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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
How would you stop a haemorrhage due to a retained placenta?
(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
How else is primary PPH managed?
VE (lacerations, uterine inversion): treat same If no retained placenta, trauma or inversion treat tone problems
27
How are tone problems treated in cases of primary PPH? (7)
* 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
What medication may you consider following the WOMAN trail for the management of pPPH?
Tranexamic acid: 1g IV within 3 hrs of delivery = reduces deaths due to bleeding
29
How is pPPH caused by a thrombin issue managed?
Manage any apparent Coagulopathie in conjunction with haematologist
30
If all else fails in the management of PPH what do you do?
Call surgeons EUA (retained fragments, tears) +/- PGF2a
31
How does balloon insufflation treat PPH?
Ballon - fill with saline, leave in for 12-24 hours. Remove saline in stages (20ml/hour)
32
What cases of PPH is balloon insufflation esp useful in?
Placental bed haemorrhage
33
What compression sutures can be used to treat PPH?
**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
What is another surgical method of management of PPH?
Uterine artery embolisation
35
What is the last resort surgical management of a PPH?
Hysterectomy
36
What are the complications of pPPH? (6)
* anemia * sepsis * renal failure/ATN * DIC * Sheehan’s syndrome * Death
37
What is Sheehan’s syndrome?
Ischaemic necrosis of the anterior pituitary following severe PPH (now rare in western countries)
38
What is the presentation of Sheehan’s syndrome? (4)
Variable presentation -failure of lactation -fatigue/loss of vigor -failure to resume menstruation -later loss of pubic and axillary hair.
39
How is Sheehan’s syndrome treated?
Hormonal replacement
40
What is secondary PPH?
Excessive bleeding between 24hr and 6 weeks following delivery: Usually at 8-10 days. 1% of all deliveries.
41
What causes secondary PPH? (3)
Endometritis +/- retained tissue +/-displacement of clot GTN (gestational trophoblastic disease) Incidental gynae pathology
42
What are the clinical features of sPPH? (5)
* Pv bleeding * heavy offensive lochia * dyspareunia * Fever * abdo pain (Lochia = vaginal discharge after giving birth)
43
What are the clinical features of sPPH seen on examination?
Enlarged uterus If infection – open os, cervical excitation, uterine or adnexal tenderness.
44
What are the investigations needed for secondary PPH?
Labs: fbc/inflamm markers/u+e/x-match HVS Ultrasound pelvis/TVUS
45
What is the treatment for secondary PPH?
Antibiotics (alone initially if chronic) ERPC if heavy bleeding, open os, RPOC in u/s
46
What is the epidemiology of major primary PPH?
* complicates 1.3% of deliveries * usually within 1st hour * most common cause = atomic uterus (70-90%)
47
What is the management for major primary PPH?
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
How would you assess a major primary PPH?
1. iMEWS = level of shock 2. Estimated blood loss 3. Cause of haemorrhage
49
What would you look at following a major pPPH in the HDU once they have been stabiled?
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
What are the signs of shock following a major pPPH? (4)
* HR> 100 * RR>30 * vasoconstriction * BP <100 systolic : 25% of maternal BV Consider Central line
51
What are the clinical features of shock in pregnancy related blood loss?
52
What blood transfusion/products are given for major pPPH?
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
What are the obstetric causes of DIC? (5)
* APH (especially placental abruption) * PPH * pre-eclampsia * miscarriage (septic) * amniotic fluid embolism
54
What should you consider with DIC bloods?
* platelets * PT & APTT * fibrinogen * D-dimers
55
What are the treatment goals in major obstetric haemorrhage?
Hb > 8g/dl Plts> 75 x 10/9 per litre Pt< 1.5 Appt< 1.5 Fibrogen> 1.5-2 g/dl
56
How should you assess after a haemorrhage?LD you
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
How can you stop haemorrhage?
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
If those attempts to stop a haemorhhage are unsuccessful what should then be done?
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
What is done if there is failure to control the bleeding?
Maintain bimanual compression Team: consultant obstetrician consultant anaesthetist on premises Repeat blood as before Central line if was not inserted.
60
What are the options to stop the bleeding?
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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