Post-Partum Complications

Question 1

What volumes define primary postpartum haemorrhage (PPH)

Answer 1

>500ml vaginal
>1000ml caesar

IN 24 HOURSPP: beware the slow but steady bleeder.

or any bleed with instability

Question 2

Causes of primary PPH:

Answer 2

Tone (80%)
Tissue- RPOC, acc/incr/perc
Trauma- inversion, rupture
Thrombin- DIC (amniotic fluid embolism, HELLP)

Question 3

Define secondary PPH:

Answer 3

Excessive bleeding beyond 24/24 up to 6 weeks PP

Question 4

Causes of secondary PPH:

Answer 4

Almost always infective (endometritis, septic RPOC)

Rare: abnormal involution, trophoblastic disease.

Question 5

Management of primary PPH:

Answer 5

Consider and target cause: Tone, Trauma, Tissue, Thrombin, (twin)

• Empty bladder
• Fundal massage
• OXYTOCIN 5 units IM/IV —> 40units in 1L over 4 hours
  And, unless hypertensive:
• ERGOMETRINE 0.5mg IM/IV repeat Q5min up to 1mg PRN
• MISOPROSTOL PR up to 1g
• Haemostatic resus incl TXA 1g

Other options:
- Bimanual compression (needs PSA)
- Bakri balloon (or gauze)
- Aortic compression externally
- Misoprostol 600microg PR/buccal

…. Ultimately OT/ interventional rad.

Question 6

Management of secondary PPH:

Answer 6

• As per Primary PPH
• Vaginal swabs
• Antibiotics
  –> Amoxy + Metro + Gent IV
  or
  –> Augmentin + metro PO
• USS for ?RPOC