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RANZCOG Postpartum care > Postpartum haemorrhage > Flashcards

Postpartum haemorrhage Flashcards

1
Q

Discuss uterine inversion
-Definition (1)
-Types (4)
-Incidence (2)

A
  1. Descent of the uterine fundus
  2. 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
  3. Incidence
    1:2000
    Maternal mortality rate 15%
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2
Q

Discuss uterine inversion
-Causes (8)
-Diagnosis (6)

A
  1. Causes
    -Controlled cord traction (most common)
    -Excessive fundal massage
    -Fundal placentation
    -Invasive placenta
    -Uterine anomalies
    -Short umbilical cord
    -Rapid delivery
    -Ehrles Danlos
  2. Diagnosis
    -Visualisation of the fundus externally
    -Palpation of fundus in the vagina
    -Absence of uterus abdominally
    -Lower abdominal pain
    -Haemodynamic instability
    -PPH
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3
Q

Discuss uterine inversion
-Immediate management (6)
-Management types (3)

A
  1. 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
  2. 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
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4
Q

Discuss management of women who decline blood products
-Antenatal measures (5)

A
  1. Identify antenatally and have MDT input.
  2. Discuss risks of massive obstetric haemorrhage with woman
  3. Complete advanced directive to know what she is willing to accept
  4. Maximise Hb with PO / IV Fe
  5. If large PPH anticipated consider prophylactic IR and cell saver available
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5
Q

Discuss women who decline blood products
-Intrapartum management (8)

A
  1. Active third stage
  2. Maximise volume with IVF if PPH
  3. Consider blood alternatives
    -TXA
    -Erythropoetin
  4. Consider cell savage
    -Can be used for vaginal or CS delivery
    -Reduces need for blood transfusion by 38%
  5. Consider Selective arterial embolisation
    -Successful in achieving blood loss by 86%
  6. Recombinant factor VIIa
    -Use for life threatening PPH
    -Consult with haematologist
  7. Maintain good oxygenation
  8. Avoid hypothermia
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6
Q

Discuss retained placenta
-Definition (2)
-Incidence (1)
-Risk factors (5)
-Causes (6)

A
  1. Definition
    Failure to deliver the placenta:
    -30 mins with active management
    -60 mins with physiological management
  2. Incidence - 3%
  3. Risk factors
    -Previous retained placenta
    -Previous uterine surgery
    -PTL
    -IOL
    -Multiparity
  4. Causes
    -Morbid adherence
    -Cervical constriction ring
    -Uterine structural abnormalities - fibroids
    -Poor tone
    -Full bladder
    -Cord avulsion
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7
Q

Discuss management of retained placenta
-If not bleeding (5)
-If bleeding (5)

A
  1. 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
  2. Management if bleeding
    -2 x IV access
    -Take bloods
    -Cross match 2-4 units
    -Commence oxytocin infusion
    -Transfer to OT for MROP
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8
Q

Discuss manual removal of placenta (4 + steps of MROP)

A
  1. Consent for MROP
    -Uterine perforation
    -Bleeding, infection
    -RPOC
  2. Give broad spectrum Abx in OT
  3. Ensure adequate analgesia
  4. 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
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9
Q

Discuss secondary PPH
-Definition (1)
-Incidence (3)
-Causes (4)
-Investigations (2)

A
  1. Definition
    -PPH occurring 24hrs to 6 weeks PP
  2. Incidence
    0.5-1.5%
    10% are massive PPH
    Most occur in 2nd week (40%)
  3. 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
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10
Q

Discuss primary PPH
-Definition (4)
-Incidence (4)

A
  1. Definition
    -Within 24 hours of the birth of baby
    -Minor 500-1000mL
    -Major >1000mL or haemodynamic instability
  2. 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)
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11
Q

Discuss tone as a causes of primary PPH
-Definition (1)
-Causes (5)
-Risk factors for each cause

A

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

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12
Q

Discuss tissue as a cause for primary PPH
-Definition
-Causes (2)
-Risk factors associated with causes

A
  1. Definition
    Retained products of conception
  2. Causes
    Retained placental tissue
    -Retained placenta
    -Retained cotyledon and succenturiate lobe
    -Placenta accreta spectrum
    Retained blood clots
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13
Q

Discuss trauma as a cause for primary PPH
-Definition (1)
-Causes (4)
-Risk factors associated with causes

A
  1. Definition
    Genital tract injury
  2. 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
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14
Q

Discuss thrombin as a cause for primary PPH
-Definition
-Causes
-Associated risk factors

A
  1. Definition
    Abnormalities of coagulation
  2. 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
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15
Q

