postpartum haemorrhage

Question 1

what is primary postpartum Haemorrhage ?

Answer 1

the loss of 500 ml or more of blood from the genital tract within n24 hours of the birth of the baby

Question 2

what is secondary postpartum haemorrhage ?

Answer 2

is abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally

Question 3

what are the risk factors for primary postpartum haemorrhage ?

Answer 3

Tone - abnormalities of uterine contractions
Tissue- retained products of conception
Trauma- genital tract injury
Thrombin- abnormalities of coagulation

Question 4

what is the most common cause of primary PPH ?

Answer 4

uterine atony

Question 5

what are examples of problems associated with tone that could cause a primary PPH ?

Answer 5

multiple pregnancies 
previous PPH 
fetal macrosomia 
failure to progress into second stage of labour 
prolonged third stage of labour

Question 6

what are examples of problems related to tissue that could cause primary APH ?

Answer 6

retained placenta

placenta accreta

Question 7

what are examples of problems related to trauma that could cause primary APH ?

Answer 7

episiotomy

perineal lacerations

Question 8

what can be done in an effort to prevent PPH ?

Answer 8

correction of antenatal anemia 
prophylactic utertonics ( oxytocin, ergometrin)
consider the use of tranexamic acid along with oxytocin

Question 9

what is the management for minor PPH ?

Answer 9

blood losses of 500-1000ml should be treated as follows
( given that there is no clinical shock)
intravenous access 
urgent venepuncture 
Read vital signs every 15 minutes 
start on warmed crystalloid fluids

Question 10

what is the management for major PPH ?

Answer 10

for blood losses larger than 1000 ml:
1. Resuscitate:
immediate venipuncture 
monitor temperature every 15 minutes 
attach oximetry, ECG and automated BP recording 
foley catheter to measure urine outflow 

2. Uterine massage
ensure that the bladder is empty 
administer oxytocin
administer ergometrine
adminnister carboprost
misoprostol

Question 11

when can we not use ergometrin ?

Answer 11

in hypertensive women

Question 12

when is carboprost dangerous to use ?

Answer 12

in asthmatic women , carboprost is a prostaglandin F 2 alpha

Question 13

if medical management fails what is the next best step in management ?

Answer 13

surgical management here is appropriate
1. using an intrauterine balloon tamponade is an appropriate first line
2.hemostatic suturing can also be done
stepwise uterine devascularization and internal iliac artery
ligation
3.hysterectomy

Question 14

what surgical intervention is appropriate in a haemodynamically stable patient ?

Answer 14

insertion of percutaneous catheters through the femoral artery with retrograde injection of thrombogenic material

Question 15

what is the management for traumatic PPH ?

Answer 15

suturing of any genital lacerations
a ruptured uterus may either be anatomically repaired or a hysterectomy could be performed if the damage is beyond repair

Question 16

what is the most common cause of secondary PPH?

Answer 16

retained placental tissue and fragments

Question 17

what is the management in a case of secondary PPH?

Answer 17

1. a pelvic ultrasound to exclude or confirm the presence of any retained tissue
2. vaginal and endocervical swab should be taken
3. antimicrobial therapy should be initiated when endometritis is suspected
4. surgical evacuation of remaining or retained tissue