Postpartum Haemmorhage Flashcards
Define Primary Postpartum Haemorrhage
- excessive bleeding in the first 24 hours post birth
- usually considered as >500mL after vaginal birth and >1000mL after C/S
- or showing signs of haemodynamic compromise (usually >1000mL, shock, tachycardia, hypotension)
What is considered severe PPH?
> 1000mL estimated blood loss
What is very severe or major PPH?
> 2500mL estimated blood loss
What 4 factors make a woman more likely to show signs of haemodynamic compromise?
- gestational hypertension with proteinuria
- Anaemia
- Dehydration
- Small stature
What is Secondary Postpartum Haemorrhage?
excessive bleeding (>500mL) that occurs between 24 hours post birth and 6 weeks postnatally
What are the 4 causes of PPH?
- Tone
- Tissue
- Trauma
- Thrombin (clotting disorders)
What are the common risk factors for PPH?
Tone - prolonged labour - precipitate labour - grand multiparity - multiple pregnancy - polyhydraminos - macrosomia - fibroids - intrauterine infection - uterine relaxing agents (MgSO4, general anaesthetic, tocolytics) Trauma - operative birth - cervical/vaginal lacerations Tissue - retained placenta - abnormal placentation Thrombin - Pre-eclampsia - HEELP Syndrome - placental abruption - FDIU - Bleeding disorders - Drugs (aspirin/heparin)
What is meant by establishing IV access?
inserting 2 large bore (16G) cannulae
What blood tests are important investigations in PPH management?
- Blood group
- Antibody screen
- Full blood count
- Coagulation screening (INR, APTT, fibrinogen)
Assessment (early recognition, signs/symptoms)
Communication (Call for help, effective teamwork, support for woman and her support people)
Management (resuscitation, vital signs, IV access, monitoring blood loss, oxygen saturation
Investigation
Call for help
What management is necessary for PPH where the placenta has not been born?
- call for HELP
- reassure woman
- position woman flat/lateral
- monitor vital signs (heart rate, respiration rate, blood pressure and temperature), oxygen saturation and blood loss
- consider oxygen by mask (8-12L)
- keep woman warm
- IV access
- catheter
- repeat oxytocin (another 10IU IM or IV, don’t give syntometrine/ergometrine as it may prevent birth of the placenta)
- attempt to birth placenta by controlled cord traction and massage uterus once emptied
- monitor fundal tone
- check placenta for completeness
- consider tone, tissue, trauma, thrombin
- if unsuccessful portable ultrasound, prepare for manual removal of placenta, transfer to theatre
What management is needed for PPH if the placenta has been born?
- call for HELP (and appropriate equipment)
- reassure woman
- position woman flat/lateral
- massage uterus
- if no contraindications, 250mcg ergometrine IV (or 10IU oxytocin IV if hypertensive) can repeat after 2-3 minutes
- catheter
- IV access + collect blood
- monitor vital signs (heart rate, respiration rate, blood pressure and temperature), oxygen saturation and blood loss
- oxytocin infusion (40IU/1000mL IV)
- 800-1000mcg (4-5 x 200mcg tablets) misoprostol PR
OR intramyometrial injection of Prostaglandin F2a (dinoprost) - consider oxygen by mask (8-12L)
- keep woman warm
- assess tissue (check placenta for completeness)
- assess trauma (check episiotomy or tears)
- assess thrombin (coagulation studies, are there any risk factors for clotting issues?)
- IV fluids or blood transfusion
- if bleeding continues consider bimanual compression, or aortocaval compression, transfer to theatre for examination under aesthetic and further treatment
What is the usual dose of ergometrine in the management of PPH?
- 250 micrograms
- repeat after 2-3 minutes if bleeding continues
- maximum of 4 doses (1mg)
What are the usual routes of administration for ergometrine?
IV or IM
What are the side effects of ergometrine?
- tonic uterine contraction
- nausea and vomiting
- hypertension
- rarely gangrene at site and convulsions
- cna reduce prolactin levels so potential for delayed lactogenesis
When should ergometrine not be given?
- if placenta has not been born
- severe hypertension or cardiac disease
- hypersensitivity to ergometrine
What drug is often given with ergometrine to prevent nausea/vomiting?
metoclopramide 10mg IV
What is the usual protocol for giving oxytocin in the management of PPH?
