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OBGYN > Postpartum Haemorrhage (PPH) > Flashcards

Postpartum Haemorrhage (PPH) Flashcards

1
Q

What are the two classifications of PPH?

A

Primary
- minor
- major

Secondary

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2
Q

What are primary PPH?

A

Loss of >500ml of blood (1 litre if c-section) within 24 hours of delivery

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3
Q

What is a minor primary PPH?

A

500ml-1litre

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4
Q

What is a major primary PPH?

A

> 1 litre (moderate 1-2 litres, severe >2 litres)

Life threatening 40% total (approx 2.8 litres)

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5
Q

What is a secondary PPH?

A

’Excessive’ blood loss occurring between 24 hours and 6 weeks after delivery

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6
Q

What is PPH defined as by the ACOG?

A

Cumulative blood loss of 1000ml or more or blood loss associated with signs or symptoms of hypo-volemia, in the first 24 hours, irrespective of the route of delivery

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7
Q

How do you estimate blood loss?

A

Weigh dry and soaked swab: 1g weight = 1ml of blood loss

Blood collection drapes

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8
Q

How common is primary PPH?

A

~10% of women

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9
Q

What is the etiology of primary PPH?

A

4Ts

1) Tissue

2) Tone

3) Trauma

4) Coagulopathy (Thrombin)

5) Uterine Inversion

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10
Q

What is meant by the etiology Tissue?

A

Retained placental tissue (2.5% of deliveries)

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11
Q

What is meant by Tone in the etiology of PPH?

A

Tone (80%) uterus fails to contract properly due to Atony or retained tissue

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12
Q

What trauma is part of the trauma etiology of primary PPH?

A

Perineal + vaginal (20%) / cervical / uterine (rupture)

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13
Q

What Thrombin (coagulopathy) can cause primary PPH?

A

Congenital / anticoagulant / DIC

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14
Q

What are the risk factors for PPH (history or 4Ts)?

A

Prev PPH
Prev c-section
APH

Retained placenta

Polyhydramnios, multiple pregnancy, large baby
Uterine malformation or fibroids
Prolonged or induced labour
Grand mutiparity (para 5 or more)

Instrumental or c-section delivery

Episiotomy or perineal tear

Coagulation defect or anticoagulants

Also old age, raised BMI, Pre-eclampsia, placenta accreta

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15
Q

How can you prevent PPH?

A

Active management of 3rd stage of labour
- injection of syntocinon or syntometrine after delivery of anterior shoulder (lowers incidence PPH x 60%)
- IV tranexamic acid during c-section in 3rd stage in higher risk patients

  • CTT after signs of separation

Treating anaemia in antenatal period

Giving birth with an empty bladder (full bladder reduces uterine contractions)

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16
Q

What are the general clinical features of primary PPH?

A

Excessive blood loss (should be minimal): see estimated blood loss

Be aware of concealed loss: BP/HR/RR/O2 sats/ temp/ vasoconstriction/ sweating/ level of consciousness/ urine output

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17
Q

What would you see on examination in a primary PPH due to Tissue?

A

Examine the cord/placenta ? Separated? Complete ?

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18
Q

What would be seen on examination of a pPPH due to tone?

A

Enlarged uterus (>20wks)

‘Boggy and high’ in decreased tone

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19
Q

What would be seen on pPPH due to trauma?

A

Examine perineum, vagina and cervix for tears (can massage uterus and bimanual compression)

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20
Q

What would you see on examination of pPPH due to thrombin?

A

Be aware: oozing from cannula or wound sites? Coagulopathy

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21
Q

How are PPH managed?

A

C: call for help

R: resuscitate

A: assess

SH: stop haemorrhage

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22
Q

Who should you call for help in a minor PPH?

A

midwife in charge

1st line obstetric and anaesthetic staff

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23
Q

How would you resuscitate after a minor PPH?

A

IV access: 1 x 14G

Blood for FBC, group & screen, Coag screen (+fibrinogen)

Start crystaloid infusion

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24
Q

How would you assess after a minor PPH?

A

HR/BP/RR every 15 min

Cause of haemorrhage

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25
Q

How would you stop a haemorrhage due to a retained placenta?

