Postpartum Haemorrhage

Question 1

Postpartum haemorrhage PPH) can be defined as bleeding from the genital tract following delivery of a baby. Primary PPH is defined as what?

1 - bleeding >500ml during labour
2 - bleeding >500ml starting 24h postpartum and <6 weeks
3 - bleeding >500ml within 24h of delivery
4 - any of the above

Answer 1

3 - bleeding >500ml within 24h of delivery

haemorrhage definitions (postpartum haemorrhage (PPH) 500ml, 1000ml = major PPH, >1500ml major obstetric haemorrhage)

Question 2

Postpartum haemorrhage PPH) can be defined as bleeding from the genital tract following delivery of a baby. Secondary PPH is defined as what?

1 - bleeding >500ml during labour
2 - bleeding >500ml starting 24h postpartum and <6 weeks
3 - bleeding >500ml within 24h of delivery
4 - any of the above

Answer 2

2 - bleeding >500ml starting 24h postpartum and <6 weeks

Question 3

What is the definition of a major post-partum haemorrhage?

1 - >500ml blood loss
2 - >1000ml blood loss
3 - >1500ml blood loss
4 - >2000ml blood loss

Answer 3

2 - >1000ml blood loss

• > 1500ml is a major obstetric haemorrhage

Question 4

Is haemoglobin (Hb), a measure within the FBC a good measure of acute blood loss?

Answer 4

• no
• Hb is a concentration measurement, so the blood still within body despite blood loss will appear ok
• measure lactate, as acute blood loss leads hypoxia and increased lactate levels

Question 5

During a post partum haemorrhage, order the following in the order that we would see physiological changes in?

1 - cardiac
2 - respiratory
3 - BP

Answer 5

2 - respiratory
1 - cardiac
3 - BP

Question 6

What is the incidence of primary post-partum haemorrhage in the developed world?

1 - 50%
2 - 30%
3 - 15%
4 - 5%

Answer 6

4 - 5%
- 28% in developing countries
- secondary PPH is less common

Question 7

There are many causes of PPH. Which of the following is NOT one of the Ts to help you remember?

1 - Trauma
2 - Tissue
3 - Time
4 - Thrombin
5 - Tone

Answer 7

3 - Time

• Trauma = during labour or C-section or uterine rupture
• Tissue = retained placenta, contraception products or placenta accreta
• Thrombin = haemophilia,Von WIllebrand disease
• Tone = uterine atony, placenta previa

Question 8

PPH can be caused by lots of different things and be categorised using the 4 Ts. Which of the following is the most common cause of PPH, accounting for arpox 90% of cases?

1 - retained placenta
2 - genital tract trauma
3 - uterine atony (uterus does not contract following delivery)
4 - haemophilia

Answer 8

3 - uterine atony (uterus does not contract following delivery)

• second most common accounting for 7% is genital tract trauma

Question 9

Uterine atony is by far the most common cause of PPH, which can be caused by a number of different things. Which of the following are risk factors for uterine atony?

1 - previous PPH or antepartum haemorrhage
2 - prolonged labour
3 - pre-eclampsia
4 - reduced maternal age
5 - polyhydramnios
6 - emergency Caesarean section
7 - placenta praevia, accreta, macrosomia
8 - fibroid uterus
9 - multiple pregnancy

Answer 9

4 - reduced maternal age
- increased maternal age is associated with PPH

polyhydramnios = excessive amniotic fluid

Question 10

Trauma is the 2nd most common cause of PPH. Does this only occur in C-sections?

Answer 10

• no
• can be vaginal caused by episiotomy or cervical/vaginal tears

Question 11

Is PPH more common during a vaginal delivery if there are instruments used?

Answer 11

• yes
• especially forceps called Kielland forceps

Question 12

All of the following must be checked if a woman has primary PPH following the delivery of the baby. But which of the following is MOST important.

1 - maternal placenta and membranes are clear
2 - maternal observations
3 - maternal FBC including Hb
4 - all equally important

Answer 12

1 - maternal placenta and membranes are clear
- the cause needs identifying first

Question 13

If a woman’s uterus is firmly contracted, this rules out uterine atony. What is the next most likely cause of the PPH?

