Postpartum haemorrhage

Question 1

What is primary PPH?

Answer 1

Loss of >500ml blood in first 24hrs postpartum

Question 2

What is a major PPH?

Answer 2

> 1L loss

Question 3

How common is primary PPH?

Answer 3

6-10% deliveries (major PPH affects 1.3%)

Question 4

What are the causes of primary PPH?

Answer 4

Tone: uterine atony (90%) - classically seen in prolonged labour, grand multiparity, polyhydramnios and fibroids
Tissue: retained products of conception (can be side effect of uterine atony)
Trauma: genital tract trauma (7%)
Thrombin: clotting disorders (rare, 3%) e.g. congenital disorders, anticoagulant therapy, DIC

Question 5

What is massive obstetric haemorrhage?

Answer 5

Loss of >1500ml, should prompt hospital alert (2222)

Question 6

How can primary PPH be prevented?

Answer 6

Routine use of oxytocin in third stage of labour reduces incidence of PPH by 60% (beware - may cause vomiting, contraindicated in women with HNT)

Question 7

What are the clinical features of primary PPH?

Answer 7

Excessive blood loss
Enlarge uterus (suggests uterine cause)
Tears/vaginal trauma
Consider blood in abdominal cavity

Question 8

What is secondary PPH?

Answer 8

‘Excessive’ blood loss from the genital tract from 24hrs after delivery (typically present between 5-12d)

Question 9

What are the causes of secondary PPH?

Answer 9

Retained placental tissue or clot +/- infection (endometritis)
May also be due to gestational trophoblastic disease
Uterine involution may be incomplete (will be large and tender, with open cervical os)

Question 10

How should secondary PPH be managed?

Answer 10

Abx for any infective agent (may be used alone if bleeding more chronic)
USS to look for retained products post partum
If bleeding heavy, ERPC may be performed
Histological analysis of tissue removed should be performed to check for gestational trophoblastic disease

Question 11

How should primary PPH be managed?

Answer 11

A-E emergency management (call help, high-flow 02, assess airway/intubate, cannulate, bloods inc cross-match, IV fluids, catheterise and UO)
If coagulopathy - FFP and cryoprecipitate
Deliver placenta (empty uterus of clots/retained tissue)
Massage uterus/bimanual compression to encourage contraction
If manual contractions fail - can give syntometrine IM 1 ampule; oxytocin 40 units at 10units/hr; ergometrine 500mcg IV/IM; Misoprostol 1000mcg PR; Carboprost 250mcg every 15 min up to 8 doses
Repair tears
If bleeding ongoing after 2nd dose Carboprost/suspicion of uterine rupture/retained products, take to theatre for examination under anaesthetics
Insert Rusch balloon in theatre
If uterus still atonic but bleeding responds to compression - insert B Lynch suture
If bleeding ongoing, consider internal iliac or uterine artery ligation
Uterine artery embolization useful if available
Subtotal or total hysterectomy (should not be delayed because maternal death may result)

Question 12

What should be done if woman declines a blood transfusion?

Answer 12

Ideally prepare in advance (e.g. advance directive, discussion with senior staff, clarification over which products can be used, identification of any clotting disorders, location of placenta etc)
Consider cell salvage
Ensure that the woman still refuses products at the time of transfusion
Psychological support to relatives/staff if pt dies of exsanguination

Question 13

What kind of drugs are

a) syntometrine?
b) Ergometrine?
c) Misoprostol?
d) Carbetocin

Answer 13

a) Prostaglandin and oxytocin (ergometrine and oxytocin)
b) Prostaglandin
c) Prostaglandin and oxytocin
d) Prostaglandin and oxytocin