Post-Partum Haemorrhage

Question 1

What defines a retained placenta? How is it managed?

Answer 1

• POC not expelled within 30 minutes of delivery
• Management
  
  • Manual extraction or uterine curettage
  • Misoprostol

Question 2

What is a primary post-partum haemorrhage? What are the possible aetiologies?

Answer 2

• Tone: overdistension (multiple pregnancy, polyhydramnios, macrosomia), infection, drugs, prolonged labour/failure to progress, uterine inversion, fibroids, full bladder, retained POC
• Trauma: genital tract lacerations, uterine rupture
• Tissue: retained POC
• Thrombin: coagulopathies, drugs

Question 3

Outline the management of PPH

Answer 3

• Restore or maintain adequate circulatory volume to prevent hypoperfusion of vital organs
  
  • IV access, crystalloid (up to 3.5L awaiting blood), monitor vitals/uterine tone/blood loss
  • FBE, coags, group and hold
• Restore or maintain adequate tissue oxygenation
• Reverse or prevent coagulopathy
• Eliminate the obstetric cause of PPH
  
  • Uterine massage/bimanual compression/balloon tamponade
  • Medical management: syntocinon (first line), misoprostol (second line)
  • Surgical management: evacuation of retained POC, B Lynch suture, arterial ligation/embolisation, hysterectomy

Question 4

What defines a secondary post-partum haemorrhage? What are the risk factors and common aetiologies?

Answer 4

• Definition: between 24 hours and 12 weeks after delivery, more than 500 mL blood loss (1L post-CS)
• Risk factors: pre-eclampsia, IUGR, spontaneous abortion, retained placenta, previous secondary PPH
• Aetiology
  
  • Placenta: failure to involute, retained tissue
  • Infection
  • Uterus: fibroids, polyps, cancer
  • Trauma
  • Coagulopathies

Question 5

What investigations might you consider in a woman with a secondary PPH?

Answer 5

• FBE, group and crossmatch (severity, treatment)
• Cultures, CRP, bHCG, coags, high and low vaginal swabs, antibody screen (guide treatment)

Question 6

What is a puerperal fever? What are the risk factors for developing one?

Answer 6

• Definition: any febrile condition >38 that remains or recurs in the first 14 days after birth excluding day 1
• Risk factors: prolonged ROM, frequent catheterisation, prolonged labour, interventions during birth (instruments, episiotomy), PPH, CS

Question 7

What are the most common causes for a puerperal fever?

Answer 7

• Uterine (endometritis)
  
  • Tachycardia, pelvic and lower abdomen pain, uterine tenderness, foul lochia, general malaise
  • Timing: 1-2 days post-delivery
• Ix: cultures, Mx: broad-spectrum IV antibiotics
• Breast infection
  
  • Fever, localised pain, abscess, erythema.
  • Mx - antibiotics +/- drainage of abscess. Continue breastfeeding
• UTI
• Septic pelvic venous thrombophlebitis