Postpartum haemorrhage Flashcards
What is minor PPH?
500-100ml blood loss without clinical signs of shock
What is PPH?
blood loss of 500ml or more following childbirth
What is major PPH?
> 100ml blood loss or <100ml blood loss with clinical signs of shock
What is primary PPH?
PPH occurring from 24hrs of delivery
What is secondary PPH?
PPH occurring from 24hrs up to 12 weeks post-delivery
What are the causes of primary PPH?
Tone - a not well contracted uterus
Trauma - injury as a result of childbirth (perineal tears, lacerations, episiotomy)
Tissue - retained products of conception e.g. retained placenta
Thrombin - underlying clotting disorders e.g. haemophilia or use of LMWH
What are causes of secondary PPH?
Endometritis - infection of endometrium
Retanied products of conception
What are risk factors of PPH?
Previous PPH
Grand multiparity
Overdistension of uterus (Polyhydramnios, Macrosomia, Multiple pregnancy)
Clotting disorders
Anterpartum haemorrhage
Placenta praevia
Prolonged labour
Operative birth or caesarean section
Induction of labour
What are clinical features of PPH?
Heavy bleeding from vagina
Tachycardia
Signs of shock
What are clinical features of primary PPH?
Tone - uterus may feel enlarged, soft
Trauma - visible lacerations or tears on vaginal examination
Tissue - placental tissue or membranes may be incomplete
What are clincal features of secondary PPH?
Signs of sepsis - tachycardia, hypotension, pyrexia
Uterus tender or bulky on palpation
What are investigations for PPH?
Bedside vital signs taken
Lab - FBC (anaemia), Coagulation screen, Group and save and crossmatch (transfusion), U&Es and LFTs (assess baseline function)
How is sepsis screened for in secondary PPH?
Blood cultures - establish bacteraemia
Blood tests - lactate and CRP
High vaginal swabs - culture for abx choice
Pelvic USS - look for retained products of conception
What is the management of anaemia in pregnancy?
FBC at booking and 28wks gestation
Antenatal anaemia (if microcytic or normocytic) - treated with iron supplementation and monitored for anaemia
What is the active management of the third stage of labour?
Inform women of risk of PPH if opting for passive management
For women who have risk factors of PPH, active management is strongly recommended
Offer prophylactic uterotonics to all women as part of management of 3rd stage to reduce PPH risk
What is active management of 3rd stage of labour?
- Uteronic drugs (e.g. oxytocin or syntometrine etc)
- Deferred clamping and cutting of the cord
- Controlled cord contraction
What is passive management of 3rd stage of labour?
- No routine use of uteronic drugs
- No clamping of cord until pulsation has stopped
- Delivery of placenta by maternal effort
What is management of PPH?
Obstetric emergency
ABCDE approach
- Airway
- Breathing - assess resp rate and O2 sats
- Circulation - HR, BP, CRT, estimate blood loss, warm crystalloid solution, urinary catheter to monitor urinary output, IV access and take bloods
What is the management if the placenta is retained and there is ongoing bleeding?
go to theatre for manual removal of the placenta and retained tissued
What is the management of secondary PPH?
Pelvic USS if retained products suspected
Surgical evacuation may be necessary
Blood transfusion if HB below 80g/L and patient is symptomatic of anaemia
What is the most common cause of PPH?
atony
What medications are given for atony?
Uteronic drugs (oxytocin, syntrometrine, carboprost, misoprostol)
What mechanical considerations can be done for atony?
rub uterine fundus to stimulate contractions and/or bi-manual compression
What surgical considerations can be done for atony?
intra-uterine balloon tamponade and haemostatic sutures
What is care following PPH?
Pt may need invasive monitoring in critical care
Explain what happened and discuss implications for future pregnancies
Ensure documentation is clear with accurate timing of each step taken
What are complications of PPH?
Anaemia - blood transfusion
Hypovolaemic shock leading to organ dysfuction such as AKI
Post-traumatic stress disorder
Hysterectomy
Disseminated intravascular coagulation
Sheehan’s syndrome (postpartum pituitary gland necrosis)
Death
