Postpartum Haemorrhage Flashcards
What is postpartum haemorrhage (PPH)?
Loss of more than 500ml of blood from the genital tract within 24 hours of delivering a baby.
What are the classifications of PPH by volume?
Minor, Major, Moderate, Severe
Minor PPH:
500-1000ml
Major PPH:
> 1000ml
Moderate Major PPH:
1000-2000 ml
Severe Major PPH:
> 2000ml
What are the four Ts causes of PPH?
Tone, Tissue, Trauma, Thrombin
What is the commonest cause of PPH?
Uterine atony
What can affect tone in regards to causing PPH?
Inadequate contraction of the uterus after separation of the placenta leads to profuse bleeding from the decidua
Causes of uterine atony?
multiple pregnancy, macrosomia, polyhydramnios, retained placenta, prolonged second stage of labour.
What can affect tissues in regards to causing PPH?
(tissue retained in uterus): ○ Typically part of placenta, sometimes retention of part of foetal / maternal membranes. ○ Prevents proper uterine contraction and resulting vessel occlusion.
Causes of tissue retention in uterus?
placenta praevia, placenta accreta spectrum, succenturiate placental lobe, preterm delivery
How does Trauma affect PPH ?
Trauma to genital tract leading to bleeding - includes caesarean section
Causes of trauma in PPH
vulvovaginal tears, instrumental delivery, episiotomy.
How does Thrombin affect PPH?
Normal bleeding worsened by pre-existing / obstetric coagulopathy /thrombocytopenia.
Causes of Thrombin affecting PPH?
pre-eclampsia, HELLP syndrome, DIC, puerperal sepsis, von Willebrand disease, dilutional coagulopathy (resuscitation with high volumes of crystalloid).
Managment of minor PPH
○ IV access with 14-gauge cannula ○ G+S, FBC, coagulation screen ○ Frequent observations every 15 minutes ○ Warmed crystalloid infusion
Managment of major PPH
○ As for minor PPH, plus: ○ Lie patient flat, give high flow oxygen ○ O-negative blood as soon as possible - warmed crystalloid until blood is available ○ Ongoing haemorrhage: blood component transfusion - FFP, platelets, cryoprecipitate - guided by blood counts and clotting profile
In both Minor and Major PPH, what is the treatment of underlying cause (treated as for atony)?
■Fundal massage
■ Catheterisation
■ Oxytocin and ergometrine
■ Carboprost (uterotonic)
■ Misoprostol
In both Minor and Major PPH, what are the second line surgical measures, performed in a stepwise manner?
■ Intrauterine balloon tamponade ■ Haemostatic suturing (B-Lynch) ■ Uterine devascularization / arterial ligation ■ Hysterectomy
Most common cause of major PPH (>1000ml) following birth
Uterine atony (tone ~ 70-80%)
Causes of Major PPH
Retained placenta (Tissue ~10%)
Infection (caused by retained tissue, causes atony!)
Episiotomy (Trauma ~20-30%)
Uterine atony (Tone ~70-80%)
Disseminated intravascular coagulopathy (Thrombin <1%)
Risk Factors for PPH
● Big baby
● Nulliparity and grand multiparity
● Multiple pregnancy
● Precipitate or prolonged labour
● Maternal pyrexia
● Operative delivery
● Shoulder dystocia
● Previous PPH
4 T’s - PPH
●Tone (uterine atony – the most common cause)
●Trauma (e.g. perineal tear)
●Tissue (retained placenta)
●Thrombin (bleeding disorder)
Tx for PPH
“Treat the cause.
- Stabilise: ABCDE, 2x cannula, bloods, IV fluid, oxygen
- Major haemorrhage protocol
- Stop bleeding
- Mechanical → rubbing uterus, catheterisation
- Medical → oxytocin, ergometrine, carboprost etc
- Surgical → intrauterine balloon tamponade, B-lynch suture, hysterectomy
