Postpartum Hemorrhage

Question 1

what is PPH?

Answer 1

Cumulative blood loss >1000 mL with s/s of hypovolemia within 24 hours of the delivery

Consider >500mL EBL in vaginal delivery abnormal w/ potential need for tx

Question 2

etiologies for PPH

Answer 2

4Ts
1. Tone - atony, anything causing uterine distention (multiple gestation, polyhydramnios, fetal macrosomia, fast labour, bladder distention), anything preventing uterine muscles from contracting (no oxytocin, prolonged general anesthesia)

2. Tissue - retained placenta, placental disorders, uterine rupture, uterine inversion
3. Trauma - lacerations, tears, c/s, assisted vag delivery
4. Thrombin - coagulation disorders inherited or aquired

Question 3

RF for PPH

Answer 3

previous PPH
high parity
prolonged oxytocin
prolonged GA
multiple gestation
polyhydramnios
fetal macrosomia
fibroids
quick labour
uterine inversion
type of delivery - assisted and c/s

Question 4

s/s of PPH

Answer 4

s/s of shock - pallor, hypotension, tachy, chills

uterine atony: soft, boggy uterus (non-contracted)
uterine inversion: round bulge/mass with palpation of teh fundal wall in cervix of lower uterine segment

DIC: widespread bleeding from venipuncture sites

Question 5

what ix is needed to manage a PPH?

Answer 5

1. CBC
2. electrolytes
3. group (ABO and Rh factor) and screen
4. PT/INR
5. explore uterus for underlying cause – palpation, imaging

Question 6

how do you manage/tx a PPH?

Answer 6

1. stabilize - IV access and fluids
2. give blood products - pRBCs and TXA
3. medicinal management - oxytocin, ergot alkaloids, and prostaglandins
4. consider uterine tamponade - packing or balloon
5. other interventions to tx underlying cause
6. definitive is a hysterectomy
7. consider RhoGAM is mom is Rh-, within 48 hours of delivery

Question 7

what are some potential cx of PPH?

Answer 7

• death
• DIC
• sepsis
• Sheehan syndrome
• AKI