Postpartum Haemorrhage Flashcards
What is primary PPH?
Loss of > 500ml blood PV within 24 hours of delivery of baby
Minor PPH: 500-1000ml
Major PPH: >1000ml
Massive obstetric haemorrhage > 1500ml
What are causes of primary PPH? Most common?
TTTT Tone: uterine atony, 90% Tissue: Retained products of conception Trauma: genital tract trauma Thrombin: clotting disorders
What is uterine atony? Risk factors for uterine atony?
Uterus fails to contract adequately following delivery due to a lack of tone in uterine muscle
Risk factors:
Maternal age >40, BMI > 35, Asian
Uterine over distension: multiple pregnancy, polyhydramnios, fetal macrosomia
Labour: induction, prolonged > 12 hours
Placental problem: placenta praevia, abruption, previous PPH
What are risk factors of genital tract trauma?
Instrumental vaginal deliveries
Episiotomy
C-section
What are vascular and coagulation abnormalities that increase risk of PPH?
Vascular: placental abruption, HTN, pre-eclampsia Coagulopathies: von Willebrand's disease Haemophilia A/B ITP DIC, HELLP
What are clinical features of primary PPH?
Vaginal bleeding
Dizziness, palpitations, shortness of breath
Haemodynamic instability
Signs of uterine rupture
Local truma
What investigations in primary PPH?
FBC Cross match 4-6 units Coagulation profile U&E LFT
What is management of primary PPH?
Teamwork
Resuscitaiton
Investigations and Monitoring
Measures to arrest bleeding
What is immediate management of primary PPH?
Teamwork: involve midwife, obstetrician, anaesthetist, blood bank, haematologist
Investigations and monitoring: RR, SaO2, HR, BP, temperature
Resuscitation:
Airway - protect
Breathing - 15L of 100% O2 through non-rebreathe
Circulation - assess, 2 14G cannulas and take bloods
Give X-matched blood ASAP
Until then give 2L of warmed crystalloid and 1-2L of warmed colloid
Disability - GCS
Exposure
What is definitive management for primary PPH?
Uterine atony:
Bimanual compression to stimulate uterine contraction
Pharmacological measures
Surgical measures - intrauterine balloon tamponade, haemostat suture around uterus, bilateral uterine artery ligation
Last resort - hysterectomy
Trauma:
Primary repair of laceration
If uterine rupture - laparotomy and repair or hysterectomy
Tissue:
IV oxytocin, manual removal of placenta and prophylactic abx in theatre
Thrombin
Correct coagulation abnormalities with blood products
Involve haematology
What drugs can be used to contract the uterus?
Syntocinon - synthetic oxytocin Ergometrine Carboprost - prostaglandin analogue Misoprostol - prostaglandin analogue Oxytocin
What is prevention for PPH?
Women delivering vaginally should be administered 5-10 units of IM oxytocin
Women delivering via CS should be administered 5 units of IV oxytocin
What is secondary PPH? When does it usually occur?
Excessive blood loss PV 24h after delivery to 12 weeks postpartum
Usually occurs between 5 and 12 days postpartum
What are causes of secondary PPH?
Uterine infection - endometritis
Retained placental tissue or clot
Abnormal involution of the placental site (inadequate closure and sloughing of the spiral arteries at placental attachment site)
Trophoblastic disease
What are clinical features of secondary PPH?
Excessive vaginal bleeding
Spotting on and off for days after delivery with occasional gush of fresh blood
- may present with massive haemorrahge
Fever/rigors, lower abdo pain, foul smelling lochia (normal discharge from uterus following childbirth)
- endometritis
What investigations for secondary PPH?
Bedside:
Swab - high vaginal
BP
Temperature
Bloods: FBC Coagulation Group and Save U&E CRP Blood cultures if required
Imaging:
Pelvic USS for retained placental tissue
What is the management of sensory PPH?
Antibiotics:
Ampicillin (clindamycin if pen allergic) + Metronidazole
Add gentamicin if endomyometritis (tender uterus)
Uterotonics: Syntocinon (oxytocin) Syntometrine (oxytocin and ergometrine) Carboprost Misoprostol
Surgical measure if excessive or continuous bleeding
- insertion of balloon catheter
How should you manage a woman refusing blood transfusion?
Oral iron and folate
Pre-labour plans made
Woman should make an Advanced Directive making clear her views on which blood products she will and won’t accept
Arrange US to know placental site
Give oxytocin as soon as baby is delivered
C-section if required
Ensure woman does not want to change her mind and receive transfusion
What is the risk of surgical evacuation of retained products?
Uterine perforation (as uterus is softer and thinner postpartum)
What is the sequence of Mx of uterine atony PPH
Bimanual uterine compression to manually stimulate contraction IV oxytocin ± ergometrine IM carboprost Intramyometrial carboprost Rectal misoprostol Surgical - balloon tamponade
