Postpartum haemorrhage

Question 1

What is the most likely cause of post-partum haemorrhage?

Answer 1

• Atonic uterus (90% of cases)

4 Ts: tone, trauma, tissue, and thrombin

Question 2

Define postpartum haemorrhage.

Answer 2

PPH is defined as blood loss of > 500mls and may be primary or secondary

Question 3

When does primary PPH occur?

Answer 3

occurs within 24 hours

affects around 5-7% of deliveries

Question 4

What are some risk factors for primary PPH?

Answer 4

• increased maternal age
• previous PPH
• prolonged labour
• polyhydramnios
• macrosomia
• pre-eclampsia
• placenta praevia/accreta
• ritodrine (beta-2 adrenergic receptor agonist for tocolysis)
• emergency C-section

Question 5

Which drug is a risk factor for primary PPH?

Answer 5

Ritodrine (beta-2 adrenergic receptor agonist for tocolysis)

Question 6

Is nulliparity of multiparity a RF for primary PPH?

Answer 6

Nulliparity

(although old studies thought multiparity)

Question 7

When does secondary PPH occur? Why?

Answer 7

• occurs between 24 hours - 12 weeks (previous RCOG guidance said 6 weeks but this has changed)

Question 8

What are 2 causes of secondary PPH?

Answer 8

Retained placental tissue

Endometriosis

Question 9

Summarise the signs and symptoms of haemorrhage.

Answer 9

Symptoms: anxiety, thirst, nausea, cold, pain, dizziness

Signs: rising fundus, peritonism, reduced urine output, tachypnoea, tachycardia, hypotension, narrow pulse pressure

Question 10

What approach would you adopt to a patient with PPH?

Answer 10

ABC approach + obstetric haemorrhagic protocol e.g.

• two peripheral 14G cannulae should be inserted
• FBC/group and cross-match/coagulation profile
• fluid replecament of cross-matched or O -ve blood
• rapid infuser with fluid warmer/cell saver set up

Call for senior help

Scribe and document timing of events, people present and interventions administered

Question 11

What medical management options are available for PPH?

Answer 11

Medical (below from Ten Teachers)

1. IV Syntocinon (oxytocin) 10 units
2. PR misoprostol 800-1000microg
3. Syntometrine ( IV ergometrine 500microg + Syntocinon 5 units)
4. Repeat ergometrine 500microg IM or slow IV
5. IM carboprost 0.25mg at intervals of <15mins

Question 12

If medical management of PPH fails, what are the surgical treatment options?

Answer 12

If medical options fail, surgical options include:

• 1st line - intrauterine balloon tamponade when atony is the main cause
• Ligation of the uterine arteries or internal iliac arteries
• Final, life-saving option - hysterectomy

Question 13

What is the MOA of carboprost? When is it contraindicated?

Answer 13

Synthetic prostaglandin.

It binds the prostaglandin E2 receptor, causing myometrial contractions, casuing the induction of labour or the expulsion of the placenta

Contraindicated in asthma

Question 14

What are the conservative measures that can be taken in PPH?

Answer 14

Uterine compression/rub up contractions or bimanual compression of uterus if atony is the cause

Question 15

What is Syntometrine vs Syntocinon?

Answer 15

Syntometrine ( IV ergometrine 500microg + Syntocinon 5 units)

Syntocinon = oxytocin

Question 16

If the bleed is ongoing in PPH what haematological condition should you suspect?

Answer 16

DIC

Question 17

If hypotension occurs, how much blood should you suspect has been lost?

Answer 17

>2000ml

Young fit women usually compensate well for up to 1000ml of blood loss.

Question 18

What scoring system is used to stage hypovolaemic shock?

Answer 18

Tennis score - stages of blood loss (under 15% of volume, 15–30% of volume, 30–40% of volume and above 40% of volume) mimic the scores in a game of tennis: 15, 15–30, 30–40 and 40.

Question 19

What are the signs and symptoms which are used in the Tennis score assessment?

Answer 19

• HR
• BP
• Pulse presssure
• Respiratory rate - very useful indicator of blood loss
• Urine output
• Mental status