Post partum haemorrhage

Question 1

What is PPH?

Answer 1

Blood loss equal to or > 500ml after birth of baby

Question 2

Primary PPH occurs when?

Answer 2

within 24 hours of delivery

Question 3

Secondary PPH occurs when?

Answer 3

24 hours after delivery - 6 weeks post

Question 4

Minor PPH is?

Answer 4

500-1000ml without clinical shock

Question 5

Major PPH is?

Answer 5

> 1000ml or signs of CV collapse or on going bleeding

Question 6

Remembering causes of primary PPH?

Answer 6

4 Ts

• TONE
• TRAUMA
• TISSUE
• THROMBIN

Question 7

What counts for 75%-905 of all PPH?

Answer 7

Uterine atony

Question 8

If there is atony what happens?

Answer 8

Context: when placenta delivered contractions of uterus help compress bleeding vessels in the area where placenta was attached
If there is atony then these vessels bleed freely ad PPH occurs

Question 9

Next most common cause of PPH?

Answer 9

Vaginal tear, cervical laceration, rupture

Question 10

Tissue cause of PPH?

Answer 10

Retained products of conception

Question 11

Thrombin and PPH cause?

Answer 11

Coagulopathy HELLP syndrome, sepsis or DIC

Question 12

Antenatal RFs for PPH?

Answer 12

Anaemia 
Prev Csection 
Placenta praevia or accrete 
Prev PPH 
Previous retained placenta
Multiple pregnancy 
Polyhydramnios 
Obesity 
Fetal macrosomnia

Question 13

Prevention of PPH?

Answer 13

Identify intrapartum RF: prolonged labour, operational vag delivery, C section, retained placenta
Active maangement of 3rd stage of labour with synctocin

Question 14

Management of primary PPH?

Answer 14

Stop the bleeding: massage of uterus, IV syntocinon, misoprostol PR, tranexamic acid IV, may need surgery

Assess: determine cause, blood samples, vitals

Fluid replacement: 2 large bore IV access, fluid crystalloids, blood transfusion early

Question 15

What will most women repsond to in PPH?

Answer 15

IV syntocinon

Question 16

Secondary PPH causes?

Answer 16

Retained placental tissue (RPOC)
Intrauterine infection
Rare causes like trophoblastic disease and abnormal vasculature
• Exclude RPOC with USS

Question 17

Light bleeding treatment of secondary PPH?

Answer 17

Course of ABs

Question 18

Bleeding heavy and treatment of secondary PPH?

Answer 18

Signs of infection IV borad spectrum AB and EUA

Question 19

Resus in pregnant women? (Sorry ive copied and pasted this from notes because so much effort, probs worth a read through but couldn’t break it into questions)

Answer 19

• The gravid uterus causes aortocaval compression which reduces venous return to the heart so cardiac compressions are less effective
• Ventilation is more difficult due to pressure on the diaphragm from the uterus
• The fetoplacental unit effectively steals O2 and circulating volume from the mother reducing the effectiveness of CPR
• Pregnant women are more likely to aspirate due to hormonal relaxation of the oesophageal sphincter and delayed gastric emptying
• This makes intubation a priority but it is harder than normal in pregnancy due to oedema, larger tongue and breasts
• From 20 weeks onwards need to do manual uterine displacement when performing CPR (basically if a woman looks obviously pregnant then do this)
• If no response to CPR at 4 minutes then a perimortem C section should be undertaken to assist maternal resus, minimal equipment is needed and if the mother stabalises she can be moved to theatre