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24-Obstetric Emergencies > PPH > Flashcards

PPH Flashcards

1
Q

What is the definition of primary PPH ?

A

primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth
of a baby

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2
Q

How is primary PPH classified?

A

PPH can be :
minor (500–1000 ml) or major (more than 1000 ml).
Major can be further subdivided into
moderate (1001–2000 ml) and severe (more than 2000 ml). I

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3
Q

What is the definition of secondary PPH ?

A

abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks
postnatally.

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4
Q

What is the most common cause of PPH ?

A

Uterine atony

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5
Q

What are the causes of PPH according to the kind of abnormality?

A

4T :
1-tone :abnormalities of uterine contraction
2-Tissue: retained products of conception
3-Trauma: genital tract injury
4-Thrombin: abnormalities of coagulation

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6
Q

What are the risk factors for developing PPH ?

A

1- retained placenta(Tissue) highest
2- prolonged 3rd stage (Tone)
3- preeclampsia ( thrombin)
4- episiotomy ( trauma)
5- multiple pregnancy ( tone)
6- previous PPH ( tone )
7- failure to progress in 2nd stage
8- placenta accreta ( tissue)
9- fetal macrosomia ( tone)
10- general anaesthesia ( tone )
11- perineal laceration ( trauma)

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7
Q

How to minimize the risk for developing PPH?

A

1- treating antenatal anaemia
2- reducing the risk of blood loss at delivery:
* active management 3rd stage
* prophylactic uterotonics
( 10 iu IM oxytocin/ 5 iu IV oxytocin)
( ergomethrin-oxytocin )
* tranexamic acid( 0.5- 1 g) IV at CS

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8
Q

What is the role of treating antenatal anaemia in minimizing the risk of PPH?

A

May reduce the morbidity associated with PPH

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9
Q

What is the cut off level of Hb that associated with greater blood loss at delivery?

A

Less than 90 g/ l

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10
Q

What is the role of uterine massage in the prophylaxis of PPH?

A

Has no benefit

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11
Q

What does active management of 3rd stage mean ?

A

1- use of uterotonics
2- early clamping of the umbilical cord
3- controlled cord traction

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12
Q

What does expectant management of the 3rd stage mean ?

A

Signs of placenta separation are awaited & the placenta is delivered spontaneously

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13
Q

What is the recommendations about the timing of umbilical cord clamping?

A

Should not be clamped earlier than 1 minutes from the delivery of the baby if there are no concerns over cord integrity or the baby’s wellbeing

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14
Q

What is the negative result of the active management of the 3rd stage ?

A

Lower birthweight: reflecting lower blood volume from early clamping
🔮 delaying clamping for at least 2 minutes is beneficial to the newborn

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15
Q

Prophylactic oxytocin VS ergometrine - oxytocin for the 3rd stage of labour?

A

Ergometrine–oxytocin was associated with a small
reduction in the risk of PPH
the adverse effects of :
nausea , vomiting, elevation of blood pressure, with ergometrine–oxytocin carrying a five-fold increased
risk

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16
Q

What is the regimen of choice for prophylaxis PPH in the third stage of labour ?

A

Oxytocin 10 iu IM
with the birth of the anterior shoulder, or immediately after the birth of the baby and before the cord is
clamped and cut

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17
Q

What is the role of prostaglandins in routine prophylaxis?

A

Were not preferable to oxytocin or ergomethrin for routine prophylaxis

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18
Q

What is the uterotonic that is licensed in the UK specifically for the indication of prevention of PPH in
CS But not for vaginal delivery ?

A

carbetocin (100 micrograms given as an intravenous bolus over 1 minute)

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19
Q

What is the role of tranexamic acid in the prevention of PPH ?

A

At CS in addition to oxytocin , IV ( 0.5-1 g )
to reduce blood loss in women at increased risk of PPH

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20
Q

Is visual estimation an accurate method to estimate peripartum blood loss an ?

A

No , and clinical signs and symptoms should be included

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21
Q

What are the changes in pulse & BP occurring with peripartum blood loss ?

A

🚩< 1000 ml ➡️ remain in normal range
🚩 1000 - 1500 ➡️ tachycardia + tachypnoea + slightly fall in systolic pressure
🚩 > 1500 ➡️ systolic pressure < 80
& worsening tachycardia +tachypnoea + altered mental state

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22
Q

Who should be informed when the woman presents with PPH?

A

500 - 1000 ml : midwife+ first line obstetric
> 1000 ml : MDT

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23
Q

What are the measures for minor PPH ( 500- 1000 ml) without clinical shock?

A

1- IV access ( one 14 gauge cannula )
2- urgent venepuncture 20 ml for
* group & screen
* CBC
* coagulation screen + fibrinogen
3- pulse + respiratory rate BP every 15 minutes
4- commence warm crystalloid infusion

24
Q

What are the measures for major PPH ( >1000 ml) or with clinical shock?