Discuss prevention of primary PPH
-Antenatal (5)
-Intrapartum (5)

A
  1. 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
  2. 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
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16
Q

Discuss agents for active management of the third stage
-Types of agent and dose (4)
-Comparative efficacy (8)
-Impact on PPH risk (1)

A
  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
  2. 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
  3. Impact on risk
    -Reduces PPH risk by 50%
17
Q

Discuss initial management of PPH (6)

A
  1. Recognition and call for help
    -Look at loss (Usually under estimated
    -Assess patient clinically for stability
    -Consider pt wt when considering impact of loss
  2. Communication
    MDT approach
    Expertise required depends on if minor or major.
    If >1.5L should have SMO there
    Reassurance for patients whanau is impt.
  3. 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
  4. Monitor
    Check Obs, Urine output
    Consider ART line
    Check bloods (FBC, Coags, LFTs, Cr, Acid base, Ca, lactate)
    Cross match 4 units
  5. Investigation
    4 T’s
  6. Directed treatment
18
Q

Discuss management of poor tone causing PPH
-Examination findings (3)
-Investigations (2)
-Management (12)

A
  1. Examination:
    -Boggy uterus
    -Above umbilicus
    -Filled with blood clots
  2. Investigations:
    Bloods
    USS to exclude ruptured uterus, peritoneal bleeding
  3. 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
19
Q

Discuss management of trauma causing PPH
-Examination findings (3)
-Investigations (4)
-Management (3)

A
  1. Examination findings
    -Bleeding from sites within the genital tract
    -Haematoma formation
    -Extragenital bleeding - liver capsule rupture/ splenic vessels
  2. Investigations
    -Inspect all genitalia
    -Inspect angles of CS with exteriorisation
    -USS to look for FF in peritoneum
    -MRI to look for haematoma if supralevator
  3. Management
    -Repair trauma
    -If Tx to OT apply pressure
    -Consider IR if haematoma - Broad ligament or supralevator
20
Q

Discuss management of retained tissue causing PPH
-Examination findings (3)
-Investigations (1)
-Management (1)

A
  1. Examination
    -Retained tissue or membranes
    -Ragged membranes or missing cotyledons on placental inspection
    -Retained placenta
  2. Investigations
    -EUA
  3. Management
    -Manual removal
21
Q

Discuss management of thrombin (Coagulopathy) causing PPH
-Examination findings (3)
-Investigations (2)
-Management (3)

A
  1. Examination
    -Continual bleeding with contracted uterus
    -Failure of blood to clot
    -Ooze from IV sites
  2. Investigations
    -Bloods - continue checking coags with ongoing blood loss
    -Assess for risk factors
  3. Management
    -Replace blood
    -Replace coagulation (FFP and Cryo)
    -TXA
22
Q

Discuss blood transfusion in PPH
-When to transfuse (4)
-Goals of transfusion (4)
-General principles of transfusion (5)

A
  1. 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
  2. Goals of transfusion
    -Hb >80 (RCOG)
    -Platelets >50
    -Fibrinogen >1.5 - 2
    -APTT and PT <1.5 x normal
  3. 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)
23
Q

Discuss synthetic oxytocin
-Doses (3)
-MOA (1)
-Side effects (4)
-Contra-indications (1)
-Advantages (3)
-Disadvantages (2)

A
  1. 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
  2. MOA
    -Acts on oxytocin receptors within myometrium to cause uterine contractions
  3. Side effects
    -Hypotension
    -Tachycardia
    -Hyponatremia
    -Fluid overload
  4. Contra-indications
    -Avoid bolus in severe cardiac disease
  5. Advantages
    -Well tolerated with lowest SE profile
    -Rapid onset
    -Reduces need for theraputic ecbolics by 40%
  6. Disadvantages
    -Less effective cf ergometrine at PPH prevention
    -Needs to be kept cool
24
Q

Discuss ergometrine
-Doses (3)
-MOA (2)
-Side effects (3)
-Contra-indications (4)
-Advantages (2)
-Disadvantages (2)

A
  1. 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
  2. MOA
    -Ergot alkaloid
    -Smooth muscle contractor
  3. Side effects
    -HTN
    -Nausea and vomiting
  4. Contraindications
    -HTN / PET
    -Valvular disease, coronary heart disease
    -Aortopathies
    -Aneurysms
  5. Advantages
    -Most effective ecbolic for prophylaxis and treatment
    -Able to give IM
  6. Disadvantages
    -Increased side effects
    -Slower onset cf oxytocin
25
Q

