Post Partum Haemorrhage

Question 1

What are the normal physiological mechanisms that prevent PPH?

Answer 1

1. Myometrial contractions + Uterine retraction –> Luminal obliteration (blood vessels) + vascular compression. 2. Hypercoagulable state during pregnancy. 3. Excess volemia compensates for normal blood less (<500mL).

Question 2

What is the difference between Expectant management and Passive management of the placenta during the 3rd stage of labor? What are the risks of each?

Answer 2

Expectant: - Oxytocin given (IM) - uterotonic injection. - Clamping of the umbilical cord early in third stage. - Controlled cord traction. - Decreases time to <5min RISKS - uterine retroversion, if not done correctly. Passive: - ‘Hands off’ - No uterotonic given. - Umbilical cord clamped AFTER the expulsion of the placenta. - Maternal pushing to expel placenta. No controlled cord traction. RISKS - higher risk of PPH

Question 3

What is the definition of PPH, what is the definition of severe PPH?

Answer 3

PPH - >500ml blood loss during or after labor. Severe PPH >1000mL blood loss during or after labor OR - hemodynamic instability.

Question 4

What is the difference between primary and secondary PPH?

Answer 4

Primary: within 1st 24 hours. Secondary: >24 hours

Question 5

What are the 4 T’s of PPH, in order of importance? What do they mean and what is their aetiology?

Answer 5

1. Tone. 2. Trauma. 3. Tissue. 4. Thrombus. TONE - Abnormalities of uterine contraction. - Atonic uterus Passive 3rd stage management. Prolonged third stage (>30 mins) - Over distended uterus Polyhydramnios Macrosomia Multiple pregnancy - Uterine muscle exhaustion Rapid/incoordinated labor. Prolonged labor (1st/2nd stage) - the sun should never set twice. Labor dystocia (obstructed labor). High parity. Labour augmented by oxytocin. - Intra amniotic infection Pyrexia. Prolonged ruptured membranes (>24 hours). - Drug induced uterine hypotonia Magnesium sulphate. Nifedipine. Salbutamol General Anaesthesia. - Uterine distortion Fibroids. Other structural abnormalities, scarring. TRAUMA - Genital tract trauma. Episiotomy/lacerations: Cervix, vagina, perineum. Induced labor Augmented labour Abnormal labour (dystocia) Malposition. Instrumental labour. Extensions / lacerations at c-section Malposition Deep engagement. Uterine rupture Suspect if - Sudden change in FHR - Abdo tenderness - Vaginal bleeding - Maternal tachycardia Sign if shock is disproportionate to blood loss. Uterine Inversion iF degree of shock is disproportionate to blood loss. TISSUE - retention of placental tissue. Incomplete placenta at birth. Abnormal placenta Retained cotyledon/succentruiate lobe. RF Placenta accreta. Previous uterine surgery. High parity. Abnormal placenta on US. THROMBUS - abnormalities of coagulation. - Coagulation d/o acquired during pregnancy. - Idiopathic thrombocytopenic purpura (ITP) - Von Willebrands disease - Hemophilia - Thrombocytopenia with pre eclampsia - Disseminated intravascular coagulation (DIC) - Pre eclampsia - Retained dead fetus - Severe infection - Placental abruption. - Amniotic fluid embolism. - retained blood clots. - therapeutic anticoagulation.

Question 6

What is the difference between the 2 types of vaginal haematomas, and how do these differ to a vulvar hematoma? Which is the most dangerous?

Answer 6

VAGINAL: below Levator ani: vaginal veins. above Levator ani: uterine veins (most dangerous as it bleeds out into abdomen) VULVAL: bulbospongiosus.

Question 7

What is the order of management of PPH?

Answer 7

1. Palpation + massage
2. IM syntocinon
3. Bore cannulas x2 (syntocinon and Hartmanns given)
4. G+H, FBC + XMatch
5. Identify source of bleed
   - fundal height
   - placenta and membranes intact?
   - clots present?
6. Drugs (syntocinon, misoprostil, ergoemetrine, prostaglandins)
7. Bimanual compression
8. Tamponade
9. Sx - ligation, embolisation, hysterectomy.

Question 8

What are the 3 main ways to prevent PPH?

Answer 8

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Question 9

What are the signs of placental separation?

Answer 9

SIGN OF PLACENTAL SEPARATION: 1. lengthening of the cord 2. gush of blood.

Question 10

What is the definition of Placenta Accreta, Placenta Increta and Placenta Percreta? Which is the most common?

What are the primary risk factors for managing Placenta Accreta?

What is the mx?

Answer 10

Placenta Accreta: Abnormal placental implantation, chorionic villi attach to the myometrium (“abutting”), rather than the decidua.

Placenta Increta: Chorionic villi invade into the myometrium.

Placenta Percreta: Chorionic villi invade through the myometrium to the uterine serosa/adjacent organs (ie - bladder).

PLACENTA ACCRETA IS THE MOST COMMON.

RF

• Placenta Previae
• Previous C-section or uterine surgery (ie, myomectomy - only if endometrial cavity is entered, serosal mymectomy incisions do not increase the risk).
• Maternal age>35 years.
• Multiparity (risk increases with each birth).
• Uterine pathology - ie, fibroids.
• If any of these AND placenta previa = significantly increased risk (ie, 3 previous C-sections + anterior low lying placenta = 50% increased risk of placenta accreta).

Mx.

• Gentle removal of cotyledon, manual separation.
• Rx bleeding w oxytocin + uterine massage + blood transfusion
• Packing of uterus if necessary.

–> High mortality.

Definitive treatment: hysterectomy.