Post-Partum Haemorrhage

Question 1

Define postpartum haemorrhage (minor, moderate, major)

Answer 1

Minor = 500-1000ml
Moderate (major) = 1001-2000ml
Severe (major) = >2000ml

Question 2

What is the difference between primary and secondary postpartum haemorrhage

Answer 2

Primary: blood loss of 500ml or more from the genital tract occurring within 24 hours of delivery
Secondary: excessive loss occurring between 24 hours and 6 weeks after delivery

Question 3

What are the causes of postpartum haemorrhage

Answer 3

Uterine atony - failure of the myometrium to contract down after delivery, creating the ligature to control bleeding from the placental bed (70-90%)
Retained placental tissue (RPOC)
Genital tract trauma e.g. tears, episiotomy, cervix lacerations, uterine rupture
Coagulation disturbance: pre-eclampsia, vWD, haemophilia, ITP, DIC, anticoagulants

Secondary: endometritis, RPOC, subinvolution of the placental implantation site

Question 4

What are the risk factors for postpartum haemorrhage

Answer 4

Previous post partum haemorrhage
Uterine wall scar
Prolonged labour (2nd/3rd stage)
Increased foetal size (macrosomia)
Intrapartum haemorrhage
Pre-eclampsia
Multiple pregnancy
Grand multiparity
Uterine fibroids
Raised BMI
Polyhydramnios

Question 5

What are the symptoms of postpartum haemorrhage

Answer 5

Postpartum bleeding
Dizziness
SOB
Fatigue
Anxiety

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

Question 6

What are the signs of postpartum haemorrhage on examination

Answer 6

General: pallor, SOB
Obs: Hypotension (35% loss), tachycardia (30% loss), tachypnoea, raised CRT

Pelvic: visible blood loss

Question 7

What investigations should be done for postpartum haemorrhage

Answer 7

bedside: consider high vaginal/endocervical swabs for secondary PPH
Bloods: FBC, cross-match, coagulation screen, G&S, VBG, Renal screen, LFTs
Other: Abdo/TVUSS - ?RPOC

Question 8

What is the general management for postpartum haemorrhage

Answer 8

1. Call for help - 2222 and state major obstetric haemorrhage
2. A-E assessment (2x cannula, bloods, fluids, transfuse)
3. Assess the cause of bleeding → most likely uterine atony → bimanual uterine compression
4. IV oxytocin / IM ergometrine + tranexamic acid IV
5. Continuous monitoring: temp, pulse, BP, RR< urine output
6. After resolution: document, debrief, datex

Question 9

What is the management for postpartum haemorrhage due to uterine atony

Answer 9

(following general)
Conservative
1. Bimanual uterine compression: fist into the vagina against the anterior uterine wall, other presses down on the abdomen
2. Foley catheter for complete bladder emptying

Pharm
1. IV oxytocin
2. IM ergometrine (NOT in HTN)
3. Oxytocin infusion
4. IM carboprost (CI in asthma)
5. Intramyometrial carboprost
6. Sublingual misoprostol

Surgery
1. Balloon tamponade
2. B-Lynch haemostatic suturing, stepwise uterine devascularisation and internal iliac artery ligation, selective arterial occlusion or embolization by interventional radiology
3. Hysterectomy

Question 10

What is the management for postpartum haemorrhage due to trauma

Answer 10

(following general management)
repair laceration
Uterine rupture: laparotomy + repair OR hysterectomy

Question 11

What is the management for postpartum haemorrhage due to tissue

Answer 11

IV oxytocin + start removal of placental products (manual evacuation) + IV antibiotics

Question 12

What is the management for postpartum haemorrhage due to clotting disorders

Answer 12

urgent haematology discussion

Question 13

What is the management for secondary PPH

Answer 13

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

Question 14

What are the complications of PPH

Answer 14

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

Question 15

What are the features of Sheehan syndrome

Answer 15

hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock
- agalactorrhoea
- amenorrhoea
- symptoms of hypothyroidism
- symptoms of hypoadrenalism

Question 16

What is the prognosis for PPH

Answer 16

Primary PPH has recurrence rate of 10%
Secondary PPH has recurrence rate of 20-25%