Discuss carboprost (PGF2)
-Doses (3)
-MOA (1)
-Side effects (6)
-Contra-indications (4)
-Advantages (1)
-Disadvantages (1)

A
  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)
  2. MOA
    -Synthetic prostaglandin analogue
  3. Side effects
    -Bronchospasm
    -Vasodilation
    -HTN
    -Diarrhoea, nausea
    -Cramping and abdo pain
    -Fever
  4. Contraindications
    -Asthma, pulmonary HTN, single ventricle, shunt
  5. Advantages
    -Multiple routes of administration
  6. Disadvantages
    -Increased SE profile
26
Q

Discuss misoprostol (PGE1)
-Doses (1)
-MOA (2)
-Side effects (5)
-Contra-indications (2)
-Advantages (3)
-Disadvantages (2)

A
  1. Dose
    -1000mcg SL/PR/PO
    -Repeat doses not recommended
  2. MOA
    -Synthetic prostaglandin
    -Onset of action 1-1.5hrs regardless of route
  3. Side effects
    -Fever (20-40%)
    -N/V/D
    -Headache
  4. Contraindications
    -Nil absolute
    -Caution with lung disease
  5. Advantages
    -Refrigeration NOT required
    -Multiple routes of administration
  6. Disadvantages
    -Not as effective as oxy
    -Increased SE profile
27
Q

Discuss carbetocin
-Doses (1)
-MOA (2)
-Side effects (4)
-Contra-indications (1)
-Advantages (2)
-Disadvantages (1)

A
  1. Doses
    -100mcg slow IV injection or IM
  2. MOA
    -Long acting synthetic oxytocin
    -Binds to oxytocin receptors causing uterine contraction
  3. Side effects
    -Flushing
    -Hyponatremia
    -Fluid retention
    -Hypotension
  4. Contraindications
    -Nil absolute
  5. Advantages
    -Longer duration of action so can avoid oxy infusion
    -Heat stable formulation
  6. Disadvantages
    -Not available in NZ
28
Q

Discuss tranexamic acid in use of PPH
-Dose (1)
-MOA (2)
-Evidence (2)

A
  1. Dose
    1g IV with a repeat after 30mins
  2. MOA
    -Reduces conversion of plasminogen to plasmin
    -Prevents enzymatic fibrin degradation
  3. Evidence
    -WOMAN Trial
    -Reduction in death from PPH RR 0.69
    -Reduction in need for laparotomy
29
Q

Discuss use of bakri balloon in PPH
-MOA (2)
-Efficacy (1)
-Amount to fill (1)
-Time to remain in-situ (4)

A
  1. MOA
    -Acts to tamponade bleeding
    -Can be used as a test before opting for laparotomy
  2. Efficacy
    -91% success rate in preventing hysterectomy
  3. Amount to fill
    200-500mL
  4. Time to remain in situ
    4-6 hrs likely adequate.
    Max duration 24hrs
    Remove in daylight hrs
    Cover with antibiotics
30
Q

Discuss arterial embolisation for management of PPH
-Procedure (4)
-Embolic agents used (2)
-Complications (7)
-Long term outcomes (2)

A
  1. Procedure
    -Light sedation
    -Access via femoral artery
    -Angiography to access bleeding point
    -Place embolic agents
  2. Embolic agents
    -Temporary - gelatin impregnanted sponges
    -Permanent - metal coils
  3. Complications
    -Overall complication rate 9%
    -Fever
    -Pelvic infection
    -Ischemic buttock pain
    -Temporary foot drop
    -Groin haematoma
    -Vessel perforation
  4. Long term outcomes
    -Most women retain fertility
    -Most women continue to menstruate
31
Q

Discuss compression sutures
-Types
-Failure rates (Leading to hysterectomy)
-RF for failure

A
  1. Types
    -B-Lynch (Needs laparotomy)
    -Haymen (Can be done without laparotomy)
  2. Failure rates - 25%
  3. Risk factors
    -Increasing age
    -Vaginal delivery
    -Delayed between delivery and compression sutures 2-6hrs
32
Q

Discuss the WOMAN trial
-Aim
-Study design
-Primary outcomes

A
  1. Aim
    -To determine the effect of TXA on maternal death and hysterectomy
  2. Study design
    -Double blinded RCT in 21 hospitals
    -Enrolled if PPH after VB or CS
    -1g TXA IV vs placebo
  3. Primary outcomes
    -Maternal death
    -Hysterectomy
33
Q

Discuss the WOMAN Trial
-Number included
-Results

A
  1. Number included
    -20 000
  2. 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)

RANZCOG Postpartum care (5 decks)

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