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
risk factors for uterine inversion
uncontrolled cord traction and/or excessive fundal pressure
fetal macrosomia
previous uterine inversion
use of uterine muscle relaxants during the antepartum period
difficult removal of placenta
nulliparity
uterine abnormalities
prolonged delivery
retained placental tissue
clinical features of acute uterine inversion
brisk postpartum haemorrhage
lower abdo pain
round mass protruding from cervix or vagina
absent fundus
urinary retention
chronic uterine inversion clinical features
Hx of PPH
irregular bleeding
asymptomatic, round vaginal mass
vaginal discharge
chronic pelvic pain
diagnosis of uterine inversion
clinical diagnosis
can be confirmed via USS
general measures for uterine inversion treatment
immidiate manual uterine repositioning should be performed
stop all uterotonic agents to relax the uterus
only remove the placenta after successful repositioning of the uterus
chronic uterine inversion will require surgery
define retained placenta
retention of the placental tissue inside the uterine cavity following the first 30 minutes post-partum
approx. 3% of vaginal deliveries
classification of retained placenta
adherant placenta: a placenta that is not attatched due to insufficienct uterine contractions
trapped placenta: a detatched placenta that cannot be delivered spontaneously or with light cord tractions becasue fo cervical closure
risk factors for retained placenta
prior history of retained placenta
placenta praevia
plecenta accreta spectrum
prior caesarean
uterine fibroids
prolonged use of uterotonic medications
preterm labour
assisted reproduction procedures
clinical features of retained placenta
severe bleeding before placental delivery
physical examination: visualisation of placental fragments or fetal membranes within the uterus
treatment of retained placenta
manual removal
consider administering nitroglycerin and perform under adequate anaesthesia
administr prophylactic antibiotics
surgical management where manual extraction fails
define abnormal placentation
defective decidual layer of the placenta leading to abnormal attatchment and seperation during post partum period
placenta accreta
chronionic villi attatch to the myometrium (but do not invade or penetrate the myometrium) rather than the decidua basalis
placenta increta
chorionic villi invade or penetrate into the myometrium
placenta percreta
chorionic villi penetrate the myometrium, penetrate the serosa, and in some cases, adjacenta organs/structures
classification of abnormal placentation
placenta accreta, placenta increta or placenta percreta depending on the implantation of the trophoblast into the uterine wall
risk factors for abnormal placentation
any prior damage to the endometrium
- history of uterine surgery
- prior births by c-section
- placenta praevia
- multiparity
- advanced maternal age
- assisted reproduction procedures
- asherman syndrome
clinical features of abnormal placentation
abnormal uterine bleeding
post partum haemorrrhage at the time of attemopted manual seperation of the placenta
diganosis of abnormal placentation
USS: thinning of uterine myometrial wall, placental lacunae, loss of clear space behind the placenta, disruption of junction between the bladder wall and uterine serosa
treatment of abnormal placentation
prevent pre-delivery
active management of third stage of labour
surgical procedures: dilation and curettage or vacuum removal of RPOC
caesarean hysterectomy
uterine preserving measures are contraindicated in placenta accreta spectrum due to high maternal mortality
prognosis of abnormal placentation
morbidity in approx. 27%
placenta percreta is associated with the highest level of complications
define birth trauma
can result in bleeding lacerations, puerperal haematomas and/or uterine rupture
puerperal hematoma
accumulation of blood in the vulva, vagina, or retroperitoneum, most commonly caused by iatrogenic injury during childbirth
- vulvar hematoma
- vaginal hematoma
- retroperitoneal hematoma
epidemiology of birth trauma
second most common cause of PPH (~20%)
aetiology of birth trauma
iatrogenic injury: cervical laceration, lower vaginal trauma, uterine rupture, puerpural hematoma
other: fetal macrosomia, malpresentation of the fetus, uncontrolled delivery, prolonged second stage of labour, primiparity, coagulopathy, hypertensive disease of pregnancy
features of hematoma or bleeding laceration of the female genital tract
severe pain in the labia, pelvis and/or perineum < 24 hours after delivery
severe bleeding, hypovolaemic shock
vaginal hematoma: protruding, tender, palpable vaginal mass
features of retroperitoneal hematoma
pelvic pain
signs and symptoms of hypovolaemia eg. tachy carida, hypotension, disphoresis, pale skin, dizziness
treatment of birth trauma following vaginal delivery
immidiate repair of visible bleeding lacerations
arterial embolisation for the haemodynamicaally stable pateint
incision and drainage of the hematoma or immidiate laparotomy for the haemodynamically unstable patient
treatment of birth trauma following caesarean section
uterine artery ligation
uterine pressure suture technique (B-Lynch) if other measures fail
if there is life threatening complications in birth trauma
hysterectomy
define velamentous cord insertion
abnromal cord insertion into chorioamniotic membranes, resulting in exposed vessels only surrounded by thin fetal membranes, the absense of protective Wharton Jelly
epidemiology of velamentous cord insertion
1% of single pregnancies
15% of twin pregnancies
associated with an increased risk of haemorrhage during third stage labour
risk factors for velamentous cord insertion
placenta praevia
low-lying placenta
multiple pregnancies
assisted reproduction procedures
succenturiate placenta
clinical features of velamentous cord insertion
possibel painless vaginal bleedings, typically in the third trimester: blood loss only occurs in the fetus
features of fetal hypoxia, especially following rupture of membranes
diagnosis of velametnous cord insertion in the prenatal period
transabdominal US: helps to determine the correlation between the placenta and the cervical os
transvaginal color doppler US: indicated to rule out vasa praevia
management of velamentous cord insertion if diagnosed prenatally
regular fetal asessment
deliver <40 weeks
menagement of velametnous cord insertion if diagnosed intrapartum
vaginal delivery if there are no signs of fetla distress
emergency c-section: signs fetal distress, PPH, vasa praevia
complications of velamentous cord insertion
vasa praevia
fetal death
premature infant
fetal growth restriction
fetal malformation
definition of subinvolution of placental implantation site
a condition in which the uterus remains abnormally large following delivery because of the persistance of dilated uteroplacental vessels
epidemiology of subinvolution of placental implantation site
occurs most commonly in the second week post partum
second most common cause of secondary post partum haemorrhage
risk factors for subinvolution of placental implantation site
multiparity
caesarean delivery
uterine atony
endometritis
coagulopathy
retained products of conception
clinical features of subinvolution of placental implantation sute
abnormal, severe uterine bleeding, most commonly during second week post partum
fever, chills
lower abdominal pain
signs of hypovolaemia
diagnsotics of subinvolution of placental implantation site
USS: hypoechioc tortuous vessels in the myometrium
pulsed wave doppler
histopathological examination: large, dilated myometrial arteries with thickeneed walls and intravascular thrombosis.
treatment of subinvolution of placental implantation site
uterotonic agens eg. IV oxytocin
surgical - D&C
severe bledding - uterine artery embolisaation, hysterectomy for patients with severe bleeding
