PPH Flashcards
What does post partum haemorrhage refer to?
-bleeding after delivery of baby and placenta
How much blood must be lost to be classified as PPH?
- 500ml after vaginal delivery
- 1000ml after c section
What can PPH be classified into?
- minor PPH - <1000ml
- major PPH -> 1000ml (subclassified into moderate PPH 1000-2000ml and sever >2000ml)
- primary PPH: within 24hrs of birth
- secondary PPH: from 24hrs to 12 weeks after birth
What are the causes of PPH?
4 Ts:
- Tone (uterine atony -most common cause)
- Trauma (e.g perineal tear_
- Tissue (retained placenta)
- Thrombin (bleeding disorder)
What are some RFs for PPH?
- previous PPH
- multiple pregnancy
- obesity
- large baby
- failure to progress in 2nd stage
- prolonged third stage
- pre-eclampsia
- placenta accreta
- retained placenta
- instrumental delivery
- general anaesthesia
- episiotomy or perineal tear
What measures can be done to reduce risk of PPH?
- treat anaemia during antenatal period
- give birth with empty bladder (as full bladder reduces uterine contraction)
- active management of 3rd stage
- IV tranexamic acid can be used during C section in high-risk pts
What does management of PPH involve?
is an obstetric emergency:
- resus with ABCDE approach
- lie woman flat, keep her warm and communicate with her and partner
- insert two large-bore cannulas
- bloods for FBC,U&E and clotting screen
- group and cross match 4 units
- warmed IV fluid and blood resus as required
- oxygen (regardless of sats)
- fresh clotting abnormalities or after 4 units of blood transfusion
What can the treatment options to stop the bleeding in PPH be split into?
- mechanical
- medical
- surgical
What do mechanical treatment options involve in PPH?
- rubbing the uterus (fundus) to stimulate uterus contraction
- catheterisation (bladder distention prevents uterine contraction)
What do medical treatment options involve in PPH?
- oxytocin (slow injection followed by continous infusion)
- ergometrine (IV or IM) stimulates smooth muscle contraction (contraindicated in hypertension)
- carboprost (IM) - prostogalandin analogue which stimulates uterine contraction
- misoprostol (sublingual) also prostaglandin analogue
- tranexamic acid (IV) - antfibrinolytic so reduced bleeding
What do surgical treatment options involve in PPH?
- Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
- B-lynch suture - putting a suture around the uterus to compress it
- uterine artery ligation - stops supply to uterus reducing blood flow
- hysterectomy as a last resort
What is secondary PPH most likely due to?
-retained products of conception (RPOC
or
-infection - endometritis
What are the investigations for secondary PPH?
- US to look for RPOC
- endocervical and high vaginal swabs for infection
What is the management of secondary PPH?
- surgical evaluation of retained products of conception
- antibiotics for infection