Postpartum haemorrhage

Question 1

What is a postpartum haemorrhage?

Answer 1

Blood loss >500m at vaginal delivery or >1000 mL at C section.

Primary PPH: within 24h.

Secondary PPH: 24h-6wk

Antepartum = after 24wk and before 2nd stage of labour

Question 2

What is the aetiology of postpartum haemorrhage?

Answer 2

Primary: Tone, Tissue, Trauma, Thrombin. (uterine atony, trauma, retained placenta or membranes, coagulopathy)

Secondary PPH: endometritis, retained placenta membranes.

Question 3

What are the RFs of PPH?

Answer 3

Mother: Multiple pregnancy, PHDMN, APH, grand multiparity, fibroid, previous PPH, prolonged labour, augmented labour, instrumental delivery, personal/ FHx, anticoagulant use, C section, pyrexia in labour, episiotomy

Foetus: high BW, placental abnormalities.

Question 4

What is the epidemiology of PPH?

Answer 4

5% of deliveries.

9% of maternal deaths 2020.

Question 5

What is in the history of PPH?

Answer 5

Primary: excessive PV bleed after delivery (verify whether placenta is complete)

Secondary: PV bleed, abdominal pain, PV discharge, fever.

Question 6

What is in the examination of PPH?

Answer 6

Primary:

· Shock, high HR, high RR, anaemia

· Abdomen: ? atonic uterus above umbilicus

· Speculum: exclude trauma (perineal, vaginal or cervical)

· Vaginal: evacuate clots form cervix (inhibits contraction)

Secondary:

· Abdomen: tender uterus

· Speculum: assess bleding, cervical os open?

· Vaginal: ?uterine tenderness

Question 7

What is the pathology of PPH?

Answer 7

See aetiologies. Placental blood flow >500ml/min at term. With atony, poor uterine contraction leads to little spiral artery constriction therefore blood loss.

Question 8

What Ix would you do for PPH?

Answer 8

I: FBC, UE, clotting, X match

II: FBC, UE, clotting, ALB, X match, USS to assess retained products. Microbiology HVS.

Question 9

What is the management of PPH?

Answer 9

I:
· ABC (2x large IV bore cannulae) fluid, blood transfusion if necessary

· Atony: bimanual compression, uterotonics (oxytocin bolus with IM ergometrine, IM carboprost, PR misoprolol). Theatre.

· Consider: intrauterine balloon insertion, uterine artery embolisation, laparotomy and inserion of brace, hysterectomy.

· Trauma: requires suturing (consider theatre).

· Retained products: manual evacuation in theatre.

· Coagulopathy: correct with FFP/Cryo/PL

II:

· Resuscitate

· IV antibiotics

· ERPC only if unaboidable )(risk of uterine perforation)

Question 10

What are the complications/ prognosis of PPH?

Answer 10

Death, hysterectomy, high VTE risk, renal failure, DIC, Sheehan’s pituitary apoplexy.

4th most common cause of death in mothers in UJ. Leading cause worldwide.