Post-Partum Haemorrhage

Question 1

What are the definitions of post-partum haemorrhage?

Answer 1

Primary PPH:

• >500ml of blood within 24 hours of delivery

Secondary PPH:

• excessive bleeding (not a volume) from the vagina between 24hours and 6 weeks following.

Question 2

What are some risk factors for PPH?

Answer 2

• overdistension of the uterus - multiple pregnancies, polyhydramnios
• APH
• operative/instrumental delivery
• general anaesthetic
• previous PPH

Question 3

What are the Causes of primary PPH? How do you categorise them?

Answer 3

4 Ts of PPH:

• Tone
  
  • uterine atony (70-80%)
    
    • posterior lie, polyhydramnios, obstructed labour
    • give syntocin 10units or ergometrin (causes HTN)
• Trauma
  
  • lacerations (20%)
    
    • episiotomy
    • perineal tears (1st, 2nd, 3rd, 4th)
• Tissue
  
  • retained products of conception
  • abnormal placenta (accreta, percreta, increta)
• Thrombin
  
  • coagulopathy
    
    • Pre-eclampsia
    • Placental abruptions (resulting in DIC DIC)
    • Other DIC causes:
      
      • Amniotic fluid embolism (BAD)
      • Sepsis
      • Liver disease

Question 4

What things should you do to assess PPH?

Answer 4

1. Vitals
   
   • HR (>100bpm worry)
   • BP (hypotension)
   • temperature
2. check abdomen
   
   • feel for uterus (position, contracted - rub uterine fundus)
3. genital examination (for laceration)
4. observe blood to determine volume
   
   • check placenta
   • Ix - HVS, US, cultures
     
     • change in Hb >30mins (too long)

Question 5

What is the Management of PPH?

Answer 5

• Assess vitals and Resuscitate
  
  • estimated blood loss >1500mls or if estimated >1L with symptoms
  • fluids - wide bore IV insertion
• stop haemorrhage
  
  • mechanical
    
    • uterine massage for atonic uterus,
    • empty bladder
  • pharmacological
    
    • oxytocin (syntocinon) IM
    • ergometrine IV or IM
    • misoprostol PR
    • dinoprost (into myometrium)
  • inspection of birth canal for trauma
• theatre if not controlled:
  
  • manual removal of placenta
  • uterine packing
  • balloon tamponade
  • laparotomy
  • B/L ligation of arteries
• rupture = laparotomy - consider hysterectomy.

Question 6

What are some causes of secondary PPH? What is the management of each?

Answer 6

Causes: (can occur together)

• infection (endometritis)
• retained products of conception
• gestational trophoblastic disease
• coagulopathy

Management:

• antibiotics
  
  • high fever always triple therapy (amoxycillin, gentamicin, metronidazole).
• surgery
  
  • Asherman’s syndrome (adhesions within the uterus) risk
  • dilatation and curettage

Question 7

What is Sheehan’s syndrome? What causes it?

Answer 7

• Postpartum pituitary gland necrosis - hypopituitarism from ischaemic necrosis due to blood loss

Question 8

A 37 year old para 4 has had retained placenta complicated with PPH in 3 of her pregnancies. How would you manage subsequent pregnancies?

Answer 8

• routine ANC modifying RFs (anaemia, coagulopathy, placentation, blood group + cross match)
• equipment ready (O2, IDC, fluids, misoprostol, oxytoxic)
• active management in the 3rd stage of labour:
  
  • prophylactic oxytoxic
  • cord management (clamp early) - controlled traction
  • massage fundus
  • empty the bladder
  • document blood loss.

Question 9

What is the commonest cause of secondary PPH? What are some common differentials? What is the management?

Answer 9

Endometritis (retained products of conception)

DDx:

• prolonged lochia
• incidential bleeds
• early return to menstruation

Treatment:

• broad antibiotics
• removal of POC + Antis prior to prevent Ashermann’s

Question 10

What are some complications of pharmacologic management of PPH?

Answer 10

• syntocin
  
  • painful contractions
  • n/v
  • hypotension
• egometrine
  
  • avoid if possible - causes tonic uterine contraction (may delay expulsion)
  • n/v, high BP
• misoprostol
  
  • has extra SE of flushing, diarrhoea, fever, and headache.
• PGF2aplha - dinoprost (similar to misoprostol - headache)