Post partum haemorrhage

Question 1

Define PPH

Answer 1

Loss of more than 500ml after spontaneous vaginal delivery, or more than 1L after c-section

Question 2

How do we classify PPH and what do these classifications mean?

Answer 2

Primary PPH - within 24 hours of delivery

Secondary PPH - between 24 hours and 12 weeks

Question 3

What are the four broad causes of PPH?

Answer 3

Tone (lack of)
Trauma
Tissue
Thrombin

Question 4

What can cause tonal problems resulting in PPH and what is this called? (Split into 4)

Answer 4

UTERINE ATONY can be caused by:

• an overdistended uterus - e.g. due to polyhydramnios, macrosomia or multiple gestations
• muscle exhaustion - due to prolonged or rapid labour, GA, oxytocin use, 6 or more kids etc
• uterine anatomy abnormality e.g. fibroids, placenta praevia or abruption
• intraamniotic infection due to prolonged rupture of membranes

Question 5

What tissue problems can cause PPH?

Answer 5

Retained products - membranes, cotyledon, succenturiate lobe

Gestational trophoblastic neoplasia

Abnormal placentation (placenta accreta, increta, percreta)

Question 6

What is placenta accreta?

Answer 6

When the placenta attaches to the endometrium; it attaches too deeply into the wall of the uterus, making it difficult to be shed during labour.

ACCreta = ATTaches to the endometrium (75 percent)

Question 7

What is placenta increta?

Answer 7

When the placenta invades the myometrium

INcreta = INvades myometrium (18 percent)

Question 8

What is placenta percreta?

Answer 8

When the placenta invades through the uterine muscle wall into the serosal layer and sometimes even organs like the bladder.

PERcreta = PROtrudes through the myometrial layer (7 percent)

Question 9

Gestational trophoblastic neoplasia

Question 10

What trauma can cause PPH?

Answer 10

Episiotomy
Uterine rupture
Uterine inversion
Haematoma

Question 11

What thrombin problems can cause PPH?

Answer 11

Haemophilia
DIC
Aspirin use
ITP
TTP
VWD (most common)
Therapeutic anti-coagulation

Question 12

Most common causes of secondary PPH

Answer 12

Retained products of conception (RPOC)
Infection of the endometrium (endometritis)

Less commonly:
Trophoblastic disease

Question 13

Investigations for secondary PPH

Answer 13

Obs - check for temp, pulse and BP

Palpate uterus for tenderness

Endocervical and vaginal swabs for culture

USS for RPOC

Question 14

Mx of secondary PPH

Answer 14

Antibiotics or evacuation of RPOC (manually if within 1 week, digitally with USS if more than that).

Question 15

Signs of primary PPH

Answer 15

Generally - shock - tachycardia, hypotension, signs of anaemia

Abdomen - atonic uterus (above umbilicus)

Speculum - exclude trauma

Vaginal - clots in cervix (which inhibit contraction)

Question 16

Signs of secondary PPH

Answer 16

Abdo - tender uterus
Vagina - uterine tenderness
Speculum - See if cervical os is still open, assess bleeding

Question 17

How do you classify PPH based on volume?

Answer 17

Major = above 1 L or if in shock (call 222)

Minor = 500ml-1L without shock

Question 18

Management of minor/major PPH - medical and surgical

Answer 18

B there in one SEC

Medical:
1. Bimanual compression (one hand compresses the uterus through the vagina, and the other hand squeezes the uterus from the abdomen)
2. Syntocinon IM/IV 10U
3. Ergometrine/syntometrine IM
4. Carboprost IM

Also: Crystalloid or colloid up to 3.5L
Catheter to prevent full bladder obstructing uterine contraction

Surgical:
Balloon tamponade
B lynch suture
Ligation of arteries (interventional radiology)
Hysterectomy

Question 19

Complications of PPH

Answer 19

Sheehan’s
Death
Renal failure
VTE
Hysterectomy

Question 20

Epidemiology stats for PPH

Answer 20

4th most common cause of maternal death in the UK
Leading cause of maternal mortality worldwide