Postpartum and Antepartum Haemorrhage - GT52, GT63 Flashcards
What is classified as a ‘minor’ PPH?
500-1000ml
What is classified as a ‘major’ PPH?
> 1L or clinical shock
Major moderate =1001 to 2000ml
What is classified as a ‘major severe’ PPH?
> 2L
How many direct deaths were due to haemorrhage in 2011-2013?
Where does this rank in causes?
13
2nd highest cause of direct death
What are the risk factors for PPH (+OR)?
- Multiple pregnancy (3.3)
- Previous PPH (3.6)
- PET (5)
- Fetal macrosomia (2.11)
- Failure to progress in 2nd stage (3.4)
- Prolonged 3rd stage (7.6)
- Retained placenta (7.8)
- Placenta accreta (3.3)
- Episiotomy (4.7)
- Perineal laceration (2.4)
- GA (2.9)
Which uterotonics/medication should be given at time of delivery to reduce the risk of PPH?
- 10iu IM oxytocin if no risk factors
- 5iu IV oxyrocin at CS slowly +/- IV tranexamic acid if increased risk (decreased >1L loss at CS)
- Syntometrine if no problems with BP (5x risk of elevating) and high risk for PPH
What is carbetocin and what are the recommendations for use?
Longer acting oxytocin derivative
Not superior to oxytocin for risk of PPH but decreased need for further uterotonics at CS
What is the EBL in the presence of BP <80mmHg systolic, worsening tachypnoea and tachycardia and altered mental state?
Usually >1.5L
When does the RCOG recommend a consultant attends in a case of PPH?
If >1.5L and ongoing
How often should obs be measured for minor PPH (500-1000ml)?
15 mins
How much fluid can be infused while awaiting blood in a major PPH?
Up to 3.5L warmed crystalloid (initially 2L isotonic, then crystalloid/colloid)
Hydroxyethyl starch should not be used
What blood parameters should be aimed for in massive blood loss?
Hb >80
Plt >50
APTT and PT <1.5 x normal
Fibrinogen >2g
When should FFP be considered in haemorrhage?
If ongoing bleeding after 4 RBCs
Then maintain 6:4 RBC:FFP
Dose of 12-15ml/kg until results of coag known. >15ml/ kg if coagulopathy
Consider early if AFE or abruption (disordered coag)
What are the drawbacks of early FFP?
Risk of TACO - Transfusion associated circulatory overload and transfusion-related acute lung injury
What should be considered if 8 RBCs have been transfused with ongoing bleeding and no haemostatic/plt tests available?
give 2 pools cryoprecipitate
1 pool of platelets
How often should obs be measured for major PPH (>1L)?
Temp 15 mins
Continuous HR BP and SpO2
What % of women will avoid a hysterectomy with use of intrauterine balloon?
91% of women who have balloon placed
Leave at least 4-6 hours
What is the failure rate of haemostatic brace sutures leading to hysterectomy?
25%
(Risk factors - increased age, vaginal delivery, late recourse to suture)
Higher rate of ischamia if concurrent vessel ligation
What is the step-wise uterine devascularisation?
- One uterine artery
- Both uterine arteries
- Low uterine arteries
- One ovarian artery
- Both ovarian arteries
How many women require hysterectomy following intenal iliac artery ligation?
40%
In what % of women is UAE successful in arresting bleeding?
86.5%
What is the uterine perforation rate with SEVAC in postpartum period?
1.5%
What % of pregnancies are complicated by APH?
3-5%
How much is a ‘minor’ APH?
<50ml
How much is a ‘major’ APH?
50-1000ml with no signs of shock
What is the rate of recurrent abruption?
4% (OR 7.8)
19-25% if 2 x previous abruptions
Other than previous abruption, what are the risk factors for placental abruption?
- PET
- FGR
- Malpresentation
- Polyhydramnios
- Advanced maternal age
- Multiparity
- Low BMI
- Assisted conception
- Intrauterine infection
- PROM
- Abdominal trauma
- Smoking
- Cocaine/amphetamine use
- Bleeding in T1/haematoma on T1 US (RR5.6)
- Maternal thrombophilias - conflicting evidence
What is the background risk of placental abruption?
1%
What are the risk factors for placenta praevia?
- Previous PP (AOR 9.7)
- Previous CS (RR 2.6 overall)
- 1 = OR 2.2
- 2 = OR 4.1
- 3 = OR 22.4 - Previous TOP
- Multiparity
- Age >40
- Multiple pregnancy
- Smoking
- Deficient/disrupted endometrium
- Assisted conception
What % of abruptions occur in low risk pregnancies?
70%
What are the fetal consequences of unexplained APH?
Preterm delivery (OR 3.17)
Stillbirth (OR 2.09)
Fetal anomalies (OR 1.42)
Lower birthweight
How many cases of abruption with US fail to diagnose?
Up to 3/4
When should CEFM be employed with APH?
- Active bleeding in labour
- Minor APH and evidence of placental insufficiency (e.g. FGR)
- Can IA if one minor episode and no subsequent concerns for fetal wellbeing
When should Rh- women with APH be given AntiD
- All non-sensitised following APH
- If recurrent bleeding >20/40 every 6/52
- Dose >20/40 = 500IU and Kleihauer to determine extra if >4ml FMH
In massive blood loss how much FFP and cryo can be given while awaiting clotting results?
Up to 4 FFP and 10 units of cryo (2 packs)
What is a massive APH?
> 1000ml and or shock
Sequelae of APH?
Olgohydramnios
PPROM
Growth restriction
PTL or C/S
