Post partum haemorrhage Flashcards
RF of PPH
Antenatal Over distension of uterus: LGA, Polyhydrosis, Grand multi, Multiple gestation placenta bed abnormalities Fibroids abnormal uterus structure eg septum abnormal implanted e.g. Acretia Placenta priva Chroniamnolitis Previous APH or Abruption Return placenta Coagulation Preexisting anaemia - need to treat Hb<100 Pre eclampsia Anticoagulation Maternal: Previous PPH, Increase age, Increase BMI, asian ethnicity Intrapartum prolonged or precipitates labour Caesarian Tears Augmentation instrumental delivery Chorioamnionitis Uncommon causes - uterine rupture, invasion, Amniotic fluid embolism
the four Ts of PPH
Tone 70%
Tissue 10% eg retained products
Trauma - 20% says the research but not the doctors here
Thrombin 1%
Prevention of PPH
Antenatal Detect and treat anaemia ID high risk patient and document Mx plan Refer to specialists Intrapartum High risk pt IV access, G and H, X-match Syntocinon infusion ready Active Mx of third stage
Mx of PPH
Call for help Active management for 3rd stage uteronic - Oxytocin 10unit IM, 5 units IV or 40 units in 1L at 125mls (syntocinon: Oxytocin + ergometrine) Clamp and Controlled cord traction with counter pressure of fundus Pregnancy is hyper coagulable state. Rub up a contraction 3 As: Assess amount of bleeding, address womens concerns, adjust to lay the bed flat. ABCD Bimanual Misoprostol OT B Lynch suture Bakri ballon internal iliac artery ligation Hysterectomy Massive transfusion protocol
Massive transfusion protocol
Criteria actively bleeding and lost 2.5 L and already had 4 U…..
4 U RBC
4 U FFP
Cryoprecipitate 10U
Platelets - single adult dose (after 8-10 U of RBC)
Repeat as necessary - guided by laboratory finds
Consider - Haematologist
Calcium Glutinate
Tranexamic acid
Recombinant factor 7
Main cause of PPH in our population
Uterine atony
Define Primary and secondary PPH
Primary is less then 24hr.
Secondary is between 24hr to 6 wks
Secondary PPH
defined - 24hr to 6 weeks Epidemiology - 1% Causes Endometritis - most common Retained products - most common Trauma Coagulopathy GTD - gestational tropablastic disease.` Sub involution of uterus Mx - underlying cause
Cx of PPH
Hypovolaemic shock Renal failure Hepatic failure DIC ARDS Death Sheehan syndrome
Retained products - defined
placenta undelivered after 30 min postpartum
Causes of Retained products
placenta separated but not delivered
Abnormal placental implantation e.g. placenta accreta, placenta intreat, placental removal
RF for retained product
Placenta previa, Prior C/S post pregnancy curettage prior manual placental removal Uterine infection
Clinical features of retained products
Incomplete placenta removed
Risk of postpartum haemorrhage and infection
Ix of retained products
Explore uterus
assess degree of blood loss
Mx of retained products
2 lg bore IV and group and hold
Active 3rd stage labour: control cord traction and Oxytocin
Manual removal if this fails
D&C if required.
