Postpartum haemorrhage Flashcards
Discuss uterine inversion
-Definition (1)
-Types (4)
-Incidence (2)
- Descent of the uterine fundus
- Types
First degree: descent within the endometrial cavity
Second degree: descent through the cervix
Third degree: descent through the vaginal introitus
Fourth degree: inversion of both the uterus and vagina - Incidence
1:2000
Maternal mortality rate 15%
Discuss uterine inversion
-Causes (8)
-Diagnosis (6)
- Causes
-Controlled cord traction (most common)
-Excessive fundal massage
-Fundal placentation
-Invasive placenta
-Uterine anomalies
-Short umbilical cord
-Rapid delivery
-Ehrles Danlos - Diagnosis
-Visualisation of the fundus externally
-Palpation of fundus in the vagina
-Absence of uterus abdominally
-Lower abdominal pain
-Haemodynamic instability
-PPH
Discuss uterine inversion
-Immediate management (6)
-Management types (3)
- Immediate management
-Stop uterotonics
-Consider tocolytics to avoid constriction ring
-Stop controlled cord traction
-Replace before removing placenta
-Prevent re-inversion with bakri/ Uterotonics
-Cover with broad spectrum Abx - Management types
Manual replacement (Johnson’s manoeuvre)
Hydrostatic technique
-Replace placenta into vagina
-Secure vagina so it stays closed
-Use free flowing warm saline to fill vagina and increase vaginal pressure to replace inverted uterus
Surgical correction with laparotomy
-Huntington’s procedure - pull uterus back by walking the round ligaments
-Haultain’s procedure - dissect posterior wall to release constriction ring then manually replace
Discuss management of women who decline blood products
-Antenatal measures (5)
- Identify antenatally and have MDT input.
- Discuss risks of massive obstetric haemorrhage with woman
- Complete advanced directive to know what she is willing to accept
- Maximise Hb with PO / IV Fe
- If large PPH anticipated consider prophylactic IR and cell saver available
Discuss women who decline blood products
-Intrapartum management (8)
- Active third stage
- Maximise volume with IVF if PPH
- Consider blood alternatives
-TXA
-Erythropoetin - Consider cell savage
-Can be used for vaginal or CS delivery
-Reduces need for blood transfusion by 38% - Consider Selective arterial embolisation
-Successful in achieving blood loss by 86% - Recombinant factor VIIa
-Use for life threatening PPH
-Consult with haematologist - Maintain good oxygenation
- Avoid hypothermia
Discuss retained placenta
-Definition (2)
-Incidence (1)
-Risk factors (5)
-Causes (6)
- Definition
Failure to deliver the placenta:
-30 mins with active management
-60 mins with physiological management - Incidence - 3%
- Risk factors
-Previous retained placenta
-Previous uterine surgery
-PTL
-IOL
-Multiparity - Causes
-Morbid adherence
-Cervical constriction ring
-Uterine structural abnormalities - fibroids
-Poor tone
-Full bladder
-Cord avulsion
Discuss management of retained placenta
-If not bleeding (5)
-If bleeding (5)
- Management if not bleeding
-Change position / sit up right
-Empty bladder
-Breast feed or nipple stimulation
-Do not give more uterotonics
-Make plan to deliver if still retained after 1 hr from diagnosis - Management if bleeding
-2 x IV access
-Take bloods
-Cross match 2-4 units
-Commence oxytocin infusion
-Transfer to OT for MROP
Discuss manual removal of placenta (4 + steps of MROP)
- Consent for MROP
-Uterine perforation
-Bleeding, infection
-RPOC - Give broad spectrum Abx in OT
- Ensure adequate analgesia
- Procedure
-Follow cord into uterine cavity to locate placenta
-Shear placenta off separation plane
-Stabilise uterus with external hand on fundus
-Remove placenta and membranes - check if complete
-Check cavity is empty
-Commence oxytocin infusion
Discuss secondary PPH
-Definition (1)
-Incidence (3)
-Causes (4)
-Investigations (2)
- Definition
-PPH occurring 24hrs to 6 weeks PP - Incidence
0.5-1.5%
10% are massive PPH
Most occur in 2nd week (40%) - Causes