A

(Ie 3rd stage >30 min)

Manual removal = hand in uterus (regional or general) can separate placenta
2nd hand prevents uterus being pushed up
(IV antibiotics)

26
Q

How else is primary PPH managed?

A

VE (lacerations, uterine inversion): treat same

If no retained placenta, trauma or inversion treat tone problems

27
Q

How are tone problems treated in cases of primary PPH? (7)

A
  • uterine massage or bimanual compression
  • empty bladder
  • syntocinon IV (5IU)
  • ergometrine IV/IM (0.5mg)
  • IV syntocinon (40IU in 500ml normal saline - 125ml/hr)
  • carboprost (PgF2a) IM (up to 8 doses)
  • Misoprostol (rectally)
28
Q

What medication may you consider following the WOMAN trail for the management of pPPH?

A

Tranexamic acid: 1g IV within 3 hrs of delivery = reduces deaths due to bleeding

29
Q

How is pPPH caused by a thrombin issue managed?

A

Manage any apparent Coagulopathie in conjunction with haematologist

30
Q

If all else fails in the management of PPH what do you do?

A

Call surgeons

EUA (retained fragments, tears) +/- PGF2a

31
Q

How does balloon insufflation treat PPH?

A

Ballon - fill with saline, leave in for 12-24 hours. Remove saline in stages (20ml/hour)

32
Q

What cases of PPH is balloon insufflation esp useful in?

A

Placental bed haemorrhage

33
Q

What compression sutures can be used to treat PPH?

A

B–Lynch/brace suture: milton keynes Obgyn. Described in 1997. for atonic uterus. Anterior and posterior walls apposed by vertical brace sutures using delayed absorbable material.

34
Q

What is another surgical method of management of PPH?

A

Uterine artery embolisation

35
Q

What is the last resort surgical management of a PPH?

A

Hysterectomy

36
Q

What are the complications of pPPH? (6)

A
  • anemia
  • sepsis
  • renal failure/ATN
  • DIC
  • Sheehan’s syndrome
  • Death
37
Q

What is Sheehan’s syndrome?

A

Ischaemic necrosis of the anterior pituitary following severe PPH (now rare in western countries)

38
Q

What is the presentation of Sheehan’s syndrome? (4)

A

Variable presentation
-failure of lactation
-fatigue/loss of vigor
-failure to resume menstruation
-later loss of pubic and axillary hair.

39
Q

How is Sheehan’s syndrome treated?

A

Hormonal replacement

40
Q

What is secondary PPH?

A

Excessive bleeding between 24hr and 6 weeks following delivery: Usually at 8-10 days. 1% of all deliveries.

41
Q

What causes secondary PPH? (3)

A

Endometritis +/- retained tissue
+/-displacement of clot

GTN (gestational trophoblastic disease)

Incidental gynae pathology

42
Q

What are the clinical features of sPPH? (5)

A
  • Pv bleeding
  • heavy offensive lochia
  • dyspareunia
  • Fever
  • abdo pain

(Lochia = vaginal discharge after giving birth)

43
Q

What are the clinical features of sPPH seen on examination?

A

Enlarged uterus
If infection – open os, cervical excitation, uterine or adnexal tenderness.

44
Q

What are the investigations needed for secondary PPH?

A

Labs: fbc/inflamm markers/u+e/x-match
HVS
Ultrasound pelvis/TVUS

45
Q

What is the treatment for secondary PPH?

A

Antibiotics (alone initially if chronic)

ERPC if heavy bleeding, open os, RPOC in u/s

46
Q

What is the epidemiology of major primary PPH?

A
  • complicates 1.3% of deliveries
  • usually within 1st hour
  • most common cause = atomic uterus (70-90%)
47
Q

What is the management for major primary PPH?

A

Call for Help
Call
Senior Midwife
Obstetric On call team
Anaesthetic On call team
Porter
Alert
Haematologist
Blood Transfusion service
Theatre Team
Assign
a midwife for communication & documentation

ABC, keep warm
Airway/Breathing
May need intervention if low consciousness level
O2 by mask (10-15litres/min)

Circulation
Elevate legs (autotransfusion)
IV access: 2 x 14 or 16 gauge cannulae
Blood for:
Cross match ( 4-6 units of blood)
Full blood count
Clotting screen (fibrinogen, APTT, PT, D-dimer).
Base line urea and electrolytes and LFTs

Fluid: initially give crystalloids 1000ml each cannula, then 1.5L colloid
(crystalloids: hartmann’s or normal saline)

Massage the uterus/bimanual compression

48
Q

How would you assess a major primary PPH?

