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Obstetrics > PPH > Flashcards

PPH Flashcards

1
Q

Define PPH according to mode of birth and severe/very severe and Hct.

A

> /= 500mls VB
/= 1000mls CS
Severe >/= 1000mls; very severe >/= 2500mls

Can be retrospectively diagnosed by a 10% decline in postpartum haematocrit.

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2
Q

When would you transfuse as determined by Hb drop?

A

folllowing postpartum Hb of less than 80g/L

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3
Q

What are the subclassifications of PPH?

A

3rd stage: haemorrhage a/w retained, trapped or adherent placenta
Other immediate: haemorrhage following delivery of placenta, postpartum haemorrhage (atonic)
Delayed and secondary: haemorrhage a/w reatined portiosn of placenta or membranes.
Postpartum coagulation defects: postpartum afibrinogenaemia or fibrinolysis.

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4
Q

What is the aetiology of PPH and % (4)?

A

Tone (70%)
- atonic uterus
Trauma (20%)
- Lacerations of the cx, vagina and perineum
- Extension lacerations at CS
- Uterine rutpure or inversion
- Non-genital tract trauma (e.g. subcapsular liver rupture)
Tissue (10%)
- retained products, placenta (cotyledon or succenturiate lobe), membranes or clots, abnormal placenta
Thrombin (< 1 %)
- coagulation abnormalities

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5
Q

Describe your initial resuscitation response to a PPH?

A

DRSABC ( as relevant)
Ax:
- rate and volume of bleeding
- lie flat, oxygen 15L/min, keep warm
- continuous HR and SpO2, Q15 mins BP and temp
- Ensure routine 3rd stage oxytocic given
- 4Ts

Urgent bloods:

  • FBC, chem20, coags, blood gas
  • X-match if none current

Initial fluid resuscitation

  • Used warmed fluids
  • PIVC (x2) 14-16G
  • avoid crystalloid IV > 1-2L
  • IDC- monitor ouput and maintain accurate fluid balance
  • if indicated, 2 units RBC (Onegative or group specific)

Tranexamic acid 1g IV over 10 mins.

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6
Q

Outline how you would evaluate the 4Ts and what your management (including surgical mng if required)?

A

‘Tissue’: placenta out + complete:

  • Apply CCT and attempt delivery
  • Transfer to OT if placenta adherent/trapped OR cotelydon and membranes missing.
  • > Sx: MROP

‘Tone’: Fundus firm?

  • Massage fundus/expel uterine clots
  • Empty bladder (IDC may be required)
  • First line drugs:
    • > oxytocin 5IU IV over 1-2 minutes
    • > ergometrine 250mcg IM or IV over 1-2 minutes
    • > Oxytocin 5-10units per hour IV infusion (30IU in 500ml @ 83-167ml/hr)
    • > misoprostal 800-1000mcg PR

2nd line drugs:
15-methylprostaglandin F2a (carboprost) 250mcg IM or 500 mcg intramyometrial

Surgical option: intrauterine balloon tamponade
Laparotomy: 
 - Interim aortic compression
- B-Lynch compression suture
- Bilateral uterine artery ligation 
- angiographic embolisation
- hysterectomy (consider early).
'Trauma': genital tract infection
 Inspect cx, vagina, perineum
Clamp obvious arterial bleeders
Repair - secure apex
Transfer to OT if unable to access site 
Sx: OT, secure apex, optimise exposure
'Thrombin' blood clotting? keep warm, check ionised calcium
Intrauterine balloon tamponade
Bilateral uterine artery ligation
Angiographic embolisation or 
Hysterectomy

Unknown cause:
-> laparotomy - EUA

Postnatal care:

  • VTE
  • Treat anaemia
  • psychological support
  • f/u and self-care
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7
Q

RFs for PPH? (not exhaustive)

A

PET (thrombin)

previous PPH (tone)
Uterine fibroid (tone)
ART (?)
Multiple gestations (tone)
Polyhydramnios (tone)
Prolonged 2nd stage/failure to progress (tone)
Prolonged 3rd stage (tone)Precipitate labour (tone)
perineal trauma
Macrosomia (tone)
CS in labour (trauma)
Abnormal placentation
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8
Q

A women requires an anatenatal blood transfusions. What must you ensure?

