Postpartum haemorrhage

Question 1

A 27-year-old has lost approximately 1 L of blood 30 min after delivery of the foetus and placenta. What is your immediate management? Discuss differentials.

Answer 1

Impression/opening statement
Given the significant blood loss of at least 1L in the post-partum period, I am concerned about a massive primary PPH and the potential for hypovolaemic shock secondary to this.

Primary PPH = Hb <24hrs from birth
Secondary PPH = Hb >24hrs from birth

Key goals of management include

• Initial stabilisation of the patient
• Assessment for identification of underlying cause, appropriate management

Question 2

PPH - Assessment

Answer 2

Assessment
Would call for senior assistance in managing this PPH
Take an A to E approach to assessment
A - likely intact
B - Likely intact, administer airway adjuncts and supplemental 02 as required. Would take brief and targeted history in this setting; ask about any parti
C - gain large bore IV access, HR, BP monitoring, ECG. take initial bloods including VBG/ABG, coags, FBC, G+xmatch, activate MTP and replace like with like if signs of HD instability.
D - GCS, may inform airway management
E - Temperature
F - Fluid resus

Question 3

PPH - Key differentials

Answer 3

Key differentials
Think of the four T’s
- Tone (uterine atony): this is the most common cause, due to failure of myometrium to contract and gain haemostasis of blood vessels
- Trauma: vaginal and or perineal tears
- Tissue: retained products of conception; part or whole of placenta intact prevents the normal process of uterine contraction and can result in significant bleeding
- Thrombin - coagulopathy /bleeding diathesis (is rare for primary PPH)

Question 4

PPH - History and Examination

Answer 4

History

• sx: onset of bleeding, temporal relationship to labour and timing, volume, consequences of blood loss (fatigue, LOC, confusion, breathlessness).
• Details of pregnancy, risk factors, type of delivery, instrumentation, etc
• Risk factors: multiparity, macrosomia, bleeding diathesis,

Examination

• General inspection + vitals
• abdo examination: uterine tone
• Pelvic examination: speculum for vaginal tears, identify site/source of bleeding

Question 5

PPH - Management

Answer 5

Management
- O&G referral, may need to prep for theatres for definitive surgical management

Supportive

• fundal massage
• active management of 3rd stage of labour and Hb

Definitive
Tone: fundal massage, syntocinon/oxytocin for increasing uterine contractions - part of normal active management of 3rd stage of labour

Tissue: Surgical management and theatres if placenta accrete/inccreta, D&C or vacuum currettage if not

Trauma: suturing/closure of vaginal/perineal tears, otherwise haemostatic measures (pressure). Otherwise, consider intra-abdominal causes, particularly if c-section

Thrombosis: review notes to understand aetiology

• consider tranexamic acid administration
• blood replacement and FFP + cryoprecipitate

Otherwise:
IR measure may be taken for non-remitting and life-threatening bleeding.