1 - retained or incomplete placenta
2 - genital tract trauma
3 - placenta accreta
4 - uterine inversion

Answer 13

2 - genital tract trauma
- 2nd most common cause of PPH
- needs repairing asap

Question 14

Uterine inversion is a dangerous complication, where the uterus can turn inside out. What can be done in an attempt to minimise the risk of uterine inversion?

1 - hysterectomy
2 - c-section
3 - controlled cord retraction
4 - monitoring using ultrasound

Answer 14

3 - controlled cord retraction

Question 15

Uterine rupture is a rare but complication with high morbidity and mortality and is associated with c-section. Patients present with continuous vaginal bleeding and abdominal pain. How is the diagnosis made?

1 - laparotomy
2 - ultrasound
3 - monitoring observations
4 - vaginal examination

Answer 15

1 - laparotomy
- treatment is surgery via repair of hysterectomy

Question 16

Which tests must be performed in a patient with PPH?

1 - FBC
2 - coagulation profile
3 - group and save and crossmatch
4 - rhesus status
5 - all of the above

Answer 16

5 - all of the above
- most will already be known prior to labour and PPH, but if not they should be performed asap

Question 17

What tells the doctor that the baby is ok?

1 - ultrasound
2 - maternal feeling of movement
3 - CTG
4 - all of the above

Answer 17

4 - all of the above

Question 18

What test can be used to assess for the presence of foetal blood in maternal circulation, which can occur during haemorrhage and affects Rhesus status?

1 - FBC
2 - Kleihauer test
3 - blood smears
4 - blood cross matching

Answer 18

2 - Kleihauer test

Question 19

Why should renal function be assessed in individuals with PPH?

1 - risk of hypovolaemia
2 - risk of polyhidrosis
3 - risk of pyelonephritis
4 - all of the above

Answer 19

1 - risk of hypovolaemia
- will see low urine output and drop in BP due to excessive blood loss, cause kidney injury

Question 20

Pregnant women who has develop vaginal bleeding and who are rhesus negative should be given anti-D within what time frame from the onset of bleeding?

1 - <12 hours
2 - <48 hours
3 - <72 hours
4 - <120 hours

Answer 20

3 - <72 hours

Question 21

When a women has PPH, which of the following should be 1st line management?

1 - mechanical approach through uterine fundus and rub
2 - IV oxytocin
3 - ABC, 2 peripheral cannulas
4 - medication (ergometrine, carboprost, misoprostol sublingual, tranexamic acid, some or all may be used)

Answer 21

3 - ABC, 2 peripheral cannulas
- also need to lie the woman flat, request blood based on group and save and crossmatch and commence warmed crystalloid infusion

Question 22

Following the ABC approach, which of the following should be the next thing that is done?

1 - mechanical approach through uterine fundus and rub
2 - IV oxytocin
3 - open surgery with hysterectomy
4 - medication (ergometrine, carboprost, misoprostol sublingual, tranexamic acid, some or all may be used)

Answer 22

1 - mechanical approach through uterine fundus and rub

• may insert catheter to avoid bladder distension

Question 23

Following the mechanical approach through uterine fundus and rub, which 2 of the following should be the next thing that is done?

1 - mechanical approach through uterine fundus and rub
2 - IV oxytocin
3 - open surgery with hysterectomy
4 - medication (ergometrine, carboprost, misoprostol sublingual, tranexamic acid, some or all may be used)

Answer 23

2 - IV oxytocin
4 - medication (ergometrine, carboprost, misoprostol sublingual, tranexamic acid, some or all may be used)

Question 24

If medical options have failed in a women with PPH, what should be the 1st line option if the cause is uterine atony?

1 - intrauterine balloon tamponade
2 - B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
3 - hysterectomy

Answer 24

1 - intrauterine balloon tamponade
- inserted vaginally or abdominally if c-section

Followed by:

B-Lynch suture, ligation of the uterine arteries or internal iliac arteries or if all else fails a hysterectomy

Question 25

Primary PPH can lead to Sheehan syndrome. What is this?

1 - necrosis of pituitary gland due to blood loss
2 - necrosis of hypothalamus due to blood loss
3 - necrosis of adrenal gland due to blood loss
4 - liver necrosis due to blood loss

Answer 25

1 - necrosis of pituitary gland due to blood loss
- results in hypopituitarism