A

ensure blood is CMV antibody negative (specify on request)

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9
Q

You are reviewing a woman antenatally and she is a Jehovah witness. What other derivates of blood products could you offer her in the event of a PPH?

A

Albumin solutions, cryprecipitate, clotting factor concentrates (including fibrinogen) and immunoglobulins

Intraoperative cell salvage?

Hysterectomy is the definitive procedure for minimise life-threatening haemorrhage when transfusion is not an option.

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10
Q

In preventing PPH, what things should you discuss with a women antenatally?

A

Planned location of birth
Optimisation of pre-birth Hb
Identification of placental site
Recommendation for active mng of 3rd stage of labour.
Recognition of the risk of uterine atonia a/w delay in first and second stages of labour and corrective measures(e.g. intrapartum oxytocin infusion and assisted/operative birth).
Discuss blood products

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11
Q

In what circumstance may you decide to cross match blood?

A

when clinically significant antibodies are present on a group and save

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12
Q

Which uterotonic is the drug of choice for active third stage mng of labour? What are the doses for by VB or CS?

A

Oxytocin
VB: 10U IM
CS: oxytocin 5U IV over 1-2 minutes

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13
Q

What must you always ensure to do when applying controlled cord traction? What does this prevent?

A

Suprapubic counter pressure PRIOR to CCT

To prevent uterine inversion.

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14
Q

For women requesting physiological third stage mng, when would you recommend active mng?

A

Excessive bleeding
Delay in placental birth greater than one hour
Woman requests to shorten third stage

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15
Q

What is syntometrine?

A

ergometrine 500mcg and oxytocin 5 units, given as 1ml IM injection for active mng of 3rd stage.

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16
Q

What significant adverse side effect is associated with syntometrine?

A

Nausea

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17
Q

What is one of the practical benefits of carbetocin?

A

Stable at room temperature.

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18
Q

Describe postnatal risk management for PPH

A

actively encourage/assist women to void soon after birth
Promote endogenous release of oxytocin by:
- Keeping the woman warm and calm post birth
- assisting with early breast feeding (if preferred feeding method)
- facilitating skin to skin contact with baby.

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19
Q

When would you suspect puerperal haematoma?

A

Suspect if:

  • unable to identify the cause of PPH (4Ts) and/or
  • Hallmark sign is excessive or persistent pain
    • tachycardia is an early sign
  • Other signs
    • abnormal vital signs
    • hypovolaemic shock disproportionate to the revealed blood loss
    • feelings of pelvic or rectal pressure
    • Urinary retention
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20
Q

What would make you think that there was retained POC causing PPH?

A

fundus atonic and unresponsive to uterotonics

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21
Q

You have not been able to identify any of the 4 Ts as a cause for PPH. What are your unknown causes of PPH?

A

Uterine rupture/inversion
concealed bleeding (e.g. vault haematoma)
Non-genital causes (e.g. subcapsular liver rupture)

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22
Q

If transfusion required for PPH, how much and what type of blood should you use?

A

2 units of RBC (O negative of group specific unavailable)

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23
Q

Oxytocin is first line for uterine atony. What does, by which route of administration and how frequently (including max dose) can you give?

A

Oxytocin 5IU IV over 1-2 minutes.
Can repeat dose after 5 mins.
Max dose: 10IU IV

Oxytocin infusion: 30IU in 500mls 0.9% NaCl or Harmannn’s.
-> administer 5-10IU per hr via infusion pump (equates to 83-167mls per hour of oxytocin 30U in 500mls).
(over 4 hours is common)

24
Q

What are some adverse side-effects of oxytocin administration?

A

Hypotension, tachycardia, arrhythma and myocardial ischaemia

25
Q

What type of drug is carbetocin and oxytocin?

A

Oxytocin is a synthetic pituitary hormone which stimulates uterine contraction.
Carbetocin is an oxytocin analogue.

26
Q

By what means can you administer ergometrine?

A

IM and IV

27
Q

What type of drug is ergometrine?

