POSTPARTUM HAEMORRHAGE Flashcards
What is the definition of postpartum haemorrhage with regard to normal vaginal delivery?
Bleeding from the genital tract of more than 500 mL after delivery of the infant.
What is the difference between primary and secondary postpartum haemorrhage?
Primary: Bleeding more than 500 mL within 24 hours of delivery
Secondary: Bleeding more than 500 mL that starts 24 hours after delivery and occurs within 12 weeks.
What is the incidence of primary post-partum haemorrhage?
5% in the developed world
28% in the developing world
What is the most common cause of primary post-partum haemorrhage?
Uterine atony 90%
What are the causes of primary postpartum haemorrhage?
Uterine atony
Genital tract trauma
Retained placenta / placenta accreta
Coagulation disorders
Uterine inversion
Uterine rupture
What are the risk factors for uterine atony and therefore postpartum haemorrhage?
Multiple pregnancy
Grand multiparity or nulliparity
Fetal macrosomia
Polyhydramnios
Fibroid uterus
Prolonged labour
Previous PPH
Antepartum haemorrhage
Why does multiple pregnancy increased the risk of PPH?
Placental site is larger than with a singleton. There is also over distension which increases risk of uterine atony.
What are the risk factors for genital tract trauma?
Macrosomia
Episiotomy
Instrumental delivery, especially Keilland’s forceps
What is the average amount of blood loss with caesarian section?
500 mL, therefore PPH in this case is termed as anything above 1 L.
What are the symptoms of uterine inversion?
Blood loss
Abdominal pain
Feeling of prolapse
What is the main risk factor for uterine rupture as a cause of PPH?
Previous caesarian section
What are the coagulation disorders than might cause PPH?
Chronic:
Haemophilia
Von Willebrands
Acute:
DIC
What is placenta accreta?
This is when the placenta is morbidly adherent to the uterine wall.
What is placenta increta?
When the placenta invades into the myometrium.
What is placenta percreta?
When the placenta invades all the way through the myometrium.
What are the complications of primary postpartum haemorrhage?
Haemorrhagic shock and death
Sheehan’s syndrome
What is Sheehan’s syndrome?
Avascular necrosis of the pituitary gland resulting in hypopituitarism on the back of PPH.
How do we prevent primary PPH and the complications of it?
Monitoring and treatment of low Hb in antenatal period
Identify those with risk factors early on
Active management of the third stage of labour
What does the active management of the third stage of labour involve?
Use of oxytocic drugs prophylactically
Controlled cord traction to deliver placenta (Brandt-Andrews method)
Clamping and cutting umbilical cord
What is the oxytocic drug that we commonly use prophylactically in the active management of the third stage of labour?
IM syntometrine - 5 units of syntocinon and 0.5mg ergometrine
What is the contraindication to using syntometrine as part of active management of the third stage of labour? What is given instead?
Hypertension
Syntocinon is given instead
What are the causes of secondary postpartum haemorrhage?
Retained products
Endometritis (infection)
Persistent molar pregnancy / choriocarcinoma
What are the symptoms of retained products?
Prolonged heavy vaginal bleeding or persistent offensive discharge
How should you go about examining a woman with primary PPH?
ABCDE
Estimate blood loss (frequently underestimated)
Abdominal palpation should assess whether uterus is contracted or not
Assess fundal height - should be at or below umbilicus. If above indicated retained products or clots. If cannot be palpated consider uterine inversion.
Examine genital tract for trauma
Remember to examine placenta and membranes to see that cotyledons appear complete and there is no suggestion of a succentric lobe.
What investigations would you need to do in someone with primary PPH?
FBC
Clotting screen, including fibrin degradation
U+Es
Group and save or crossmatch
Urine output
USS - check for retained products if persisting
What investigations would you need to do in someone with secondary PPH?
FBC
Clotting screen, including fibrin degradation
U+Es
Group and save or crossmatch
Urine output
USS - check for retained products if persisting
High vaginal swab - endometritis
hCG - if stays high indicates molar pregnancy
How do you manage a patient suffering primary PPH caused by uterine atony?
- ABCDE approach - think about giving transfusion
- Massage uterus abdominally
- IV syntocinon 10 units STAT and/or IV ergometrine 500 micrograms - followed by an IV infusion
- IM carboprost - F2 alpha prostaglandin or Misoprostol PR
- other options include: balloon tamponade, B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
- if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
What is generally considered a massive postpartum haemorrhage?
Above 1500 mL in 24 hours
How would you manage a patient where there is evidence of retained or incomplete placenta causing PPH?
Manual removal under anaesthetic
How do we manage placenta accreta, where there is no sign of active bleeding?
May be appropriate to leave placenta in situ.
Abx should be given
Consider use of folate antagonist - methotrexate
How do we manage placenta accreta where there is active bleeding?
Surgery possibly including hysterectomy
How do we manage a patient with uterine inversion?
Resuscitate patient
Replace uterus either manually or hydrostatically
Oxytocin infusion
What is the most serious presentation of uterine inversion?
Severe lower abdominal pain followed by collapse due to neurogenic shock and haemorrhage.
Why has the rate of uterine rupture decreased recently?
Lower segment caesarian section rather than classical
