of placental abruption
IUGR hypoxia death small for gestational age and fetal growth restriction prematuritiy
clinical features of placental abruption
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
RFs of placental abruption
proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age
Maternal Ix of APH
fetal Ix during a APH
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
Mx of placenta praevia
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
