post partum hemorrhage

Question 1

define post partum hemorrhage ? what is the difference between primary and secondary post partum hemorrhage

Answer 1

defined as bleeding from the genital tract >500 ml (>1L if cesarean section) after delivery of the baby (stage 2 of labour)
primary = < or equal to 24 hours after delivery of the fetus
secondary = > 24 hours after delivery of the fetus

Question 2

4 general causes of post partum hemorrhage?

Answer 2

1. tone (majority)
2. tissue
3. trauma
4. thrombus

Question 3

uterus should contract below the Level of the … after delivery of the placenta ?

Answer 3

placenta

Question 4

what can predispose to PPH due to lack of tone?

Answer 4

Risks if there is something that causes over distension of the uterus
1. multiple pregnancies
2. polyhydraminos
3. macrosomia
4. previous PPH (uterus is primed)

Question 5

what can predispose PPH due to retained tissue ?

Answer 5

1. placenta accrete
2. uterine abnormality
3. previous placental anomaly

Question 6

what can lead to PPH caused by trauma? and predisposing factors

Answer 6

tear
higher risk with macrocosmic baby, quick labour, instrumental delivery

Question 7

predisposing factors to PPH caused by a coagulopathy ?

Answer 7

vWF disease
low platelets
meds (heparin)

Question 8

management of PPH ?

Answer 8

1. make sure scene is safe, call for help
2. ABCDE for bleeding
   - ABC: 2 large bore IVs, take bloods for FBC, coag, group and cross match
   - give IV fluids + blood
   - monitor with: ECG, oximeter, Foley catheter, Hb bedside testing
   - massage the uterus, empty the bladder
   - give uterotonics: oxytocin (stat IM dose), ergometrine (stat IM dose) (syncotin (0.5 mg ergometrine and 5IU oxytocin), prostaglandins (carboprost, misoprostol 800 mcg sublingual, prostaglandin F2alpha - remember can cause bronchoconstriction),
   - transexamic acid if >1 L blood loss
   - find source of bleeding: tone (meds), tissue (take it out via manual extraction, if accrete needs hysterectomy, trauma (suture the tear, make sure not a uterine rupture), thrombus (give back what they are missing)
   - if they are still bleeding - go to theatre: B Lynch suture to squash uterus down, balloon tamponade, IV radiology to ablate, hysterectomy as a last resort

Question 9

how do we treat secondary PPH?

Answer 9

usually due to infection
take or occasionally can also be due to retained products
- in the case of suspected infection take high vaginal swab and give antibiotic
- if suspected retained products do ultrasound if patient is stable and ERPC (evacuation of retained products of conception