Postpartum haemorrhage

Question 1

What is a postpartum haemorrhage?

Answer 1

Blood loss of more than 500ml after a vaginal delivery or 1000ml after a c-section

Question 2

What is a minor vs major postpartum haemorrhage?

Answer 2

Minor < 1 litre
Major > 1 litre

Question 3

How can a major PPH be further classified?

Answer 3

Moderate PPH - 1000-2000ml
Severe PPH - > 2000ml

Question 4

What is a primary PPH?

Answer 4

PPH within 24 hours of delivery

Question 5

What is a secondary PPH?

Answer 5

PPH after 24 hours post delivery (up to 12 weeks postpartum)

Question 6

What are the causes of PPH?

Answer 6

4 Ts
- Tone - uterine atony
- Trauma
- Tissue - retained placenta
- Thrombin - clotting/bleeding disorder

Question 7

What are the risk factors for primary PPH?

Answer 7

PPH in previous pregnancy
BMI >35
Prolonged labour
Pre-eclampsia
Increased maternal age
Emergency C-section
Polyhydramnios
Placenta praevia
Placenta accreta
Macrosomia
Prolonged third stage of labour
Multiple pregnancy
Instrumental delivery

Question 8

How can PPH be prevented?

Answer 8

Treating anaemia during pregnancy
Giving birth with an empty bladder
Active management of third stage
- IM oxytocin during third stage
IV tranexamic acid during C section in high risk patients

Question 9

How should a patient be stabilised during a PPH?

Answer 9

ABCDE
Lie woman flat and keep her warm
Insert two large-bore cannulas
FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation
Oxygen

Question 10

What management options are there for stopping bleeding in a PPH?

Answer 10

Mechanical
Medical
Surgical

Question 11

What are the mechanical management options for PPH?

Answer 11

Rubbing the uterus through the abdomen
- Stimulates contractions
Catheterisation
- Prevents bladder distension that prevents uterine contractions

Question 12

What are the medical management options for PPH?

Answer 12

IV oxytocin
IV or IM Ergometrine - stimulates muscle contraction
IM carboprost - prostaglandin analogue
Sublingual misoprostol - prostaglandin analogue
IV tranexamic acid

Question 13

What are the surgical management options for PPH?

Answer 13

Intrauterine balloon tamponade - presses against the bleeding from the uterus
- First line
B-lynch suture - a suture around the uterus to compress it
Uterine artery ligation
Hysterectomy

Question 14

What is the most likely cause of secondary PPH?

Answer 14

Retained products of conception or infection

Question 15

What are the investigations for secondary PPH?

Answer 15

Ultrasound for RPOC
Endocervical and high vaginal swab for infection

Question 16

What is the management of secondary PPH?

Answer 16

Surgical evaluation for RPOC
Antibiotics for infection

Question 17

What is the most common cause of PPH?

Answer 17

Uterine atony

Question 18

What is uterine atony?

Answer 18

Failure of the uterus to contract adequately after childbirth

Question 19

What is Sheehan’s syndrome?

Answer 19

A complication of PPH where ischaemic necrosis of the anteiror pituary is caused by blood loss

Question 20

How does Sheehan’s syndrome manifest after a PPH?

Answer 20

Hypopituitarism
Lack of postpartum milk production
Amenorrhoea