Postpartum_Haemorrhage_Flashcards
What is postpartum haemorrhage (PPH)?
PPH is defined as blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.
When does primary postpartum haemorrhage occur?
Within 24 hours. It affects around 5-7% of deliveries.
What are the 4 Ts causes of primary PPH?
Tone (uterine atony): the vast majority of cases, Trauma (e.g., perineal tear), Tissue (retained placenta), Thrombin (e.g., clotting/bleeding disorder).
What are the risk factors for primary PPH?
Previous PPH, prolonged labour, pre-eclampsia, increased maternal age, polyhydramnios, emergency Caesarean section, placenta praevia, placenta accreta, macrosomia, nulliparity.
What is the management for primary PPH?
PPH is a life-threatening emergency - senior members of staff should be involved immediately. ABC approach, two peripheral cannulae, 14 gauge, lie the woman flat, bloods including group and save, commence warmed crystalloid infusion.
What are the mechanical management steps for primary PPH?
Palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’), catheterisation to prevent bladder distension and monitor urine output.
What are the medical management options for primary PPH?
IV oxytocin: slow IV injection followed by an IV infusion, ergometrine slow IV or IM (unless there is a history of hypertension), carboprost IM (unless there is a history of asthma), misoprostol sublingual, interest in the role of tranexamic acid.
What are the surgical management options for primary PPH?
Intrauterine balloon tamponade, B-Lynch suture, ligation of the uterine arteries or internal iliac arteries, hysterectomy if severe and uncontrolled haemorrhage.
When does secondary postpartum haemorrhage occur?
Between 24 hours - 12 weeks.
What are the common causes of secondary PPH?
Typically due to retained placental tissue or endometritis.
summarise
Postpartum haemorrhage
Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.
Primary postpartum haemorrhage
Primary PPH occurs within 24 hours. It affects around 5-7% of deliveries.
The causes of PPH are said to be the 4 Ts:
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
Risk factors for primary PPH include*:
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
Management
PPH is a life-threatening emergency - senior members of staff should be involved immediately
ABC approach
two peripheral cannulae, 14 gauge
lie the woman flat
bloods including group and save
commence warmed crystalloid infusion
mechanical
palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
catheterisation to prevent bladder distension and monitor urine output
medical
IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)
carboprost IM (unless there is a history of asthma)
misoprostol sublingual
there is also interest in the role tranexamic acid may play in PPH
surgical: if medical options fail to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Secondary postpartum haemorrhage
Secondary PPH occurs between 24 hours - 12 weeks. It is typically due to retained placental tissue or endometritis.
You are called to see a lady who has delivered her second child 2 hours ago. The baby was term, weighed 4.1kg, and was healthy. The labour was natural, lasted 6 hours, and she chose to have a physiological third stage. The nurse tells you she thinks she has lost approximately 800ml of blood, but her observations are stable and the bleeding appears to be slowing.
What is the most common cause of her blood loss?
Birth trauma
Uterine atony
Normal post partum blood loss
Retained placenta
Anticoagulant use
Uterine atony
The most common cause of PPH by far is uterine atony
Primary postpartum haemorrhage is defined as the loss of 500ml or more from the genital tract within 24 hours of the birth of a baby. This can be further defined as minor haemorrhage (500-1000ml) or major haemorrhage (>1000ml), and causes 6 deaths/million deliveries.
Causes can be grouped into the ‘four T’s’:
tone
tissue (retained placenta)
trauma
thrombin (coagulation abnormalities)
A 36-year-old multiparous patient has an uncomplicated delivery at 39 weeks gestation. One hour following delivery, the patient develops severe post partum haemorrhage which is acutely managed in the labour ward. Seven weeks later, the patient presents with difficulty breastfeeding due to a lack of milk production. Which of the following conditions is most likely to explain this history?
Hyperprolactinaemia
D2 receptor antagonistic medication
Pituitary adenoma
Sheehan’s syndrome
Asherman’s syndrome
Sheehan’s syndrome
This clinical history suggests Sheehan’s syndrome. Sheehan’s syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan’s syndrome is a lack of postpartum milk production and amenorrhoea following delivery. Diagnosis of Sheehan’s is by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.
The other options of hyperprolactinaemia, D2 receptor antagonistic medication, and pituitary adenoma are causes of galactorrhoea and not of a lack of milk production. Asherman’s syndrome is seen as adhesions and fibrosis of the endometrial cavity most commonly associated with dilation and curettage procedures.
