Post - Partum Haemmorhage Flashcards
Definition
PRIMARY PPH: blood loss per-vagina > 500mL within 24 hours of delivery of the BABY
Minor- >500mL – 1000mL
- >500 (vaginal)
- >1000 (c-section)
Major- > 1500mL
- MOH (maj obstetric haemorrhage)
SECONDARY PPH: excessive vaginal bleeding from > 24 hours – 12 weeks postpartum (most commonly between 7-14 days)
Aetiology/ Risk factors
Epidemiology
- Major cause of obstetric morbidity and mortality worldwide
Aetiology
PRIMARY PPH (4 T’s)
- Tone
- Uterine atony
- This is the most common cause of primary PPH
- The uterus fails to contract adequately following delivery due to lack of tone in the uterine muscle
- Tissue
- Retention of placental tissue i.e. placenta accreta, retained placenta
- This prevents the uterus from contracting
- 2nd most common cause of primary PPH
- Trauma
- Damage sustained to the reproductive tract during delivery
- Perineum
- Cervix
- Vaginal
- Uterine
- ‘Thrombin’
Coagulopathies or vascular abnormalities which increase the risk of primary PPH
Vascular:
- Placental abruption
- Hypertension
- Pre-eclampsia
- Coagulopathies:
- vWD
- Haemophilia A/B
- ITP
- Acquired coagulopathy e.g. DIC, HELLP
- DRUGS
SECONDARY PPH
Uterine infection (endometritis)
- Retained placental fragments or tissue
- Abnormal involution of placental site
- Trophoblastic disease
- Bleeding disorders (e.g., vWd)
Risk Factors
Maternal factors
- Maternal age > 40 years
- Uterine over-distension (multiple pregnancy, polyhydramnios) => harder to contract
- Placental problems
- Fibroids
- Accreta
- Retained placenta
- Previous PPH
- Urinary retention - bladder compressing on uterus making it harder to contract
- HTN etc –> preeclampsia rf
Foetal Factors
- LGA/ macrosomia
- Shoulder dystocia –> more likely to cause perineal tears
Labour
- Prolonged >12hrs - also rf for secondary PPH
- Esp in stage 2/3
- Instrumental deliveries
- Episiotomy
- Anaesthetic - due to vasodilatory effect
- Chorioamnionitis - due to vasodilatory effect
- sepsis - due to vasodilatory effect
- Caesarean section (also a risk factor for uterine infection in secondary PPH)
Symptoms and signs
Presenting Symptoms
Primary
- SOB
- Dizziness
- Palpitations
- Excessive PB bleeding during delivery
Secondary
- Excessive PV bleeding/ spotting postpartum
- Fever
- Rigors
- Endometritis- lower abdominal pain and a tender uterus with a closed internal os
- Retained products of conception- crampy lower abdominal pain, inappropriately large uterus, open internal os and history of prolonged 3rd stage of labour
Signs O/E
- Haemodynamic instability àtachypnoea, tachycardia, hypotension
- Prolonged capillary refill time
- Uterine rupture symptoms
- Bleeding on speculum examination
Secondary
- Lower abdominal tenderness
- Foul smelling lochia (uterine discharge following delivery)
Investigations
BP – hypotensive?
Pulse- tachycardic?