-Endometritis
-RPOC
-AVM and pseudoaneurysm
-Sub involution of placental site
Investigations
-Swabs / bloods for endometritis
-USS (wide range of sens and spec) ET >25mm suggestive of RPOC
Discuss primary PPH
-Definition (4)
-Incidence (4)
- Definition
-Within 24 hours of the birth of baby
-Minor 500-1000mL
-Major >1000mL or haemodynamic instability - Incidence
-Overall 5-15%
-Minor 18%
-Major 1-5%
-6th most common cause of direct maternal NZ deaths
-25% of maternal deaths globally
-Most common cause of maternal deaths globally (99% in low income countries)
Discuss tone as a causes of primary PPH
-Definition (1)
-Causes (5)
-Risk factors for each cause
Definition:
Abnormalities of uterine contractions
Most common cause of PPH
Risk factors
Over distension of the uterus
-Polyhydramnios
-Multiple gestation
-Macrosomia
Functional or anatomical distortion of uterus
-Precipitous labour
-Prolonged labour
-Fibroids
-Uterine anomalies
-Placenta praevia
Uterine relaxants
-Nifedipine, MgSO4, Terbutaline, halogen GA, GTN
Bladder distension
Intra-amniotic infection - chorio from PROM
Discuss tissue as a cause for primary PPH
-Definition
-Causes (2)
-Risk factors associated with causes
- Definition
Retained products of conception - Causes
Retained placental tissue
-Retained placenta
-Retained cotyledon and succenturiate lobe
-Placenta accreta spectrum
Retained blood clots
Discuss trauma as a cause for primary PPH
-Definition (1)
-Causes (4)
-Risk factors associated with causes
- Definition
Genital tract injury - Causes
Lacerations of perineum, vagina, cervix
-Precipitous labour
-Operative delivery
Extensions / lacerations during CS
-Deep engagement
-Malposition
Uterine rupture
-Previous uterine surgery
Uterine inversion
-Excessive cord traction
-High parity
Extra genital bleeding
-Liver capsule rupture
-Splenic rupture
Discuss thrombin as a cause for primary PPH
-Definition
-Causes
-Associated risk factors
- Definition
Abnormalities of coagulation - Causes
Pre-existing states
-Haemophilia
-IPT, vWD
Acquired states in pregnancy
-Gestational thrombocytopenia
Disseminated intravascular coagulation
-IUFD
-Sepsis
-Abruption
-AFE
-Acute fatty liver disease
Therapeutic anticoagulation
-Heparin / warfarin
Discuss prevention of primary PPH
-Antenatal (5)
-Intrapartum (5)
- Antenatal prevention
-Treat antenatal anaemia -intermittent PO Fe or IV
-Determine placental site and insertion
-Screen for diabetes to avoid macrosomia
-Maintain healthy body weight
-Identify women with risk factors and advise delivery in a unit with a blood bank on site - Intrapartum
-Have management plan for at risk women
-Manage prolonged labour
-Offer active management to all women
-Consider prophylactic TXA in women at high risk of PPH
-Prophylactic fundal massage NOT effective
Discuss agents for active management of the third stage
-Types of agent and dose (4)
-Comparative efficacy (8)
-Impact on PPH risk (1)
- Types of uterotonic for PPH prophylaxis
-10IM oxytocin (RANZCOG First line)
-5IV oxytocin
-Syntometrine (5IU oxy + 500mcg ergo) (Use if RF for PPH)
-TXA in addition to uterotonic 1g IV in CS - Comparative efficacy
-All have similar efficacy at reducing PH >1L
-Syntometrine reduces risk of minor PPH OR 0.82 but 5 x increase in SE
-Syntometrine not better at preventing severe PPH or need for blood Tx
-Can be used if there are RF for PPH as reduces minor PPH
-Oxytocin is better than miso
-Carbetocin reduces need for further uterotonics in CS for prophylaxis
-No difference between carbetocin and oxy for reduced risk in VB
-TXA reduces risk of 1L PPH in CS - Impact on risk
-Reduces PPH risk by 50%
Discuss initial management of PPH (6)
- Recognition and call for help
-Look at loss (Usually under estimated
-Assess patient clinically for stability
-Consider pt wt when considering impact of loss - Communication
MDT approach
Expertise required depends on if minor or major.
