post-partum haemorrhage

Question 1

aetiology of PPH

Answer 1

Tone - prolonged labour, IOL, multiparity etc
trauma - operative delivery, cervical/vaginal lacerations
tissue - retained placental tissue, abnomrla placentation
Thrombin - pre eclmpsia/HELLP, amniotic fluid, sepsis, bleeding disorders, drugs, medical disorders

Question 2

management for trauma

Answer 2

clamp vessels and repair wounds
if excessive/severe - tranexamic acid and send to theatre

Question 3

management for tissue

Answer 3

retained placenta - intitiial attempts for placental seperation including oxytocin
transfer to theatre for manual removal
retained tissue - trnsfer to theatre for manual removal
potential need for USS to locate tissues

Question 4

management for tone

Answer 4

Ongoing massage/bimanual compression
Administer uterotonics
* Syntometrine IM 1 ampoule (if not already given for prophylaxis or contraindicated)
* Or syntocinon or ergometrine
* Commence syntocinon infusion in hartmans
Examine the placenta for completeness if delivered and the vagina to exclude uterine inversion
If ongoing uterine atony
* Carboprost 250microg IM = 1ml ampoule. Continue uterine massage as required.
* If uterus is still atonic after 15 minutes administer second same dose carboprost and arrange CAT1 transfer to theatre
* Consider tranexamic acid

to theatre for ongoing compression, carboprost, and TXA

Question 5

management for thrombin

Answer 5

straight to theatre
TXA
massive transfusion protocol activation

Question 6

risk factors for PPH

Answer 6

age >35
uterine overdistension - twins, polyhydramnios
uterine exhaustion - long labour, precipitate labour (extremely rapid labour)
grand multiparity
assisted delivery or operative delivery
abnormal placentation
history of APH
intra-amniotic infection
previous PPH
tocolytic drugs (MgSO4, nifedipine)

Question 7

resus measures

Answer 7

A-E
assess cause
massage atonic fundus and apply pressure to the perineal trauma during resus (may be achieved by bimanual compression)
Iv access
take blood for: FBC, G+H, X-match, coags, d-dimer, ROTEM
insert IDC
monitor maternal observations
keep patient warm
critical bleeding protocol

Question 8

ROTEM

Answer 8

used to identify low fibrinogen, low platelets, low coag factors, excess fibrinolysis
used to inform treatment with fibrinogen concentrate, cryoprecipitate, tranexamic acid, platelets etc

Question 9

surgical measures

Answer 9

intrauterine balloon catheter
laparotomy
- B lynch suture
- pelvic vessel ligation
- hysterectomy
embolisation of uterine arteries

Question 10

complications

Answer 10

death
DIC
transfusion complications
renal failure
sheeehan’s syndrome - pituitary necrosis
risk of infection
loss of fertility