Postpartum and Antepartum Haemorrhage - GT52, GT63

Question 1

What is classified as a ‘minor’ PPH?

Answer 1

500-1000ml

Question 2

What is classified as a ‘major’ PPH?

Answer 2

> 1L or clinical shock

Major moderate =1001 to 2000ml

Question 3

What is classified as a ‘major severe’ PPH?

Answer 3

> 2L

Question 4

How many direct deaths were due to haemorrhage in 2011-2013?

Where does this rank in causes?

Answer 4

13

2nd highest cause of direct death

Question 5

What are the risk factors for PPH (+OR)?

Answer 5

• 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)

Question 6

Which uterotonics/medication should be given at time of delivery to reduce the risk of PPH?

Answer 6

• 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

Question 7

What is carbetocin and what are the recommendations for use?

Answer 7

Longer acting oxytocin derivative

Not superior to oxytocin for risk of PPH but decreased need for further uterotonics at CS

Question 8

What is the EBL in the presence of BP <80mmHg systolic, worsening tachypnoea and tachycardia and altered mental state?

Answer 8

Usually >1.5L

Question 9

When does the RCOG recommend a consultant attends in a case of PPH?

Answer 9

If >1.5L and ongoing

Question 10

How often should obs be measured for minor PPH (500-1000ml)?

Answer 10

15 mins

Question 11

How much fluid can be infused while awaiting blood in a major PPH?

Answer 11

Up to 3.5L warmed crystalloid (initially 2L isotonic, then crystalloid/colloid)

Hydroxyethyl starch should not be used

Question 12

What blood parameters should be aimed for in massive blood loss?

Answer 12

Hb >80
Plt >50
APTT and PT <1.5 x normal
Fibrinogen >2g

Question 13

When should FFP be considered in haemorrhage?

Answer 13

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)

Question 14

What are the drawbacks of early FFP?

Answer 14

Risk of TACO - Transfusion associated circulatory overload and transfusion-related acute lung injury

Question 15

What should be considered if 8 RBCs have been transfused with ongoing bleeding and no haemostatic/plt tests available?

Answer 15

give 2 pools cryoprecipitate

1 pool of platelets

Question 16

How often should obs be measured for major PPH (>1L)?

Answer 16

Temp 15 mins

Continuous HR BP and SpO2

Question 17

What % of women will avoid a hysterectomy with use of intrauterine balloon?

Answer 17

91% of women who have balloon placed

Leave at least 4-6 hours

Question 18

What is the failure rate of haemostatic brace sutures leading to hysterectomy?

Answer 18

25%
(Risk factors - increased age, vaginal delivery, late recourse to suture)

Higher rate of ischamia if concurrent vessel ligation

Question 19

What is the step-wise uterine devascularisation?

Answer 19

1. One uterine artery
2. Both uterine arteries
3. Low uterine arteries
4. One ovarian artery
5. Both ovarian arteries

Question 20

How many women require hysterectomy following intenal iliac artery ligation?

Answer 20

40%

Question 21

In what % of women is UAE successful in arresting bleeding?

Answer 21

86.5%

Question 22

What is the uterine perforation rate with SEVAC in postpartum period?

Answer 22

1.5%

Question 23

What % of pregnancies are complicated by APH?

Answer 23

3-5%

Question 24

How much is a ‘minor’ APH?

Answer 24

<50ml

Question 25

How much is a ‘major’ APH?

Answer 25

50-1000ml with no signs of shock

Question 26

What is the rate of recurrent abruption?

Answer 26

4% (OR 7.8)

19-25% if 2 x previous abruptions

Question 27

Other than previous abruption, what are the risk factors for placental abruption?

Answer 27

• 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

Question 28

What is the background risk of placental abruption?

Answer 28

1%

Question 29

What are the risk factors for placenta praevia?

Answer 29

• 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

Question 30

What % of abruptions occur in low risk pregnancies?

Answer 30

70%

Question 31

What are the fetal consequences of unexplained APH?

Answer 31

Preterm delivery (OR 3.17)
Stillbirth (OR 2.09)
Fetal anomalies (OR 1.42)
Lower birthweight

Question 32

How many cases of abruption with US fail to diagnose?

Answer 32

Up to 3/4

Question 33

When should CEFM be employed with APH?

Answer 33

• 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

Question 34

When should Rh- women with APH be given AntiD

Answer 34

• 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

Question 35

In massive blood loss how much FFP and cryo can be given while awaiting clotting results?

Answer 35

Up to 4 FFP and 10 units of cryo (2 packs)

Question 36

What is a massive APH?

Answer 36

> 1000ml and or shock

Question 37

Sequelae of APH?

Answer 37

Olgohydramnios
PPROM
Growth restriction
PTL or C/S