If >1.5L should have SMO there
Reassurance for patients whanau is impt. - Resuscitate
Airway
Breathing (O2 10-15L)
Circulation
-IV access
-IV fluids (Max 3.5L then consider infusion). Warm is better
-Consider O-ve / K - blood
-Keep warm
-Lie flat - Monitor
Check Obs, Urine output
Consider ART line
Check bloods (FBC, Coags, LFTs, Cr, Acid base, Ca, lactate)
Cross match 4 units - Investigation
4 T’s - Directed treatment
Discuss management of poor tone causing PPH
-Examination findings (3)
-Investigations (2)
-Management (12)
- Examination:
-Boggy uterus
-Above umbilicus
-Filled with blood clots - Investigations:
Bloods
USS to exclude ruptured uterus, peritoneal bleeding - Management
Deflate bladder
Bimanual compression and fundal rub
Uterotonics
TXA
Fluid resus
Consider Blood replacement
Tamponade with balloon
Compressive sutures - If CS
Can do both balloon and compression
Consider vascular ligation - O’Leary technique
-Ligation of uterine arteries
-Ligation of internal iliac arteries
Consider IR for arterial embolisation
Consider hysterectomy
-2 consultant decision
Discuss management of trauma causing PPH
-Examination findings (3)
-Investigations (4)
-Management (3)
- Examination findings
-Bleeding from sites within the genital tract
-Haematoma formation
-Extragenital bleeding - liver capsule rupture/ splenic vessels - Investigations
-Inspect all genitalia
-Inspect angles of CS with exteriorisation
-USS to look for FF in peritoneum
-MRI to look for haematoma if supralevator - Management
-Repair trauma
-If Tx to OT apply pressure
-Consider IR if haematoma - Broad ligament or supralevator
Discuss management of retained tissue causing PPH
-Examination findings (3)
-Investigations (1)
-Management (1)
- Examination
-Retained tissue or membranes
-Ragged membranes or missing cotyledons on placental inspection
-Retained placenta - Investigations
-EUA - Management
-Manual removal
Discuss management of thrombin (Coagulopathy) causing PPH
-Examination findings (3)
-Investigations (2)
-Management (3)
- Examination
-Continual bleeding with contracted uterus
-Failure of blood to clot
-Ooze from IV sites - Investigations
-Bloods - continue checking coags with ongoing blood loss
-Assess for risk factors - Management
-Replace blood
-Replace coagulation (FFP and Cryo)
-TXA
Discuss blood transfusion in PPH
-When to transfuse (4)
-Goals of transfusion (4)
-General principles of transfusion (5)
- When to transfuse
-Hb <70 (Normal Hb can be misleading)
-Ongoing bleeding
-Shock
-More than 3.5L IV fluids given
-No clear guidelines. Needs clinical evaluation - Goals of transfusion
-Hb >80 (RCOG)
-Platelets >50
-Fibrinogen >1.5 - 2
-APTT and PT <1.5 x normal - General principles of transfusion
-Following 4-6 units of RBC give FFP if coags unknown
-If suspected thrombin as cause give FFP earlier
-Only transfuse if ongoing bleeding
-If PT/APTT >1.5 normal give FFP
-If Fibrinogen is <2 give cryo / fibrinogen
-If platelets <75 give platelets
-Consider recombinant FVIIa if life threatening bleeding. Only give if fibrinogen >0.5 (Not routinely recommended)
Discuss synthetic oxytocin
-Doses (3)
-MOA (1)
-Side effects (4)
-Contra-indications (1)
-Advantages (3)
-Disadvantages (2)
- Doses
-5IU IV Bolus at CS onset few mins NNT 29
-10IU IM slower onset but longer duration of action. NNT 35
-40IU in 500mL at 10 Units/hr - MOA
-Acts on oxytocin receptors within myometrium to cause uterine contractions - Side effects
-Hypotension
-Tachycardia
-Hyponatremia
-Fluid overload - Contra-indications
-Avoid bolus in severe cardiac disease - Advantages
-Well tolerated with lowest SE profile
-Rapid onset
-Reduces need for theraputic ecbolics by 40% - Disadvantages
-Less effective cf ergometrine at PPH prevention
-Needs to be kept cool
Discuss ergometrine
-Doses (3)
-MOA (2)
-Side effects (3)
-Contra-indications (4)
-Advantages (2)
-Disadvantages (2)
- Doses
-Syntometrine 500mcg + 5IU oxy (1mL IM can repeat after 2hrs. Max 3mL in 24hrs)
-250mcg IV or IM. Repeat Q5M up to 1mg (4 times)
-IM takes 30mins to take effect - MOA
-Ergot alkaloid
-Smooth muscle contractor - Side effects
-HTN
-Nausea and vomiting - Contraindications
