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OB > Postpartum Hemorrhage > Flashcards

Postpartum Hemorrhage Flashcards

1
Q

What is the definition of postpartum hemorrhage?

A

Excessive bleeding during or following the 3rd stage of labour that affects the general condition of the patient
- vaginal birth: >500ml
- C section: > 1000ml

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2
Q

What are the types of post-partum hemorrhage?

A

PRIMARY
- during 3rd stage of labour or within 24hrs after delivery

SECONDARY
- after the 1st 24hrs from delivery till the end of puerperium (6 weeks)

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3
Q

What are the causes of postpartum hemorrhage?

A

PRIMARY
- tone
- tissue
- trauma
- thrombin

SECONDARY
- retained placental fragment
- infections
- submucous fibroid polyp
- choriocarcinoma
- local lesion
- puerperal inversion
- E-withdrawal bleeding

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4
Q

What are the pathological causes of tone dysfunction & their risk factors?

A

1- Over-distended uterus
- polyhydramnios
- multiple gestation
- macrosomia

2- muscle exhaustion
- prolonged labour
- high parity
- precipitate labour

3- intra-amniotic infections
- systemic fevers
- prolonged PROM

4- uterine distortion
- congenital anomalies
- fibroid uterus
- prolonged tocolytics

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5
Q

What are the pathological causes of tissue dysfunction & their risk factors?

A

1- retained products of conception
- incomplete placenta or fetal membranes at delivery
- previous uterine surgery

2- abnormal placenta
- placenta Previa
- placenta accreta

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6
Q

What are the pathological causes of trauma & their risk factors?

A

1- uterine inversion
- high parity
- fundal placenta
- cord traction

2- lacerations
- precipitate labour
- instrumental delivery
- rigid perineum

3- extension of Caesarian incision
- deep fetal engagement
- fetal malposition

4- uterine rupture -> previous surgery

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7
Q

What are the pathological causes of thrombin dysfunction & their risk factors?

A

1- inherited -> Hemophilia A, Von Villebrand’s Deficiency
- history of coagulopathies or liver disease

2- acquired -> ITP, HELLP, DIC
- pre-eclampsia
- IUFD
- severe infection
- placental abruption
- amniotic fluid embolism

3- therapeutic -> anticoagulants
- history of DVT or pulmonary embolism

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8
Q

What are the symptoms of retained placenta in case of PPH?

A

1- placenta not delivered
2- placenta delivered
- bleeding without pain -> atony
- bleeding with pain -> traumatic
- severe pain -> inversion
- fluid blood with no clots -> coagulopathy

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9
Q

What will be the clinical picture of a patient with PPH?

A

1- Compensated: postural hypotension
- HR < 100
- SBP is normal
- blood loss 750-1000cc

2- Mild: increased PR + thirst + weakness -
- HR 100-120
- SBP: slight fall
- blood loss 1000 - 1500cc

3- Moderate: pallor, oliguria, confusion
- HR 120 - 140
- SBP 80 - 60
- blood loss 1500 - 2000cc

4- Severe: Anuria, air hunger, coma, death
- HR >140
- SBP 60 - 40
- blood loss > 2000cc

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10
Q

What is the clinical picture of hemorrhagic shock?

A
  • tachycardia
  • rapid weak pulse (thready)
  • hypotension
  • pallor
  • cyanosis of fingers
  • cold clammy sweat
  • oliguria or anuria
  • dimness of vision
  • mental confusion
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11
Q

How is diagnosis of PPH suspected?

A

ABDOMINAL EXAM
- uterus is large & lax -> atonic bleeding
- uterus is contracted -> traumatic bleeding

VAGINAL EXAM
- amount of bleeding & color
- biannual examination to assess uterine size & shape
- exploration of lower genital tract for any lesions

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12
Q

What is the difference between atonic & traumatic PPH?

A

ATONIC
- soft lax uterus
- fundal level is high
- degree of shock is not proportionate with amount of vaginal bleeding
- predisposing factor for uterine atony

TRAUMATIC
- hard, globular uterus
- fundal level corresponds to date
- degree of shock is proportionate to amount of vaginal bleeding
- history of difficult labour or instrumental delivery

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13
Q

What are the complications of PPH?

A
  • anemia
  • shock
  • renal failure
  • Sheehan’s syndrome
  • Asherman’s syndrome
  • DIC
  • thrombo-embolism
  • transfusion reaction / hepatitis
  • postpartum infections
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14
Q

What are the uterotonic drugs used for prevention of PPH?

A

OXYTOCIN
- acts within 2 mins & lasts 30 mins when give IM
- safe in HTN

METHERGINE
- acts within 4 mins & lasts 4 hours when given IM
- causes tonic contractions
- increases risk of hypertension, vomiting, & headache

MISOPROSTOL

CARBETOCIN (analog of oxytocin)

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15
Q

How is primary PPH managed?

A

1- Resuscitation
- 2 wide IV lines -> 16 cannulae
- Fluid replacement -> colloids or crystalloids 1000ml, fresh blood, or FFP
- warmth
- O2 inhalation
- hydrocortisone 100mg IV
- antibiotics
- foot of bed slightly elevated or anti-shock garments

2- Monitor vital signs

3- Cross match 6 units of blood & clotting screening

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16
Q

How is placental hemorrhage managed before delivery of placenta?

A

1- give oxytocin + massage uterus gently
2- umbilical vein injection (oxytocin)
3- deliver placenta actively
- Brandt-Andrew’s method
- Crede method
- Manual removal under GA

17
Q

What should be suspected in case of failure of manual removal of placenta under GA?

A

1- uterine rupture -> hysterectomy OR cut cord short + methotrexate

2- constriction ring -> acute tocolysis (terbutalline SC) then complete manual delivery

3- placenta accreta spectrum -> hysterectomy OR cut cord short + methotrexate

18
Q

How is post partum hemorrhage managed after delivery of placenta?

A

1- inspect placenta & fetal membranes for any missing part
2- massage uterus & give methergin
3- if no response -> explore cavity manually under GA
4- if atony persists -> bimanual compression under GA (5-30mins)
5- intra-myometrial injection of PG-F2a
6- uterine tamponade
7- Transcatheter arterial embolization
8- exploratory laparotomy

19
Q

What are the advantages of transcatheter arterial embolization?

A
  • ease of bleeder detection
  • rapid control of hemorrhage
  • lower incidence of re-bleeding
  • avoidance of surgical risks
  • fertility preservation
  • shorter hospitalization
20
Q

What are the techniques used in exploratory laparotomy to control hemorrhage?

A

1- haemostatic suturing techniques
- B-Lynch Suture (C section)
- Hayman suture (vaginal delivery)
- Cho multiple square sutures

2- Artery ligation -> ovarian, then uterine, then internal iliac

3- emergency hysterectomy

21
Q

How is DIC managed?

A

1- Fresh blood transfusion
2- coagulation factor VII
3- Fibrinogen 4 - 10 gms IV
4- FFP -> initial 4 units then 1 unit/6 units RBCs
5- antifibrinolysis: tranexamic acid
6- maintain INR <1.5 control

22
Q

How is secondary PPH managed?

A

1- blood transfusion if severe
2- Methergin & antibiotics
3- Surgical removal of retained products
4- treat any local genital tract cause

OB (42 decks)

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