Postpartum haemorrhage Flashcards
Definition of primary PPH
Blood loss of 500 ml or more from the genital tract within 24 hours of delivery
Definition of secondary PPH
Excessive blood loss 500ml between 24 hours and 12 weeks after delivery
Causes of primary PPH ( 4x Ts)
- Tissue - Placenta being retained or abnormal placental site
- Tone - Uterine atony
- Thrombosis problem - coagulation problem
- Trauma - of the genital tract
Most common cause of PPH
- Uterine atony - failure of uterus to contract after delivery
Antenatal risk factors for PPH
- Previous PPH
- Low lying placenta ( placenta previa)
- Maternal age > 35
- High BMI
Medical management
- IV synctocinon / Oxytocin
2. IV Carboprost
Surgical management
Intra unterine balloon tamponade
What are the risk factors for uterine atony and therefore postpartum haemorrhage? ( all increase distention of uterus )
Multiple pregnancy
Grand multiparity or nulliparity
Fetal macrosomia
Polyhydramnios
Fibroid uterus
Prolonged labour
Previous PPH
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 is the main risk factor for uterine rupture as a cause of PPH?
Previous caesarian section
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 are the causes of secondary postpartum haemorrhage?
Retained products
Endometritis (infection)
Persistent molar pregnancy / choriocarcinoma
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