- 10IU/1ml IM or IV for active managment of 3rd stage
- may give repeat bolus of 10IU IM or IV (instead of ergometrine if placenta has not been born or if blood pressure is elevated)
- 40IU in 1000mL of sodium chloride 0.9% IV infusion at rate of 250mL/hour if placenta has been born
What is the usual dose of misoprostol in the management of PPH?
800 to 1000 micrograms PR (4-5 tablets)
What is the usual stock strength of misoprostol given PR?
200 microgram tablets
What are the side effects of misoprostol? When should it not be given?
- nausea and vomiting
- diarrhoea
- abdominal pain
- headache
- flushing
- chills
- pyrexia
- hypersensitivity to misoprostol
- may cause GI upset in infant due to transfer in breastmilk
When is misoprostol given in management of PPH?
when neither oxytocin or ergometrine are successful at stopping bleeding
Other than oxytocin, ergometrine and misoprostol, what drugs may be given in managing PPH?
- prostaglandin F2a intramyometrial injection
- syntometrine (oxytocin and ergometrine)
What are the main complications of major PPH?
- shock
- anaemia
- clotting disorders
- organ damage (particularly lung injury and renal failure)
What are the main signs of hypovolaemic shock?
- hypotension
- anxiety
- confusion
- decreased level of consciousness
- shortness of breath/ hyperventilation
- restlessness
- palpitations/ tachycardia
- chills
- pale and clammy
- thirst
- oliguria
What are the risk factors for postpartum venous thromboembolism?
- age>35
- parity>4
- clotting disorders
- dehydration
- pre-eclampsia
- prolonged labour
- immobility
- obesity
- varicose veins
- surgery
- excessive blood loss
- instrumental birth
What equipment should be in a PPH box?
- cannulation (16G, 18G, swabs, tegaderm, tape)
- pathology (23G, 21G needles, blood tubes, tourniquet, swabs, bags, slips, 10mL syringes)
- IV giving sets (standard/pump) + accessories (luer-lock connectors, additive labels, multi-adapters, 3-way adapter)
- bags of sodium chloride/hartmanns/gelofusine
- catheter (14ch foley, bag/urimeter, 10mL water for injections, 10mL syringe)
- ampules of saline/water for injections
- misoprostol 200mcg tablets
in fridge :
- oxytocin 10IU ampoules
- ergometrine 500mcg ampoules
- prostaglandin F2a (dinoprost)
- additive lables
- syringes (2mL, 5mL)
- needles (19G, 23G, 25G and spinal)
In many healthy pregnant women there are no clinical signs of shock until what volume of blood loss?
- > 1000-1500ml of blood loss
Apart from the 4 Ts, what other causes may cause PPH?
- uterine rupture
- uterine inversion
- puerperal haematoma
- other causes (liver rupture, amniotic fluid embolism)
Once bleeding is controlled, what ongoing midwifery care is vital for women who have had PPH?
- monitoring vital signs, fundal tone, blood loss, haemoglobin
- promote mother/infant bonding
- transfer (to postnatal ward/ICU/HDU/tertiary facility)
- documentation
- psychological support and debriefing
- management of anaemia
- VTE prophylaxis, monitor for DVT/PE
- education about self care
- advice regarding follow up
What IV fluids/blood products may be given in managing PPH depending on the severity of the clinical situation?
- crystalloids: normal saline
- colloids: hartmann’s solution
- red blood cells (O-neg if group unknown or crossmatched)
- fresh frozen plasma
- cryoprecipitate
- platelets
- IV calcium gluconate
What are the signs that a massive transfusion protocol should be used?
- assessed by lead clinician (will seek advice of haematologist)
- woman actively bleeding and any of:
- greater than 4 units of RBC in 2500mL
- clinical or laboratory signs of coagulopathy
In a massive transfusion protocol, the lead clinician in consultation with a haematologist will be monitoring which clinical parameters?
- temperature
- pH
- base excess
- lactate
- Ca2+
- Platelets
- Prothrombin time (PT) and activated partial thromboplastin time (aPPT)
- International normalised ratio (INR)
- Fibrinogen
What is the usual indication to give fresh frozen plasma?
