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Part 2 FCA > Postpartum haemorrhage > Flashcards

Postpartum haemorrhage Flashcards

1
Q

Define postpartum haemorrhage

A

Cumulative blood loss of > 1000 ml or bleeding associated with signs/symptoms of hypovolaemia within 24 hours of birth process regardless of delivery route.

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2
Q

What are the four T’s which detail the four most common causes of post partum haemorrhage

A

Tone - Uterine atony
Trauma - Laceration / hematoma / inversion / rupture
Tissue - Retained products or invasive placenta
Thrombin - Coagulopathy

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3
Q

How much blood can be lost before there is an increase in heart rate and/or decrease BP

A

25% of patient’s blood volume

± 1500 mls

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4
Q

Why are Hb and Hct levels poor indicators of acute blood loss if no plasmalyte is given

A

The levels would take 24 - 48 hours to reflect the true concentration of Hb / haematocrit

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5
Q

Which blood marker is predictive of severe PPH and what are the problems with sampling this parameter in PPH?

A

Fibrinogen < 200 mg/dL

Problems

  1. Fibrinogen assays have a long turn around time
  2. Large variation in baseline levels: 210 - 900 mg/dL
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6
Q

Define severe PPH

A

Need for:

  1. Multiple blood products
  2. Angiographic embolization
  3. Surgical intervention
  4. Maternal death
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7
Q

Summarise the risk factors for PPH

A 
Retained placenta
Failure to progress
Morbidly adherent placenta
Lacerations
Instrumental delivery
Large for gestational age baby
Hypertensive disorders
Induction of labour
Prolonged 1st or 2nd stage

Previous PPH

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8
Q

Which four risk factors are associated with the highest odds for predicting the need for massive transfusion

A
  1. Abnormal placentation
  2. Placental abruption
  3. Severe preeclampsia
  4. Intrauterine fetal demise
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9
Q

Outline the stepwise management of major obstetric haemorrhage

A
  1. Pre-empt and predict with risk factors
  2. Recognize, declare, communicate, get help
  3. High capacity IV access (2 x large bore)
  4. Crystalloids / colloids / Packed cells
  5. ETT ± CVC ± A-line
  6. Forced air-warming blanket
  7. Oxytocin bolus 2.5 –> 3U by slow IV bolus injection
  8. Oxytocin infusion 40 U in 1000mls at 250 ml/hr
    (Prophylactic oxytocin is 20 u in 1000 mls at 125 ml/hr)
  9. Syntometrine (5U oxytocin + 0.5 mg ergometrine)
    –> dilute into 5ml syringe and give 2.5 mls stat and 2.5 mls after 5 minutes if needed
  10. Prostaglandin E1 = misoprostal 200 mcg tablets: 2 - 3 tablets PR or SL(better no first pass)
  11. Prostaglandin F2 alpha –> 1 mg into 4 ml = 0.25mg/ml –> 1 ml intramyometrally into each of four quadrants
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10
Q

What is the ED 90 for oxytocin in uncomplicated low-risk labour.

What is the ED 90 for oxytocin in arrested/obstructed labour

A

uncomplicated = 0.35 U

Complicated = 3U

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11
Q

List the problems with oxytocin administration

A
  1. Tachyphylaxis (rapidly diminishing response to successive doses of a drug rendering it less effective)
  2. Vasodilatation (caution in shock)
  3. ADH properties –> water retention and hypoNa (with infusions)
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12
Q

How long does oxytocin bolus dose last

A

± 1 hour

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13
Q

What are the problems with ergometrine

A 
Elevation in MAP of 11%
Elevation PA pressure 30%
C/I
1. Pre-eclampsia
2. Hypertension
3. Cardiac disease
4. Porphyria

Very high incidence of nausea and vomiting

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14
Q

What is the onset of ergometrine and how long do the effects last

A

IV - immediate
IM - 5 minutes

Duration: 3 hours

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15
Q

What are the advantages and disadvantages of misoprostal (PG E1)

A

Advantages

  1. Cheap
  2. No refrigeration (c.f. oxytocin/ergometrine)
  3. SL more reliable (less first pass metabolism)

Disadvantages
1. Less effective than oxytocin and ergometrine

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16
Q

What are the problems with PGF2alpha

A
  1. Bronchospasm –> V/Q mismatch –> hypoxaemia
  2. Systemic hypertension
  3. Pulmonary hypertension if used IV
  4. Cannot be given IV
  5. Can only be used intramyometrally as a last line agent
17
Q

What is the error of visual estimation of blood loss (drapes, surgical swabs)

A

300 ml blood loss - error = 16%

2000ml blood loss - error = 41%

18
Q

What is the rule of 30

A 
SBP down by 30 mmHg
HR up by 30 bpm
RR more than 30 breaths/min
Hb/Hct drop by 30%
Urine output < 30 ml/hour

Then patient has lost at least 30% of their blood volume and is in moderate leading to severe shock

19
Q

What is the shock index? What is the normal shock index in obstetric and non-obstetric patients

A

Shock index is HR/SBP

Non-obstetric patients > 0.7 is abnormal
Obstetric patients > 0.9 is abnormal

20
Q

Describe the definitions of severity of postpartum haemorrhage

A

PPH
> 500ml post vaginal and > 1000 post C/S
(updated to > 1000ml with signs+symptoms of hypovolaemia within 24 hours delivery)

Severe PPH
> 1500
> 4U Packed cells
> 4 g/dL Hb down
or haemorrhage associated with haemodynamic instability

Major PPH
> 2500 ml

Massive PPH
One blood volume or 10 packed red blood cells in 24 hours.

21
Q

Describe the massive transfusion products ordered

A
  1. Fixed-ratio 5 RCC + 5 FFP + 1 pooled platelets + Cryoprecipitate

Maintain platelet count> 50 x 10^9/L

Give tranexamic acid: 1g repeatable once

22
Q

When should the surgeon proceed straight subtotal hysterectomy

A
  1. Uterine rupture that is irreparable

2. Placenta increta or percreta

23
Q

What are the surgical techniques used for:

  1. Atonic uterus
  2. Uterine tears
  3. Placental side bleeding
A
  1. Atonic uterus - B-Lynch compression suture or STAH
  2. Uterine tears - Stepwise uterine artery devascularization / Uterine artery ligation or STAH
  3. Placental site - Stepwise uterine artery devascularization / Balloon tamponade / STAH
24
Q

What is the lloyd davis position

A

Trendelenburg lithotomy

Part 2 FCA (2 decks)

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