Post partum haemorrhage - primary and secondary Flashcards by Adele Atkins

Define post-partum haemorrhage

The loss of >500ml of blood per vagina within 24hrs of delivery

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What are the two types of PPH

Minor

Major

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Describe minor PPH

500-1000ml of blood loss

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Describe major PPH

> 1000ml

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What are the causes of primary PPH

4 Ts
Tone
Tissue
Trauma
Thrombin

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What does tone refer to?

Uterine atony

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Describe uterine atony

The uterus fails to contract adequately following delivery due to a lack of tone in the uterine muscle

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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

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What does tissue refer to?

Retention of placental tissue which prevents the uterus from contracting

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What does trauma refer to?

Damage sustained to the reproductive tract during delviery

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List some risk factors for trauma

Instrumental vaginal delivery
Episotomy
C-section

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What does thrombin refer to?

Coagulopathies and vascular abnormalities which increase risk of PPH

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List some vascular causes of PPH

Placental abruption
Hypertension
Pre-eclampsia

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List some coagulopathies which may cause PPH

Von willebrand’s disease
Haemophillia A/B
ITP or acquired coagulopathy (DIC/HELLP)

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What are the clinical features from history of PPH

Bleeding from the vagina
Dizziness
Palpitations
Shortness of breath

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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

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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

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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

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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