A

An ergot alkaloid. Stimulates contraction of uterine smooth muscle.

28
Q

What does of IM ergometrine can you give and how frequently?

What is the max dose.

A

250mcg IM
Repeat after 5 mins.
MD: 500mcg to 1000 microgs.

29
Q

What is the dose of IV ergometrine for PPH?

A

250mcg-500mcg IV over 1-2 mins.
- > dilute 250mcg to 5mls of 0.9% NaCl
May repeat every 2-3 mins to max 250mcg to 1mg

30
Q

What are the C/I to ergometrine? (6)

when administering ergometrine, what should you think to administer at the same time?

A 
retain placenta
PET
Severe/persistent sepsis
Renal disease
hepatic disease
cardiac disease

-> anti-emetic.

31
Q

By what means can you administer misoprostal for PPH?

A

S/L or PR

32
Q

What dose of misoprostal can you give S/L or PR?

How often?

A

800-1000mcg (either toue)

repeated doses not recommended.

33
Q

What are some prescribing considerations with regards to misoprostol?

A

Not LAM approved as first line medication.

Increases pyrexia greater than 38C

34
Q

How long does misoprostol take to work?

A

1- 2.5 hours (therefore early administration may help sustain uterine tone achieved through other first line drugs)

35
Q

What can you use for 2nd line agent for uterine atonia?

What is the dose , by what means, how often and MD?

A

Carboprost 250mcg IM
Repeat prn Q15-90 mins (not less than 15mins intervals)
Max dose: 2mg (8 doses)

Can also be given intramyometrial, 500mcg. (manufacturer does not recommend intramyometrial use..prescribed at clinicians discretion).

36
Q

What should you do before administering carboprost?

A

O2 therapy

monitor HR< O2 sats, BP

37
Q

A women has intractable bleeding during a PPH. She is rushed to OT with bimanual compression. The bleeding has settled somewhat with bimanual compression. What surgical intervention may this lead you to try?

A

Bakri (intrauterine balloon tamponade)

38
Q

What surgical procedures can be employed for intractable PPH?

A

Laparotomy
Aortic compression (below the level of the renal arteries as a temporising measure)
Maintain uterine contraction
- > Consider B-Lynch compression suture.
If compression or tamponade unsuccessful, consider:
- > bilateral uterine artery ligation
- >bilateral utero-ovarian artery ligation.
- > if expertise available, bilateral internal ilaiac artery ligation.
Perform hysterectomy (early if life threatened)

39
Q

What are risk factors for cervical trauma leading to PPH?

A

precipitous labour
Assisted vaginal birth.
cervical suture.

40
Q

What are some risk factors for uterine rupture?

A 
Previous uterine sx or CS
Oxytocin administration
malpresentation or undiagnosed cephalopelvic disproportion
dystocia during 2nd stage of labour
Grand multiparity
macrosomic fetus
Placenta percreta
Uterine abnromalities (e.g. rudimentary horn)
41
Q

What are some maternal and fetal S&S of uterine rupture?

A

Maternal:
tachycardia and signs of shock, sudden SOB, constant abdominal pain, possible shoulder tip pain, uterine/suprapubic tenderenss, change in uterine shape, pathological Bandl’s ring

Fetal:
abnormal CTG tracing, loss of fetal station.

If haematuria, rupture may have extended into the bladder (concern in postpartum period)

42
Q

What are RFs for uterine inversion?

A 
Uterine over distension
Invasive placentation
Short umbilical cord/excessive umbilical cord traction
Tocolysis
Oxytocin use
Primiparity
Manual extraction of the placenta
43
Q

What is the presentation of uterine inversion?

A

Sudden onset of PPH
Irregularly shaped or absent palpable fundus
A completely inverted uterus may appear as a bluish grey mass at the introitus
Haemodynamic instability
Excruciating pain and hypovolaemic shock disproportionate to revealed blood loss.

44
Q

How do you dx uterine inversion?

What is the success rate for non-surgical measures for correcting uterine inversion.?

A

Use bimanual examination to locate the uterine fundus in the lower uterine segment or vagina.
Non-surgical measures reported successful in 99 out of 102 uterine inversiosn.