-HTN / PET
-Valvular disease, coronary heart disease
-Aortopathies
-Aneurysms - Advantages
-Most effective ecbolic for prophylaxis and treatment
-Able to give IM - Disadvantages
-Increased side effects
-Slower onset cf oxytocin
Discuss carboprost (PGF2)
-Doses (3)
-MOA (1)
-Side effects (6)
-Contra-indications (4)
-Advantages (1)
-Disadvantages (1)
- Doses
-250mcg IM Q15Mins to max of 8 doses (2mg)
-75% of patients respond to single dose
-Intramyometrial off licence but RANZCOG support use with experienced clinician (0.5mg Dilute in 20mL NS) - MOA
-Synthetic prostaglandin analogue - Side effects
-Bronchospasm
-Vasodilation
-HTN
-Diarrhoea, nausea
-Cramping and abdo pain
-Fever - Contraindications
-Asthma, pulmonary HTN, single ventricle, shunt - Advantages
-Multiple routes of administration - Disadvantages
-Increased SE profile
Discuss misoprostol (PGE1)
-Doses (1)
-MOA (2)
-Side effects (5)
-Contra-indications (2)
-Advantages (3)
-Disadvantages (2)
- Dose
-1000mcg SL/PR/PO
-Repeat doses not recommended - MOA
-Synthetic prostaglandin
-Onset of action 1-1.5hrs regardless of route - Side effects
-Fever (20-40%)
-N/V/D
-Headache - Contraindications
-Nil absolute
-Caution with lung disease - Advantages
-Refrigeration NOT required
-Multiple routes of administration - Disadvantages
-Not as effective as oxy
-Increased SE profile
Discuss carbetocin
-Doses (1)
-MOA (2)
-Side effects (4)
-Contra-indications (1)
-Advantages (2)
-Disadvantages (1)
- Doses
-100mcg slow IV injection or IM - MOA
-Long acting synthetic oxytocin
-Binds to oxytocin receptors causing uterine contraction - Side effects
-Flushing
-Hyponatremia
-Fluid retention
-Hypotension - Contraindications
-Nil absolute - Advantages
-Longer duration of action so can avoid oxy infusion
-Heat stable formulation - Disadvantages
-Not available in NZ
Discuss tranexamic acid in use of PPH
-Dose (1)
-MOA (2)
-Evidence (2)
- Dose
1g IV with a repeat after 30mins - MOA
-Reduces conversion of plasminogen to plasmin
-Prevents enzymatic fibrin degradation - Evidence
-WOMAN Trial
-Reduction in death from PPH RR 0.69
-Reduction in need for laparotomy
Discuss use of bakri balloon in PPH
-MOA (2)
-Efficacy (1)
-Amount to fill (1)
-Time to remain in-situ (4)
- MOA
-Acts to tamponade bleeding
-Can be used as a test before opting for laparotomy - Efficacy
-91% success rate in preventing hysterectomy - Amount to fill
200-500mL - Time to remain in situ
4-6 hrs likely adequate.
Max duration 24hrs
Remove in daylight hrs
Cover with antibiotics
Discuss arterial embolisation for management of PPH
-Procedure (4)
-Embolic agents used (2)
-Complications (7)
-Long term outcomes (2)
- Procedure
-Light sedation
-Access via femoral artery
-Angiography to access bleeding point
-Place embolic agents - Embolic agents
-Temporary - gelatin impregnanted sponges
-Permanent - metal coils - Complications
-Overall complication rate 9%
-Fever
-Pelvic infection
-Ischemic buttock pain
-Temporary foot drop
-Groin haematoma
-Vessel perforation - Long term outcomes
-Most women retain fertility
-Most women continue to menstruate
Discuss compression sutures
-Types
-Failure rates (Leading to hysterectomy)
-RF for failure
- Types
-B-Lynch (Needs laparotomy)
-Haymen (Can be done without laparotomy) - Failure rates - 25%
- Risk factors
-Increasing age
-Vaginal delivery
-Delayed between delivery and compression sutures 2-6hrs
Discuss the WOMAN trial
-Aim
-Study design
-Primary outcomes
- Aim
-To determine the effect of TXA on maternal death and hysterectomy - Study design
-Double blinded RCT in 21 hospitals
-Enrolled if PPH after VB or CS
-1g TXA IV vs placebo - Primary outcomes
-Maternal death
-Hysterectomy
Discuss the WOMAN Trial
-Number included
-Results
- Number included
-20 000 - Results
-Death from PPH reduced in TXA group 1.5% vs 1.9% RR0.81 (NS) Death reduced by 30%
-SS reduction in death in the TXA group if given within 3 hrs of bleeding RR 0.69 but no reduction if given after 3hrs
-No difference in hysterectomy rates with TXA vs placebo
-No difference in SAE between groups
-Less laparotomies to stop bleeding in TXA group RR 0.64 (SS)
