Post partum haemorrhage - primary and secondary Flashcards
Define post-partum haemorrhage
The loss of >500ml of blood per vagina within 24hrs of delivery
What are the two types of PPH
Minor
Major
Describe minor PPH
500-1000ml of blood loss
Describe major PPH
> 1000ml
What are the causes of primary PPH
4 Ts Tone Tissue Trauma Thrombin
What does tone refer to?
Uterine atony
Describe uterine atony
The uterus fails to contract adequately following delivery due to a lack of tone in the uterine muscle
What are some risk factors for uterine atony?
Maternal - age>40, BMI>35, asian ethnicity
Uterine overdistension - multiple pregnancy, polyhydrmnios, foetal macrosomia
Labour - induction, prolonged labour
Placental problems - placenta praevia, abruption, previous PPH
What does tissue refer to?
Retention of placental tissue which prevents the uterus from contracting
What does trauma refer to?
Damage sustained to the reproductive tract during delviery
List some risk factors for trauma
Instrumental vaginal delivery
Episotomy
C-section
What does thrombin refer to?
Coagulopathies and vascular abnormalities which increase risk of PPH
List some vascular causes of PPH
Placental abruption
Hypertension
Pre-eclampsia
List some coagulopathies which may cause PPH
Von willebrand’s disease
Haemophillia A/B
ITP or acquired coagulopathy (DIC/HELLP)
What are the clinical features from history of PPH
Bleeding from the vagina
Dizziness
Palpitations
Shortness of breath
What is found on clinical examination in PPH
General examintion - haemodynamic instabolity - tachypnoea, prolonged CRT, tachycardia and hypotension
Abdominal examination - signs of uterine rupture - palpation of foetal parts as it moves into the abdomen from the uterus
Speculum exam - local trauma causing bleeding
Placenta - ensure placenta i complete
List the initial lab tests in primary post partum haemorrhage
FBC Cross match 4-6 Units of blood Coagulation profile U&Es Liver function tests
Describe the management of primary PPH
Simultaneous delivery of TRIM
Teamwork - involve appropriate colleagues
Resuscitation - ABCDE
Investigations and monitoring - RR, O2 sats, HR, BP, temp every 15 mins, catheter and central venous line considered
Measures to arrest bleeding
What is the definitive management of primary PPH dependent on?
Cause
Describe the management of uterine atony causing primary PPH
Bimanual compression to stimulate uterine contraction
Pharmacological measures - act to increase myometrial contraction
Surgical measures - intrauterine balloon tamponade, haemostatic suture around uterus, bilateral uterine or internal iliac artery ligation, hysterectomy
Describe how you perform bimanual compression
Insert a gloved hand into the vagina and form a fist inside the anterior fornix to compress the anterior uterine wall and the other hand applies pressure on the abdomen at the posterior aspect of the uterus - ensure bladder emptied by catheterisation
List some drugs used in primary PPH
Syntocinon
Ergometrine
Carboprost
Misoprostol
Describe the mechanism of action of syntocinon
Synthetic oxytocon, act on oxytocin receptors in the myometrium
Describe the mechanism of action of ergometrine
Multiple receptor sites
Describe the mechanism of action of carboprost
Prostaglandin analogue
Describe the mechanism of action of misoprostol
Prostaglandin analogue
List the side effects of syntocinon
Nausea
Vomiting
Headache
Rapid infusion hypotension
List the side effects of ergometrine
Hypertension
Nausea
Bradycardia
List the side effects of carboprost
Bronchospasm
Pulmonary oedema
HTN
CV collapse
What is the main side effect of misoprostol?
Diarrhoea
What is ergometrine contraindicated in?
Hypertension
Eclampsia
Vascular disease
What is carboprost contraindicated in?
Asthma
How is primary PPH prevented?
Active management of the 3rd stage of labour
Describe active management of 3rd stage of labour in vaginal delivery
5-10 units of IM oxytocin prophylactically
Describe active management of 3rd stage of labour in c-section
5 units of IV oxytocin
How much does active management of the 3rd stage of labour reduce the risk of PPH by?
60%
What is secondary PPH
Excessive vaginal bleeding in the period from 24hrs after delivery to 12 weeks post partum
What is the overall incidence of secondary PPH
0.47-1..44%
What are the main causes of secondary PPH
Uterine infection - endometritis
retained placental fragments or tissue
Abnormal involution of the placental site
Trophoblastic disease
What is a strong predictive factor of secondary PPH
History of secondary PPH
What is the recurrence rate of secondary PPH
20-25%
What are some risk factors for uterine infection?
C-section
Premature rupture of membranes
Long labour
Describe abnormal involution of the placenta site
Inadequate closure and sloughing of the spiral arteries at the placental attachment site
What are the clinical features of secondary PPH
Excessive vaginal pleeding
Spotting on and off with occasional gush of fresh blood
10% mahjor haemorrhage - hypovolaemic shock
Fever
Rigors
Foul smelling lochia
What features of secondary PPH may be present on examination?
Lower abdominal tenderness - endometritis
High uterus - retained products
Speculum examination - assess amount of bleeding and take high vaginal swab
What investigations are done for secondary PPH
Bloods - FBC, u&Es, CRP, coagulation, G&S, blood cultures
Imaging - Pelvic USS
How is secondary PPH managed?
Antibiotics - combination of ampicillin (clindamycin if pen allergic) and metronidazole
Uterotonics - syntocin, synometrine, carboprost and misoprostol
Surgery - if excessive or continuing bleeding - balloon catheter in uterus may be effective in continuous bleeding
Massive secondary PPH - same as for primary
