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Obstetrics and gynaecology > Post partum haemorrhage - primary and secondary > Flashcards

Post partum haemorrhage - primary and secondary Flashcards

1
Q

Define post-partum haemorrhage

A

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

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2
Q

What are the two types of PPH

A

Minor

Major

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3
Q

Describe minor PPH

A

500-1000ml of blood loss

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4
Q

Describe major PPH

A

> 1000ml

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5
Q

What are the causes of primary PPH

A 
4 Ts
Tone
Tissue
Trauma
Thrombin
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6
Q

What does tone refer to?

A

Uterine atony

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7
Q

Describe uterine atony

A

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

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8
Q

What are some risk factors for uterine atony?

A

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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9
Q

What does tissue refer to?

A

Retention of placental tissue which prevents the uterus from contracting

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10
Q

What does trauma refer to?

A

Damage sustained to the reproductive tract during delviery

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11
Q

List some risk factors for trauma

A

Instrumental vaginal delivery
Episotomy
C-section

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12
Q

What does thrombin refer to?

A

Coagulopathies and vascular abnormalities which increase risk of PPH

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13
Q

List some vascular causes of PPH

A

Placental abruption
Hypertension
Pre-eclampsia

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14
Q

List some coagulopathies which may cause PPH

A

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

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15
Q

What are the clinical features from history of PPH

A

Bleeding from the vagina
Dizziness
Palpitations
Shortness of breath

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16
Q

What is found on clinical examination in PPH

A

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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17
Q

List the initial lab tests in primary post partum haemorrhage

A 
FBC
Cross match 4-6 Units of blood
Coagulation profile
U&Es
Liver function tests
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18
Q

Describe the management of primary PPH

A

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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19
Q

What is the definitive management of primary PPH dependent on?

A

Cause

20
Q

Describe the management of uterine atony causing primary PPH

A

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

21
Q

Describe how you perform bimanual compression

A

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

22
Q

List some drugs used in primary PPH

A

Syntocinon
Ergometrine
Carboprost
Misoprostol

23
Q

Describe the mechanism of action of syntocinon

A

Synthetic oxytocon, act on oxytocin receptors in the myometrium

24
Q

Describe the mechanism of action of ergometrine

A

Multiple receptor sites

25
Q

Describe the mechanism of action of carboprost

A

Prostaglandin analogue

26
Q

Describe the mechanism of action of misoprostol

A

Prostaglandin analogue

27
Q

List the side effects of syntocinon

A

Nausea
Vomiting
Headache
Rapid infusion hypotension

28
Q

List the side effects of ergometrine

A

Hypertension
Nausea
Bradycardia

29
Q

List the side effects of carboprost

A

Bronchospasm
Pulmonary oedema
HTN
CV collapse

30
Q

What is the main side effect of misoprostol?

A

Diarrhoea

31
Q

What is ergometrine contraindicated in?

A

Hypertension
Eclampsia
Vascular disease

32
Q

What is carboprost contraindicated in?

A

Asthma

33
Q

How is primary PPH prevented?

A

Active management of the 3rd stage of labour

34
Q

Describe active management of 3rd stage of labour in vaginal delivery

A

5-10 units of IM oxytocin prophylactically

35
Q

Describe active management of 3rd stage of labour in c-section

A

5 units of IV oxytocin

36
Q

How much does active management of the 3rd stage of labour reduce the risk of PPH by?

A

60%

37
Q

What is secondary PPH

A

Excessive vaginal bleeding in the period from 24hrs after delivery to 12 weeks post partum

38
Q

What is the overall incidence of secondary PPH

A

0.47-1..44%

39
Q

What are the main causes of secondary PPH

A

Uterine infection - endometritis
retained placental fragments or tissue
Abnormal involution of the placental site
Trophoblastic disease

40
Q

What is a strong predictive factor of secondary PPH

A

History of secondary PPH

41
Q

What is the recurrence rate of secondary PPH

A

20-25%

42
Q

What are some risk factors for uterine infection?

A

C-section
Premature rupture of membranes
Long labour

43
Q

Describe abnormal involution of the placenta site

A

Inadequate closure and sloughing of the spiral arteries at the placental attachment site

44
Q

What are the clinical features of secondary PPH

A

Excessive vaginal pleeding
Spotting on and off with occasional gush of fresh blood
10% mahjor haemorrhage - hypovolaemic shock
Fever
Rigors
Foul smelling lochia

45
Q

What features of secondary PPH may be present on examination?

A

Lower abdominal tenderness - endometritis
High uterus - retained products
Speculum examination - assess amount of bleeding and take high vaginal swab

46
Q

What investigations are done for secondary PPH

A

Bloods - FBC, u&Es, CRP, coagulation, G&S, blood cultures

Imaging - Pelvic USS

47
Q

How is secondary PPH managed?

A

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

Obstetrics and gynaecology (67 decks)

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