Postpartum Haemorrhage Flashcards
Primary and secondary
What are the 2 types of PPH?
Primary and secondary
What is primary PPH?
Loss of >500mL of blood, <24 hours after delivery
What is massive obstetric haemorrhage (MOH)?
Blood loss of >1500mL which is continuing
Aetiology of primary PPH (4Ts)?
- Tone
- Tissue
- Trauma
- Thrombin
Most common cause of primary PPH (80%)?
Tone
How can tissue (retained placenta) cause primary PPH?
Partial separation of the placenta causes blood to accumulate in the uterus, which will rise.
ALSO, RFx for atony, since the uterus is less able to contract to constrict blood flow
Why might the uterus not contract, causing to primary PPH (tone)?
- It is atonic
2. Retained placenta (or part of the placenta)
RFx for atony?
- Prolonged labour
- Grand multiparity
- Overdistension of the uterus (polyhydraminos and multiple pregnancy)
- Fibroids
How can trauma cause primary PPH?
- Vaginal causes (20%) = perineal tear or episiotomy
- High vaginal tear, especially after instrumental vaginal delivery
- Cervical tears (rare)
How common is thrombin as a cause of primary PPH?
Very rare
What is coagulopathy?
Impaired ability of the blood to clot
RFx for coagulopathy?
- Congenital disorders
- Anticoagulant therapy
- Disseminated intravascular coagulation
Preventing primary PPH due to thrombin?
If prescribed, stop antenatal prophylaxis at least 12 hours before labour or delivery
Prevention of primary PPH?
Routine use of oxytocin in 3rd stage of labour (actively managed 3rd stage), helps uterus to contract, constricting blood flow
Clinical Fx that suggest uterine (tone) cause of primary PPH?
An enlarged uterus, above the level of the umbilicus
Priorities in managing primary PPH?
- Support
- Restore blood volume
- Tx developing coagulopathy
- Cessation of blood loss
How is a patient resuscitated if needed?
- Nurse patient flat
- Give O2
- IV access obtained
- Blood cross-match
- Give fluid and/or blood if needed
How is a coagulopathy treated or prevented?
Fresh frozen plasma and cryoprecipitate may be needed.
TRANEXAMIC ACID also reduces bleeding
How should a retained placenta be managed?
Remove it manually if there is bleeding, or if it has not been expelled by normal methods within 60mins of delivery
How is primary PPH treated by atony treated?
- Bimanually compress uterus
- Oxytocin and/or ergometrine is given IV to contract the uterus if trauma is not obvious
- If the above does not work, prostaglandin F2a (PGF2a) is injected into the myometrium
How is primary PPH caused by trauma treated?
Suture the tears
When should surgery for primary PPH be performed?
When primary haemorrhage continues despite medical Tx
Surgical Tx options for primary PPH?
- Bleeding from placental bed (well contracted uterus with no trauma) = Rusch balloon insertion
- Brace suture (around the entire uterus to contract it
- Uterine artery embolisation
- Hysterectomy if the above fail
What is secondary PPH?
‘Excessive’ blood loss occurring between 24 hours and 6 weeks after delivery
Causes of secondary PPH?
- Endometritis, with or without retained placental tissue (most common)
- Incidental gynae pathology
- Gestational trophoblastic disease
Examination findings with secondary PPH?
- Uterus is enlarged
- Uterus is tender
- Open internal cervical os
Ix in secondary PPH?
- Vaginal swabs
- FBC
- USS can help with retained products
Mx of secondary PPH?
- Abx
- Heavy bleeding = Evacuation of retained products of conception (ERCP)
- Chronic bleeding = Abx alone
What suggests endometritis due to retained tissues (causing secondary PPH)?
Bleeding slows (but doesn’t stop) with Abx and gets worse again after course is finished