A
  1. iMEWS = level of shock
  2. Estimated blood loss
  3. Cause of haemorrhage
49
Q

What would you look at following a major pPPH in the HDU once they have been stabiled?

A

IMEWS
Monitor: pulse, blood pressure, RR, 02 saturation, temp, peripheral perfusion, CNS (every 15 mins)
Catheter in to monitor urine output/fluid balance
(also can inhibit uterine contraction)
Estimated blood loss (weigh swabs, pads, drape)
(Check uterine tone)

50
Q

What are the signs of shock following a major pPPH? (4)

A
  • HR> 100
  • RR>30
  • vasoconstriction
  • BP <100 systolic : 25% of maternal BV

Consider Central line

51
Q

What are the clinical features of shock in pregnancy related blood loss?

A
52
Q

What blood transfusion/products are given for major pPPH?

A

realize that the blood loss is usually underestimated

Blood:
Blood once available
Group specific blood or O rhesus negative if x-match not available when fluids have gone in.
Consider:
(as per Haemotologist)
Fresh frozen plasma if PT or APTT > 1.5x normal
(or 4 units for every 6 units of red cells)
Cryoprecipitate if fibrinogen < 1.5g/L
(RCOG: 1 Litre of FFP + 2 packs of cryoprecipitate while awaiting lab results)
9
Platelet concentrates if platelet level < 50 x 10 / L

53
Q

What are the obstetric causes of DIC? (5)

A
  • APH (especially placental abruption)
  • PPH
  • pre-eclampsia
  • miscarriage (septic)
  • amniotic fluid embolism
54
Q

What should you consider with DIC bloods?

A
  • platelets
  • PT & APTT
  • fibrinogen
  • D-dimers
55
Q

What are the treatment goals in major obstetric haemorrhage?

A

Hb > 8g/dl
Plts> 75 x 10/9 per litre
Pt< 1.5
Appt< 1.5
Fibrogen> 1.5-2 g/dl

56
Q

How should you assess after a haemorrhage?LD you

A

Cause of Haemorrhage (as previous)
Examine placenta: expelled and full
Uterine tone: ? Uterus contracted
Tears/Trauma: perineum, vagina, cervix
Thrombin: oozing from wound/cannula sites

57
Q

How can you stop haemorrhage?

A

Treat any cause identified
Improve the tone:
-Massage/rub contraction
Empty bladder
Oxytocin 5 units (slow iv bolus – can repeat)
Ergometrine 0.5 mg by slow IV injection
Oxytocin infusion 40 units in 500ml at 125ml/hr
Tranexamic acid: 1g (as early as possible alongside
uterotonics)
If fails
Second line
Carboprost: PgF2A 250mcg every 15mins up to 8 doses)
Third line
- Misoprostol rectally (600mcg)

58
Q

If those attempts to stop a haemorhhage are unsuccessful what should then be done?

A

If not successful consider bimanual compression and transfer to theatre
Examination under anaesthesia
Remove retained products
Repair any tear
Bimanual compression
Prostaglandin F2a intramyometrial
(250 ug maximum eight injections / every 20 min.)
Continue bimanual compression (consider aortic compression)
Continue resuscitation and monitoring

59
Q

What is done if there is failure to control the bleeding?

A

Maintain bimanual compression

Team: consultant obstetrician consultant anaesthetist on premises

Repeat blood as before

Central line if was not inserted.

60
Q

What are the options to stop the bleeding?

A

i) Medical:
-Recombinant activated factor VII 40-90 ug/kg.
(novoseven)

ii) Uterine tamponade:
Bakri Balloon
Sengstaken- Blakemore tube
Foley’s/Rusch catheter
Uterine packing

iii) Laparotomy:
Uterine haemostatic suturing techniques:
B- Lynch
Multiple square sutures
Artery ligation:
Bilateral uterine arteries ligation
Bilateral internal iliac arteries ligation Hysterectomy

iv) Selective arterial embolisation.

OBGYN (25 decks)

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