Post-partum haemorrhage - amboss Flashcards
define
obstetric emergency
blood loss >1000mL
or
blood loss presenting with signs and symptoms of hypovolaemia wihtin 24 hours of delivery
primary PPH
within 24 hours of delivery
secondary PPH
between 24 hours post delivery
morbidity/mortality
no. 1 cause of maternal mortality and morbidity worldwide
main causes of PPH
uterine atony
maternal brith trauma
abnormal placental seperation
velamentous cord insertion
coagulation disorders
4 T’s causes of PPH
Tone: uterine atony
Trauma: laceration, uterine inversion
Tissue: retained placenta
Thrombin: bleeding diathesis
clinical features
rapid heavy vaginal bleeding
hypovolaemia: decreased blood pressure, increased heart rate, dizziness
physical examination findings
lacerations, hematoma, any other visible cause of bleeding, boggy uterus
lab investigation
haematocrit, hemoglobin to estimate blood loss
findings on speculum examination
uterine inversion
retained placental tissue or membranes
puerperal hematoma
ultrasound findings
used to determine the correlation between the placenta and the cervical os
uterine atony
abnormal placental attatchment
colour doppler ultrasound will confirm abnormal placental attatchment (eg. showing turbulent blood flow)
general measures of management
control blood loss
monitoring of vital signs and urine output
oxygenation
two large-bore IV access (>16 gauge) in the ACFs and ice pack
fluid therapy (with IV crystalloid solutions)
blood transfusions (whole blood or red cell concentrates) and/or platelet transfusions if necessary
surgical measures of management
in cases of uncontrolled bleeding - ligation of uterine or internal iliac arteries, or uterine artery embolication: decreases bleeding by reducing myometrial perfusion, but fertility remains intact because of collateral blood supply by the ovarian arteries
uterine suturing
hysterectoimy - generally a last resort
prevention of PPH
identification of anaemia and coagulopathies
sonogrpahy to identify placenta accreta in women with a Hx of caesareans
active management of third staage of labour
avoidance of unecessary episiotomy
complications of PPH
anaaemia
hypovolaemic shock
thromboembolism
Sheehan syndrome
infection
maternl death
DIC
fetal death
abdominal compartment syndrome
causes of primary PPH
uterine atony
uterine inversion
retained placenta or bnormal placentation
birth trauma
velamentous cord insertion
causes of secondary PPH
retained products of conception
subinvolution of the placental site
coagulaation disorders
postpartum endometritis
define uterine atony
failure of the uterus to effectively contract after complete or incomplete delivery of the placenta, which can lead to severe post partum bleeding from the myometriala vessles
most common caauses of PPH (~80%)
pathophysiology of uterine atony
normally the myometrium contracts and compresses the spirla aarteries which stops bleeding after delivery
failure of the myometrium to effectively contrct can lead to rapid and severe heamorrhage
risk factors for uterine atony
overdistension of the uterus: large for gestational age newborn, multiple pregnancy, polyhydramnios
exhausted myometrium: multiparity, post term pregnancy, prolonged delivery, prolonged oxytocin use
anatomical abnormalities: abnormal placental implantation, uterine leiomyomas
infection: chorioamnionitis
other: medications lowering contractions, preterm delivery, high maternal BMI
clinical features of uterine. atony
profuse vaginal bleeding
soft enlarged (increased fundal height), boggy ascending uterus
diagnosis of uterine atony
bimanual pelvic exam
speculum examination of the vagina and cervix to evaluaate possible sources of extrauterine bleeding (eg. vaginal injury caused during birth)
haemorrhage control in uterine atony
uterotonic agents: IV oxytocin, IM carboprost tromethamine, IM methylergonovine, prostoglandins such as misopristol
tranexamic acid: should be aministered as soon as possible to stop fibronolysis and reduce liklihood of mortality
early clmaping and cutting of umbilical cord
when to use tranexamic acid in uterine atony
concimmitant with uterotonic agents
should be aministered as soon as possible to stop fibronolysis and reduce liklihood of mortality
excluding coagulation disorders in uterine atony
eg. DIC, hyperfibronolysis
blood coagulation should be tested and treaatment based on results of coagulation panel
administer tranexamic acid in hyperfibrinolysis
surgical procedures for uterine atony
uterine balloon tamponade or packing: if severe bleeding persists, regardless of adequate general measures
compression sutures eg. B-Lynch suture
surgical ligation of uterine or internal iliac arteries
last resort: hysterectomy
define uterine inversion
an obstetric emergency in which the uterine fundus collapses into the endometrial cavity, resulting in a complete or partial inversion of the uterus
uncommon compliocaation of vaginal delivery
high morbidity and mortality
degrees of uterine inversion
partial uterine inversion: uterine fundus collapses into the endometrial cavity, without surpassing the cervix
complete uterine inversion: uterine fundus collapses into the endometrial cavity and descends through the cervix, but remains within the vaginal introitus
uterine prolapse: uterine fundus descends through the vaginal introitus