Postpartum Heamorrhage Flashcards
Primary vs Secondary PPH?
Primary PPH: is defined as vaginal bleeding that occurs from delivery of baby to 24 hrs postpartum.
Secondary PPH: is defined as vaginal bleeding from 24 hrs postpartum to 12 weeks postpartum.
PPH can be graded as minor, moderate and severe.
What is it dependent on?
The severity of PPH is dependent on the extent of blood loss and can be divided into minor, moderate or severe. The extent of blood loss in PPH is often underestimated.
Minor: 500-1000mls
Moderate: 1000-2000mls
Severe: > 2000mls.
Major antepartum factors include multiple pregnancy, antepartum haemorrhage and previous history of PPH. Below is a list of the main risk factors for PPH:
Abruption
Placenta praevia
Multiple pregnancy
Pre-eclampsia, gestational hypertension
Previous PPH
Ethnicity (i.e. Asian)
Obesity (i.e. BMI > 30)
Anaemia
Uterine anomalies, fibroids
The main intrapartum factors for PPH include retained placenta, C-section and induction of labour. A list of intrapartum risk factors is shown below:
C-Section (Emergency > Elective)
Induction of Labour (IOL)
Retained placenta
Episiotomy
Instrumental
Prolonged labour
> 4kg baby
Pyrexia in labour
The aetiology of PPH can be remembered as the ‘four T’s’.
The four T’s include Tone, Trauma, Tissue and Thrombin and refer in particular to primary PPH:
Tone (most common): reduction in uterine tone, typically the result of prolonged labour, macrosomia, twins, uterine anomalies or polyhydraminos. ‘Active’ management of the third stage reduces the risk.
Trauma: usually due to episiotomy, extensive perineal tears or uterine rupture.
Tissue: refers to retained placenta and placenta accreta.
Thrombin: refers to either pre-existing or newly developed coagulopathies. Coagulopathies may also result from significant APH or PPH!
General Management of PPH
Observations
Airway/breathing
High flow oxygen
Cardiovascular
Two large-bore Intravenous access
Bloods: FBC, Coag, U&S, LFTs, Crossmatch x4 units
Fluid resuscitation
Disability
Examine: ?trauma ?atony.
Exposure
Amount of blood loss?
Blood glucose level?
Febrile?
Catheter - monitor urine output
Specific Management for PPH
The specific management of a PPH can be divided into interventions aimed to reduce the risk of developing a PPH or stopping a PPH.
Reduce risk:
Anticipate those at higher risk:
Deliver on a doctor-led unit
Intravenous access
Bloods: FBC, G&S, Crossmatch in labour
“Active management of third stage”
Intramuscular Oxytocin.
Controlled cord traction (CCT) of placenta to aid delivery.
Reduces PPH risk by up to 60%.
NOTE: synthetic oxytocin can be used to stimulate contraction of the uterus. Remember a ‘baggy’ atonic uterus is a cause of PPH.
Stopping PPH: (4 THINGS)
Uterine massage: placing one hand on lower abdomen and performing repetitive massage and squeezing movements
Bimanual compression: place one hand on the lower abdomen and one hand in the vagina. Push against the body of the uterus with the hand in the vagina, while the other hand compresses the fundus.
Tranexamic Acid
Massive Obstetric Haemorrhage Call
In the event of a major postpartum haemorrhage, what should happen?
In the event of a major postpartum haemorrhage, the major haemorrhage protocol should be activated throughout switchboard (2222).
Obstetric haemorrhage protocol
Activation of the major haemorrhage protocol means you are alerting blood bank to the need for urgent blood products. A MOH call activates a team of obstetricians, midwives, anaesthetists, theatre, porters, blood bank and haematologists. Immediate access to O- blood can be found on the maternity unit but this is a limited resource.
Once the haemorrhage protocol is activated, a ‘runner’ needs to send an FBC, crossmatch and coagulation screen to blood bank. A blood pack is then sent back to the patient via the ‘runner’ with group-specific blood and fresh frozen plasma. Further products can be acquired following communication with the blood bank.
Obstetric haemorrhage team
Obstetric team (SHO/Reg/Cons)
Anaesthetic team (SHO/Reg/Cons)
Midwifery team (case midwife/Coordinating midwife)
Haematologist on call
Haematology lab
Porter
Theatres
Fluid & blood products in obstetric haemorrhage
Crystalloid: up to 2L Hartmanns.
Colloid: up to 1.5L until blood arrives.
Blood: should be given when available, O-neg, group-specific or cross-matched depending on urgency.
Fresh Frozen Plasma (FFP): 4 units FFP to every 4 units blood (PRC) or if clotting prolonged.
Platelets: if Plt < 75 and bleeding ongoing.
Cryoprecipitate: if Fibrinogen <2.
What is the most common cause of PPH?
Uterine atony is the most common cause of PPH and uterotonic drugs are used to prevent it.
Uterotonic drugs
These medications work by increasing the force and frequency of smooth muscle contraction within the uterus.
Syntocinon
Oxytocin
5-10 iU IM/IV and 40 iU infusion.
Ergometrine
Ergot alkaloid
0.5mg IM/IV
Avoid if HTN.
Carboprost
Prostaglandin PGF2α
0.25mg IM every 15mins, up to x8
Avoid if asthma.
Misoprostol
Prostaglandin PGE1
800mcg PR or SL.
In the event that uterotonic medications are ineffective in obstetric haemorrhage, or bleeding cannot be stopped, surgical intervention needs to be considered.
Examination under anaesthesia (EUA): look for retained membranes/placenta.
Repair tear
Intrauterine balloon
Brace suture (i.e. B-Lynch suture): compression suture used to mechanically compress an atonic uterus.
Uterine artery embolization/ligation: liaise with the interventional radiology department.
Hysterectomy: last resort if all other measures fail.