45
Q

What do you need to do before manually correcting an inverted uterus?
What do you do if placenta still in situ

What drugs might you use to relax the cervical ring to facilitate replacement.

A

case oxytocin infusion if running, replacement requires a relaxed uterus.
If placenta in situ leave in place for manual removal in OT.

Drugs:

  • GTN 400 mcg spray
  • terbutaline 250mcg s/c or IV
  • Mg SO4- 4g IV infusion over 5 mins
46
Q

‘Tissue’ can include which types of tissue in the uterus? And how would you deal with each..?

A

Clots in the uterine cavity due to uterine atonia - > massage fundus firmly then take steps to prevent further atonia

Trailing membranes: Use sponge holders to clamp membranes extending beyond teh introitus, without traction, roll forceps to create a rope of membranes.
- Move forceps in an up and down motion and apply gentle traction
- Maternal pushing may assist in removal
Once trailing membranes delivered:
- Perform vaginal examination (VE)
- If membranes present attempt delivery with fingers or forceps.
-Observe uterine tone and blood loss
- If large amount of membranes retained - transfer to OT for manual removal.

Retained placenta:

  • Insert in/out urinary cather or indwelling cather.
  • Ensure prophylactic 3rd stage uterotonic has been given.
  • Reattempt CCT and consider additional oxytocin (10IU IV or IM) if woman bleeding excessively.
  • Maternal pushing and repositioning may assist delivery.
  • Check RFs for abnormal placentation
  • If available, portable US may assist in placental location.
  • Can transfer to OT with bimanual compression if required.
47
Q

Which uterotonic is not recommended for ‘tissue’

A

Ergometrine: as tetanic contractions may delay placental expulsion.
Dinoprostone (prostaglandin E2 alpha)
Oxytocin IV infusion to assist the birth of placenta
Use of umbilical vein for oxytocin injection and/or misoprostol

48
Q

When would you begin to suspect that thrombin was an issue leading to PPH?

A

Oozing from puncture/cannulation/injection sites or surgical field
Haematuria
Petechial, subconjunctival and mucosal haemorrhage
Blood that no longer clots
Uterine atonia secondary to increased fibril degradation products
Temperature less than 35C

49
Q

How would you correct coagulopathy?

A

Transfuse RBC 4 units
Fibrinogen concentrate or cryoprecipitate to maintain fibrinogen level greater than 2.5g/L
FFP 2 units (aim > 50)
Platelets to maintain platelet level greater than 50 x 10^9

50
Q

Which component of blood coagulation falls the earliest ?

A

fibrinogen falls earlier than other coagulation factors and may be low despite normal PT/APTT.

Fibrinogen/fibrin deficiency (and not thrombin) is the major informative marker for the severity of haemorrhage.
Level of 2g/L or less is a/w progression of bleeding, increased RBC and blood component requirement and need for invasive procedures.

51
Q

What is the ‘lethal triad’?

A

coagulopathy, acidosis and hypothermia.

Mortality is increased

52
Q

When should you commence treatment with IV calcium with PPH?

A

When ionized calcium is less than 1.1 mmol/L, include IV 10% calcium gluconate 10ml

(citrate from transfused blood often causes hypocalcaemia)

53
Q

With which conditions is DIC associated?

A 
placental abruption
Severe PET or HELLP
acute fatty liver of pregnnacy
amniotic fluid emboism
fetal death in utero
septicaemia
dilutional coagulopathy 2* to massive transfusion
54
Q

What is criteria for activating the massive haemorrhage protocol?

A

Woman is actively bleeding and has one or more of the following criteria:

  • Major obstetric bleed (i.e. estimated blood loss > 2500mls)
  • actual or anticipated 4 RBC units in less than 4 hours + haemodynamic instability
  • clinical or laboratory evidence of coagulopathy
55
Q

Following PPH, when should you repeat Hb levels?

A

At 6 hours and then in 24 hours.

56
Q

A woman who had a PPH is unable to lactate and/or has persistent hypotension. What dx should you consider?

A

Sheehan’s syndrome

Obstetrics (14 decks)

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