[Source: Dokmeta, HS., Kilicli, F., Korkmaz, S., et al. (2006) Characteristic
features of 20 patients with sheehan’s syndrome. Gynecol Endocrinol 2006;22:27983. Retrieved from: RCOG Greentop Guideline No. 52, Prevention and Management of Postpartum Haemorrhage ]
A 25-year-old woman (G1P1) undergoes a vaginal delivery at 39 weeks gestation, followed by a physiological third stage of labour. In the hours following, she has some brown mucousy vaginal discharge with blood in it, producing approximately 100ml of blood.
On examination, the patient has a GCS of 15, a soft but tender abdomen. Her blood pressure is 132/83 mmHg, her pulse is 86 bpm, her temperature is 36.5C.
What is the most appropriate next step in her management?
Abdominal ultrasound
Give IV oxytocin
Give IV tranexamic acid
Palpate the uterus and catheterise
Provide sanitary pads
Provide sanitary pads
Postpartum haemorrhage is defined as blood loss of 500 ml after a vaginal delivery
Provide sanitary pads is correct. This patient has lost <500 ml of blood within 24 hours of delivery and is showing no signs of circulatory shock making it unlikely for the diagnosis to be a primary postpartum haemorrhage (PPH). The patient is more likely to be producing lochia, a combination of mucus, uterine tissue, and blood that is common after childbirth. This should reduce over the following days but can continue for up to 12 weeks.
Palpate the uterus and catheterise is incorrect. This patient has lost <500 ml of blood within 24 hours of delivery, making the diagnosis of PPH unlikely. The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that in all cases of PPH, an ABCDE approach should be carried out initially, along with gaining IV access and sending blood samples for testing, including group and save. Since uterine atony is by far the most common cause of PPH, the first step in management is known as mechanical management and involves palpating the uterus to stimulate contractions and catheterising to prevent bladder distention, which is indicated in this patient.
Give IV oxytocin is incorrect. This would be appropriate if palpation of the uterus had been tried without success. This patient has no indications for palpation yet, which is done before starting medical management and so is inappropriate.
Abdominal Ultrasound is incorrect. Although a useful investigation to identify retained products this patient has no indications for this and only has mild bleeding.
Give IV tranexamic acid is incorrect. Although tranexamic acid may be considered for use in PPH, it is given alongside medical management such as IV oxytocin, which is given after uterine palpation. This patient has not had uterine palpation tried yet as they currently are not showing signs of PPH.
A 24-year-old woman undergoes a vaginal delivery at 39 weeks gestation and opts for a physiological third stage of labour. Shortly after, she loses 700 ml of blood. Help is called for and an obstetric consultant carries out an ABCDE approach and commences a warmed crystalloid infusion. She has no past medical history, nor has there been any trauma during delivery.
What is the most appropriate next step in her management?
Compress the uterus and catheterise her
Give IM carboprost
Give IV carboprost
Give IV oxytocin
Intrauterine balloon tamponade
Compress the uterus and catheterise her
Following an ABC approach, initial steps to manage a postpartum haemorrhage include palpating the uterine fundus and catheterising the patient
Compress the uterus and catheterise her is correct. This patient is likely to be experiencing a primary postpartum haemorrhage (PPH) which is characterised by >500 ml blood loss within 24 hours of delivery. The most common cause of PPH is uterine atony. The initial steps of managing PPH involve an ABCDE approach and giving IV warmed crystalloid. The next most appropriate step would be to compress the uterus (rub up the uterus) which can stimulate contractions and catheterise the patient to prevent bladder distention and monitor urine output. This is known as ‘mechanical management’.
Give IV oxytocin is incorrect. This is a medical management step and would be appropriate if mechanical management (compressing the uterus and catheterising the patient) was unsuccessful. Given that this patient has not yet had any mechanical management steps tried, this stop may not be necessary and compression of the uterus and catheterisation should be tried first.
Give IM carboprost is incorrect. Similarly to the above, this is another medical management option that should be considered if mechanical methods fail. Given that this patient has had no mechanical methods tried yet, this may not be necessary and compression and catheterisation should be tried first.
Give IV carboprost is incorrect. Carboprost is given intramuscularly and is not administered intravenously as it can lead to bronchospasm, hypertension, and anaphylaxis if given intravenously.
Intrauterine balloon tamponade is incorrect. This is the first-line ‘surgical’ option for the management of PPH where mechanical and medical methods have failed. Given that this patient has not yet tried either, it would be inappropriate to jump to this step as it may not be necessary and mechanical methods alone may be sufficient.
