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OBGYN 4MB > Postpartum Haemorrhage > Flashcards

Postpartum Haemorrhage Flashcards

1
Q

Define primary postpartum haemorrhage (PPH)

A

Loss of >500ml of blood <24hrs after delivery (or >1000ml after C-section)

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2
Q

Define minor PPH

A

Loss of 500-1000ml

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3
Q

Define major PPH

A

Loss of >1000ml and continuing to bleed

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4
Q

Define massive obstetric haemorrhage

A

Loss of >1500ml and continuing to bleed (2000ml according to Reg tutorial)

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5
Q

List the causes of PPH

A

The 4 T’s:

  1. Tone - atonic uterus (80% PPH)
  2. Trauma - tears (vaginal or cervical)
  3. Tissue - retained placenta
  4. Thrombin - coagulopathy (congenital, anticoagulant therapy, DIC, stop antenatal thromboprophylaxis at least 12hrs before labour or delivery)
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6
Q

What are the risk factors for PPH?

A
  1. Antepartum haemorrhage
  2. Previous hx
  3. Previous C-section
  4. Coagulation defect or anticoagulant therapy
  5. Instrumental or caesarean delivery
  6. Retained placenta
  7. Polyhydramnios and multiple pregnancy
  8. Grand multiparity
  9. Obesity
  10. Prolonged and induced labour
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7
Q

How can PPH be prevented?

A
  • Routine use of oxytocin in third stage of labour (10 IU by IM injection if no risk factors and SVD)
  • Can use Ergometrine (causes vomiting and CI in HTN)
  • If previous C-section all women must have placental site determined by US (placenta accreta)
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8
Q

What steps are taken to prevent PPH when delivering by C-section?

A
  • Oxytocin 5 IU by slow IV injection

- Consider oxytocin infusion (40 IU in 500ml normal saline 0.9% over 4hrs) in addition to bolus

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9
Q

Describe the active management of the third stage of labour

A
  • Uterotonic (oxytocin)
  • Early clamping of umbilical cord
  • Controlled cord traction for delivery of placenta
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10
Q

What are the clinical features of PPH?

A
  1. Blood loss
  2. Large uterus (above level of umbilicus)
  3. Inspect vaginal wall and cervix for tears
  4. Collapse without overt bleeding (rare)
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11
Q

List the priorities in management of PPH

A
  1. Support
  2. Restoration of blood volume
  3. Treatment of any developing coagulopathy
  4. Cessation of blood loss
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12
Q

How do we resuscitate a patient with PPH?

A
  • Nursed flat
  • O2 given
  • IV access obtained
  • Blood cross matched
  • Fluid +/- blood given
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13
Q

How can we prevent or treat coagulopathy?

A
  • May require FFP

- Tranexamic acid reduces bleeding

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14
Q

How is retained placenta managed?

A
  • Removed manually if bleeding or it is not expelled by normal methods within 60mins of delivery
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15
Q

List the steps to identify and treat the cause of bleeding

A
  1. VE
  2. Uterus bimanually compressed
  3. Oxytocin and/or Ergometrine IV (if fails prostaglandin F2x injection into myometrium)
  4. Examination under anaesthetic if above fails
  5. Surgery
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16
Q

What different surgical techniques can be used in the treatment of PPH?

A
  1. Placement of a Rusch balloon
  2. Brace suture
  3. Uterine artery embolization
  4. Hysterectomy
17
Q

Who is alerted in the case of a minor PPH?

A
  1. Midwife in charge
  2. First line obstetric staff
  3. First line anaesthetic staff
18
Q

Who is alerted in the case of a major PPH?

A
  1. Midwife in charge
  2. Obstetric middle grade and alert consultant
  3. Anaesthetic middle grade and alert consultant
  4. Consultant clinical haematologist on call
  5. Blood transfusion lab
  6. Porters
  7. One team member to record events, fluids, drugs, vitals
19
Q

How do we resuscitate in the case of a minor PPH?

A
  1. IV access (14 gauge cannula x1)
  2. Commence crystalloid infusion
  3. Insert urinary catheter
20
Q

How do we resuscitate in the case of a major PPH?

A
  1. ABC call for senior help
  2. O2 by mask at 10-15L/min
  3. IV access (large gauge cannula x2)
  4. Position flat
  5. Keep woman warm
  6. Transfuse blood ASAP
  7. Infuse up to 3.5L of warmed fluid solution, crystalloid (2L) and/or colloid (1-2L) until blood available
  8. Recombinant factor VIIa therapy based on clinical evaluation and results of coagulation
21
Q

List the investigations and monitoring done for minor PPH

A
  1. Group and screen
  2. FBC
  3. Coagulation screening including fibrinogen
  4. Pulse and BP every 15mins
22
Q

List the investigations and monitoring done for major PPH

A
  1. Crossmatch (4 units min)
  2. FBC
  3. Coagulation screen including fibrinogen
  4. Renal and liver function for base line
  5. Temp every 15mins
  6. Continuous pulse, BP and RR
  7. Catheter to monitor urine output
  8. Two peripheral cannulae
  9. Consider arterial line monitoring
  10. Transfer to HDU when bleeding controlled
  11. Record everything
  12. Documentation of fluid balance, blood, blood products and procedures
23
Q

How do we treat uterine atony?

A
  1. Bimanual uterine compression to stimulate contractions
  2. Ensure bladder empty
  3. Syntocinon 5U slow IV injection
  4. Ergometrine 0.5mg by slow IV or IM injection (CI HTN)
  5. Syntocinon infusion unless fluid restriction necessary
  6. Carboprost 0.25mg IM repeated at intervals of not less than 15mins to a max of 8 doses (CI asthma)
  7. Direct intramyometrial injection of carboprost 0.5mg (unlicensed use)
  8. Misoprostol 600mcg orally or sublingually
  9. Balloon tamponade
  10. Haemostatic brace suture
  11. Bilateral ligation of uterine arteries
  12. Bilateral ligation of internal iliac arteries
  13. Selective arterial embolization
  14. Hysterectomy
24
Q

Define secondary PPH

A

Excessive blood loss occurring between 24hrs and 6wks after delivery

25
Q

List the causes of secondary PPH

A
  1. Endometritis
  2. Incidental gynaecological pathology
  3. GTD
26
Q

List the findings on examination in secondary PPH

A
  1. Enlarged uterus
  2. Tender uterus
  3. Open cervical os
27
Q

What investigations should be done or secondary PPH?

A
  1. Vaginal swabs
  2. FBC
  3. Crossmatch if severe
  4. US (for retained products)
28
Q

How does endometritis present?

A

Bleeding that slows, but does not stop, with antibiotics and gets worse again after course is finished (presents like this if due to retained products)

OBGYN 4MB (25 decks)

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