Postpartum haemorrhage Flashcards
What is the most likely cause of post-partum haemorrhage?
- Atonic uterus (90% of cases)
4 Ts: tone, trauma, tissue, and thrombin
Define postpartum haemorrhage.
PPH is defined as blood loss of > 500mls and may be primary or secondary
When does primary PPH occur?
occurs within 24 hours
affects around 5-7% of deliveries
What are some risk factors for primary PPH?
- 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
Which drug is a risk factor for primary PPH?
Ritodrine (beta-2 adrenergic receptor agonist for tocolysis)
Is nulliparity of multiparity a RF for primary PPH?
Nulliparity
(although old studies thought multiparity)
When does secondary PPH occur? Why?
- occurs between 24 hours - 12 weeks (previous RCOG guidance said 6 weeks but this has changed)
What are 2 causes of secondary PPH?
Retained placental tissue
Endometriosis
Summarise the signs and symptoms of haemorrhage.
Symptoms: anxiety, thirst, nausea, cold, pain, dizziness
Signs: rising fundus, peritonism, reduced urine output, tachypnoea, tachycardia, hypotension, narrow pulse pressure
What approach would you adopt to a patient with PPH?
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
What medical management options are available for PPH?
Medical (below from Ten Teachers)
- IV Syntocinon (oxytocin) 10 units
- PR misoprostol 800-1000microg
- Syntometrine ( IV ergometrine 500microg + Syntocinon 5 units)
- Repeat ergometrine 500microg IM or slow IV
- IM carboprost 0.25mg at intervals of <15mins
If medical management of PPH fails, what are the surgical treatment options?
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
What is the MOA of carboprost? When is it contraindicated?
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
What are the conservative measures that can be taken in PPH?
Uterine compression/rub up contractions or bimanual compression of uterus if atony is the cause
What is Syntometrine vs Syntocinon?
Syntometrine ( IV ergometrine 500microg + Syntocinon 5 units)
Syntocinon = oxytocin
If the bleed is ongoing in PPH what haematological condition should you suspect?
DIC
If hypotension occurs, how much blood should you suspect has been lost?
>2000ml
Young fit women usually compensate well for up to 1000ml of blood loss.
What scoring system is used to stage hypovolaemic shock?
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.
What are the signs and symptoms which are used in the Tennis score assessment?
- HR
- BP
- Pulse presssure
- Respiratory rate - very useful indicator of blood loss
- Urine output
- Mental status