- to replace clotting factors, plasma proteins and other substances
- where there is coagulopathy and excessive bleeding
- acute disseminated intravascular coagulopathy
- generally 10-15mL/kg per dose, often around 100ml, depends on clinical situation and coagulation assay
What is the usual indication to give packed red blood cells (PRBC)?
- for excessive blood loss
- to correct anaemia
- 1 unit PRBC (about 220ml) increases haemoglobin by around 1g
What adverse reactions and precautions are important to remember when giving blood products?
- human tissue so strict protocols on collection, storage, administration, monitoring, reporting adverse events, disposal of equipment
- potential for infusion reaction (increased temperature, backache, rash)
- anapylaxis
When are platelets usually given in treatment of massive PPH?
- to prevent platelets from dropping below 50x10^9/L which may contribute to excessive bleeding
Why may cryoprecipitate be given in treatment of massive PPH?
- to maintain fibrinogen levels above 2.5g/L
When may calcium gluconate be given in management of massive PPH?
- if calcium levels drop too low
- Ca2+
What is the trade name of oxytocin?
Syntocinon
What are the three main indications for oxytocin?
- induction/augmentation of labour
- active managment of third stage
- management of PPH
What is the mode of action of oxytocin?
Oxytocin is a uterotonic, it stimulates smooth muscle of uterus producing rhythmic contractions, particularly towards term when receptors are more sensitive.
What is the stock strength of oxytocin?
- 10IU/ml ampule and 5IU/ml ampule
What is the usual dose of oxytocin for IOL/augmentation and third stage management?
- dosage depends on indication and local protocol
- IOL or augmentation: usually 10IU/1000ml saline IV infusion commence at 12ml/min and increase 30 minutely
- 3rd stage: usually 10IU/ml IM or IV given after birth (sometimes 5IU IV post LUSCS)
What are adverse reactions/precautions are important to remember for oxytocin?
- painful contractions
- nausea and vomiting
- headache
- flushing
- water intoxication
- hypotension
- fetal distress
- disseminated intravascular coagulation
What is the trade name of ergometrine maleate?
Ergometrine (or syntometrine when combined with oxytocin)
What class of drug is ergometrine and what is it’s usual indication?
- uterotonic
- management of postpartum haemorrhage
What is the stock strength of ergometrine?
500 micrograms (0.5mg) per 1 mL ampoule
What is the mode of action of ergometrine?
- stimulates strong sustained rhythmic contractions of the uterus and other smooth muscle (including cervix)
- increases action of living ligatures to reduce uterine blood flow and contribute to haemostasis
- stimulation of alpha adrenegic receptors and causes vasoconstriction, which increases blood pressure
Why might syntometrine be the drug of choice in the active management of third stage of labour?
combines rapid action of oxytocin with the sustained uterotonic effect of ergometrine
What are the two main indications for giving misoprostol in the maternity setting?
- managment of post partum haemorrhage
- midtrimester termination of pregnancy
What is the usual dosage when giving misoprostol for termination of pregnancy?
200-400 micrograms Q4H PO/PV
What is the classification of misoprostol?
- Hyperacidity
- licensed for treatment of acute duodenal/gastric ulcers
- used off-licence
How long does it usually take misoprostol to have an effect when using to treat PPH?
20-30 minutes
What is the mode of action of misoprostol?
- synthetic prostoglandin
- causes sustained uterine contractions
What is the trade name of misoprostol?
Cytotec
Why is misoprostol a good option for management of PPH in developing countries?
it is shelf-stable at room temperature
What is the trade name of dinoprost trometamol?
- dinoprost
- prostin f2 alpha
What is the mode of action of dinoprost?
- prostaglandin
- rhythmic contractions of smooth muscle including uterus and GI tract (nausea, vomiting, diarrhoea, hypertension)
What is the usual stock strength and dose of dinoprost?
5mg/ml given IV into myometrium and repeated 10-15 minutes later
- administered by senior obstetrician, usually guided by ultrasound or in operating theatre
What measures for extreme PPH management may be considered in theatre?
- intramyometrial dinoprost
- hysterectomy
- bakri balloon
- internal iliac artery ligation
- pelvic artery embolisation
What is water intoxication?
- a life threatening adverse effect of large doses of oxytocin - may cause water retention, leading to hyponatremia, seizures and coma
