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ALSO > PPH > Flashcards

PPH Flashcards

1
Q

Risk of PPH

A

5-15%

First PPH in 2nd or third preg - 5%
Recurrence of PPH 15%

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2
Q

Mortality from obs haemorrhage

A

12 in 100,000

5 in 100,000 PPH

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3
Q

Define PPH - minor/major/primary/secondary

A

minor PPH >500ml
Major PPH >1000ml or any that causes haemodynamic compromise

Primary - within 24h

secondary - within 6 weeks

Bloods = PPH = >10 point drop in HB

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4
Q

Risks for tone issues causing PPH

A

LABOUR:
Long labour
Induction of labour
Rapid labour
Pyrexia/chorio

WOMAN:
Multiparous
Uterine abnormalities

BABY:
Twins
Polyhydramnios
LGA

DRUGS:
- Synto
- MgSO4
- nifedipine

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5
Q

Risks for TRAUMA issues causing PPH

A

LABOUR:
- Quick labour
- Not adequate perineal protection
- Induced/augmented labour
- Instrumental

WOMAN:
- Previous tears
- Short perineum

BABY:
- LGA
- twins
- Malposition

Risks for rupture:
- Previous CS

Risks for inversion
- Cord traction (esp with fundal contraction)
- Short cord
- High parity
- Accreta

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6
Q

Risks for TISSUE issues causing PPH

A

Accreta
Previous RPOC
Previous CS
High parity

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7
Q

Risks for THROMBIN issues causing PPH

A

Cooagulation disorders

Pre-eclampsia

HELLP

Abruption

Fetus that died in utero

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8
Q

Management of 3rd stage labour

A

Primips - within 1 hour

Multips - within 30 minutes

Recommendation - 5 units IV synto or 10 IM. Controlled cord traction

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9
Q

How does delayed cord clamping help baby

A

reduces fetal anaemia

Especially to reduce fetal tranfusions and interventricular haemorrhage in pre-term babies

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10
Q

How is expectant management of 3rd stage done

A

immediate skin to skin
women in upright position to give birth to placenta

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11
Q

What is blood volume in pregnancy

A

100ml/kg

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12
Q

Immediate resus measures for PPH

A

DRS ABCD

Danger - assess quickly and addres spartner
Response - ?woman conscious
Send for help
A - open?
B - 15L O2
C - IVC, IDS, IVF, bloods

Assess the 4 Ts:
- Tone - fundal massage and give drugs
- Trauma - assess tear and apply pressure and think PAIN RELIEF
- Tissue - is placenta intact? Expel clots
- Thrombin - coag disorder history?

Activation of the massive transfusion protocol if necessary

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13
Q

What could an unclear cause of an unstable PP patient be?

A

Uterine rupture

Perineal haematoma

Uterine inversion

TAKE TO THEATRE IF NEED TO EXPLORE

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14
Q

What needs to happen prior to bimanual massage?

A

Insert IDC

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15
Q

What does the massive transfusion protocol include?

What is the criteria?

A

Transfusing whole blood volume within 24h or HALF blood volume within 4h

Needing 4x unit RBC within 4h or lab evidence of coagulopathy

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16
Q

What are the aims for parameters during a massive obstetric haemorrhage

A

Ph >7.2

Lactate <4

TEMP >35

Calcium >1.1

Plt>50

INR <1.5
PT/APTT <1.5x normal
Fibrinogen >2

17
Q

What are the operative measures that can be use for PPH?

A

Balloon tamponade - foley catheter/rusche balloon/Bakri balloon

Haemostatic suture - B lynch

Ligation of uterine arteries

Ligation of internal ilic arteries

baloon catheterisation of major pelvic vessels

hysterectomy

18
Q

What are the drugs used for atony

A

Syntoninon
- 10 units IM or 5 units IV
- 40 units over 4h (1L hartmanns)
- Side effects: N&V

Ergometrine
- 500mcg IM or 250 mcg IV
- CI: hypertension/pre-eclampsia (diastolic >90), retained placenta, heart disease, sepsis, renal or heptic sydfunction
- Side effects: headache, N&V, HTN, chest pain/arrythmias
- Can repeat in 2h

Syntometrine
- 1ml (max 3ml in 24h) - % units synto + 500mcg ergo
- Same SEs
- Same Contraindications
- Can repeat in 2h

Carboprost
- 250mcg IM
- CI: asthma, severe renal/hepatic disease
- Side effects: diarrhoea, fevers
- Can repeat every 15 minutes up to 8 doses

Misoprostol
- 800-1000mcg
- CI: allergy
- Side effects: fever
- Cautions: asthma

TXA
- ASAP when starts bleeding

19
Q

What is the problem with misoprostol in PPH

A

SLOW

Oral - 8 minutes (lasts 2h)
SL - 11 minutes (lasts 3h)
rectal - 100 minutes (lasts 4h)

20
Q

Describe how bi-manual massage is done

A

one hand on uterus via abdo pushing fundus downwards and one hand (fist) in anterior fornix of vagina

Massage with both hands

21
Q

When is using a Bakri balloon inappropriate

A

bleeding from cervical/vaginal trauma
Cervical cancer
uterine rupture

22
Q

Describe how to put a bakri balloon in

A

Make sure placenta complete and maks sure bleeding not from vaginal/cervix lacerations.

(pre-warm saline - 500ml in sterile bowl)

  1. Insert IDC
  2. Clean vagina/cervix
  3. Put speculum in and grab anterior cervix and put balloon in
  4. Insert water, max 500ml
  5. Gentle trction on balloon and tape to thigh
  6. If bleeding continues –> surgery
23
Q

How to take a Bakri balloon out?

A

Can only stay in fo 24h

Need IV abx as can cause infection

Take water out gradually

24
Q

How do you look for cervical tears

A

Get two sponge forceps and work around like a clock to look for tears

25
Q

how to deal with perineal haematomas

A

Small ones - do nothing

Larger ones - if there is ongoing signs of volume loss despite replacement there might be ongoing ooze. Can incision the haematoma and drain and irrigate. Can do a layered closure to get rid of dead space.

26
Q

What would make you suspiscious of a uterine rupture

A

BRADYCARDIA PRIOR TO DELIVERY ** MAIN SIGN**

Shock outwith PV blood loss

Expanding abdo

Painful abdo

Vagnal bleeding

27
Q

What would make you suspiscious of a uterine inversion

A

FUNDAL PLACENTA

Symptoms:
- pain in third stage
- cannot palpate fundus or can palpate a dimple
- haemorrhage (94% cases)
- shock

1/2nd - mass in vagina
3rd - mass out of introitus

28
Q

How to treat uterine inversion?

cervical shock?

A

grab fundus and push back inside towards umbilicus and then make fist

If cervical ring already formed then use terbutaline to relax uterus.

If they develop a symptomatic bradycardia - atropine

AFTER GIVE ALL THE PPH DRUGS

29
Q

How do you do a manual removal of the placenta

A

Adequate analgesia

ABX 30 minutes before (cefazolin + metronidazole)

Be aware could be abnormal placentation

Surgery vs in the room - bleeding/analgesia

After - 40 units synto

30
Q

What can cause DIC

A

severe pre-elclampsia

IUFD

sepsis

abruption

amniotic fluid embolism

ALSO (8 decks)

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