Bloods
- FBC
- Crossmatch 4-6 units of blood
- Group and save
- Coagulation screen (including fibrinogen)
- Plasma fibrinogen should be maintained > 2g/L during ongoing PPH
- If platelets < 75x109/L, need to transfuse
- U&Es
- LFTs
Secondary
Blood cultures
High vaginal and endocervical swabs for secondary PPH
Pelvic USS
Can assist in diagnosis of retained placental tissue
Management
MAKE SURE TO NOT UNDERESTIMATE THE BLOOD LOSS IN TERMS OF THE PATIENT (e.g., a rugby 6ft woman is v different to a tiny woman)
Minimising Risk of PPH
- Treat anaemia
- Screen with an FBC at booking and 28 wks
- Iron supplements
Prophylactic uterotonics offered in the 3rd stage of labour to ALL women to reduce risk of PPH
- IM 10IU oxytocin- women without risk factors for PPH delivering vaginally
- IV 5IU oxytocin- women delivering by C-section
- In women at risk, consider 0.5-1g tranexamic acid in addition to oxytocin
- Ergometrine-oxytocin- may be used if there is NO hypertension in women at increased risk
Primary Minor PPH (500-1000mL without shock)
Resuscitation (ABC approach)
Airway- protect the airway as may lose consciousness
Breathing- 15L/min 100% oxygen through non-rebreathe mask
Circulation- IV access (1 large bore (14 gauge) cannula) and urgent venepuncture for:
- Group and save
- Cross-match
- FBC
- Coagulation screen, including fibrinogen
Monitor observations every 15 minutes- pulse, RR, BP, temperature, O2 saturations
Commence warm crystalloid infusion
Primary Major PPH (> 1000mL)
Call for help (emergency buzzer), consultant, anaesthetic team, alert haematologist, blood transfusion lab
ABC approach: assess airway and breathing, evaluate circulation
Position the patient flat
Keep the woman warm
Breathing- give 10-15mL/min oxygen
IV access- 2 large bore cannulae, consider arterial line monitoring
- Put in hand so it is easier after for mum to craddle baby
Send blood for: FBC, clotting, G&S and cross-match
Blood transfusion ASAP if clinically required
- If still not haemodynamically stable after transfusion of 4 units of packed red cells, give FFP at 12-15mL/kg
- Blood: O RhD negative, K negative
- FFP: if PT/APTT prolonged 12-15mls/kg
- 4 units RBCs, give 4 FFP
- Platelets: <75, give 1 pool of platelets
- Cryoprecipitate: fibrinogen <2g/l. give 2 pools
- Cryoprecipitate may be used to replace fibrinogen
Aim to:
- Hb >80
- Plts >50
- PT <1.5x normal
- APTT <1.5x normal
- Fibrinogen >2 g/l
- Until blood is available, infuse up to 3.5L warm clear fluids, initially 2L of warmed crystalloid
- Foley catheter to measure urine output
Initial Management of PPH
(as most common cause is uterine atony, initial measures are to try and stimulate contractions)
STEP 1: Palpate the uterine fundus and rub it – to stimulate contractions
STEP 2: Ensure the bladder is empty (Foley catheter)
STEP 3: IV Oxytocin 5IU- slow injection (can repeat dose)
Give them some tranexamic acid too
STEP 4: IV/IM Ergometrine 0.5mg (CONTRAINDICATED in hypertension)
STEP 5: Oxytocin infusion (40IU/500ml at 125ml/hour) unless fluid restriction needed
STEP 6: IM Carboprost 0.25mg repeated at intervals > 15 minutes (maximum 8 doses)
CONTRADICTED IN ASTHMA
STEP 7: Sublingual Misoprostol 800mg
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 surgical measures: Haemostatic B-lynch suture around the uterus, bilateral uterine or internal iliac ligation, hysterectomy
EMERGENCY: bimanual compression
Measures for Specific Causes
Uterine atony:
Bimanual compression
- To stimulate uterine contraction
- Insert gloved hand into vagina and form a fist to compress against the anterior uterine wall. The other hand presses down on the abdomen to apply pressure to the posterior uterine wall.
Pharmacological measures to increase uterine myometrial contractions (see above step-by-step protocol)
Surgical methods
- 1st line- IU balloon tamponade - puts pressure on inside the uterus to stop bleeding
- 2nd line - B-Lynch Haemostatic suture around the uterus
- Kinda like braces pushing fundus down and helping uterus to contract
- 3rd line - Bilateral uterine or internal iliac ligation
- Hysterectomy (v. last case scenario)
Trauma: repair laceration, if uterine rupture: laparotomy + repair OR hysterectomy
Tissue: IV oxytocin + start removal of placental products (manual evacuation) + IV antibiotics
Thrombin: consult haematology team
Secondary PPH (RCOG Green Top Guidelines)
High vaginal and endocervical swab- assessment of vaginal microbiology
Appropriate antimicrobials if endometritis suspected
Pelvic USS- exclude retained products
Surgical evacuation of retained placental tissue
IV Antibiotics
- Ampicillin + metronidazole
+ gentamicin - if there is endomyometritis or overt sepsis
Complications Prognosis
Complications
Anaemia
- Anterior pituitary ischaemia- Sheehan’ syndrome (may have difficulty breast feeding due to lack of milk production)
- Dilutional coagulopathy
- Sepsis
- Myocardial ischaemia
- Cardiac arrest
- Orthostatic hypotension
- Postpartum depression
Prognosis
Primary PPH has recurrence rate of 10%
Secondary PPH has recurrence rate of 20-25%