A

1- call for help
2- resuscitation ABC
3- O2 mask 15 L
4- fluid balance: 2 L crystalloid followed by 1,5 L colloid
5- blood transfusion
6- blood products: FFP ,PLT , cryoprecipitate, Factor 7a
7- keep patient warm

25
Q

What pharmacological & mechanical strategies can be used in women with major PPH?

A

1- Rub up the uterine fundus
2- empty bladder( Foley catheter leave in place)
3- oxytocin 5 iu slowly IV
4- ergomethrin 0,5 mg slow IV or IM
5- oxytocin infusion 40 iu / 500 ml crystalloid ( 125 ml / h )
6- Carboprost 0.25 mg IM every 15 minutes up to 8 times
7-Carboprost ( prostaglandin F2a)
0,5 mg intramyometeial
8- Misoprostol 800 mcg SUBLINGUAL
9- Tranexamic acid 1 g IV

26
Q

What are the investigations that should be performed in case of major PPH or clinical shock?

A

1- 2 cannula 14 gauge
2- FBC , coagulation,fibrinogen, U&Es, LFTs ,RFTs
3- cross match 4 units + FFP+PLT+cryoprecipitate
4- ECG + oxymeter
5- Foley catheter
6- Hb bedside testing
7- consider central & arterial lines

27
Q

What is the role of Hedroxyethyl starch HES ( colloid) in the management of major PPH?

A

Should not be used
( increased renal dysfunction)

28
Q

What are the indications of administering FFP in the management of PPH?

A

1- PT or aPTT are prolonged ( > 1,5 times ) & the haemorrhage is ongoing ➡️ 12 - 15 ml / kg
2- if haemorrhage continues after 4 units of RBCs & haemostatic tests aren’t available ➡️ 4 units of FFP
⚠️ each unit 250 ml

29
Q

What is the indication for platelet administration in case of major PPH ?

A

1 pool of platelet ( 300 ml)
If haemorrhage is ongoing & PLT count < 75,000

30
Q

What is the indication of cryoprecipitate administration in case of major PPH?

A

2 pools of cryoprecipitate
If the haemorrhage is ongoing & fibrinogen < 2 g / L

31
Q

What are the main therapeutic goals of the management of massive
blood loss ?

A

Hb greater than 80 g/l

platelet count greater than 50

prothrombin time (PT) less than 1.5 times normal

activated partial thromboplastin time (APTT) less than 1.5 times normal

fibrinogen greater than 2 g/l.

32
Q

Is testing blood for CMV necessary before transfusion in the management of PPH ?

A

CMV-negative blood or platelets are not needed for
transfusion during delivery or in the postpartum period.

33
Q

Is testing blood for CMV necessary before transfusion in the management of PPH ?

A

CMV-negative blood or platelets are not needed for
transfusion during delivery or in the postpartum period.

34
Q

What are the risks associated administration of FFP ?

A

1- transfusion associated circulatory overload TACO
2- transfusion related acute lung injury TRALI
3- relatively small increments in fibrinogen level ➡️ cryoprecipitate or fibrinogen concentrate are required

35
Q

How much the increase in fibrinogen would make by 2 pools of cryoprecipitate ?

A

1 g / L

36
Q

What are the benefits associated with infusion of fibrinogen?

A

1- improves clinical hemostasis
2- reduces the use of FFP
3- reduces the post transfusion events like TACO

37
Q

Is there a role for antifibrinolytic drugs in the management of PPH ?

A

Consideration should be given to the use of tranexamic acid in the management of PPH

38
Q

Is there a role for recombinant factor VIIa (rFVIIa) therapy?

A

The routine use of rFVIIa is not recommended in the management of major PPH
It may cause hypothermia, acidosis and low platelets, thromboembolic events

39
Q

How should women with major PPH be monitored ? And where?

A

1- continuous pulse & BP & respiratory rate ( using oximeter & ECG)
2- monitor the temperature every 15 minutes
3- recording on modified early obstetric warning score MEOWS
🔮 transfer to intensive therapy unit once the bleeding is controlled
OR : high dependency unit

40
Q

What is the role of chemical thromboprophylaxis in the management of PPH ?

A

Once the bleeding is arrested & coagulopathy is corrected chemical thromboprophylaxis is administered unless in cases of thrombocytopenia

41
Q

How much time the misoprestol takes to increase the uterine tone ?

A

1 - 2,5 hours
Regardless of the route of administration

42
Q

What is the first line surgical intervention for women with uterine atony as a cause of PPH?

A

Intrauterine balloon tamponade
Preferable: urological Rusch balloon
( larger capacity, easy to use, low cost)

43
Q

What surgical treatments can be employed to arrest the bleeding?

A

1- uterine balloon tamponade
2- Haemostatic brace suturing: B-lynch, modified B-lynch
3- stepwise uterine devascularisation & iliac artery ligation
4- selective arterial occlusion OR embolization by interventional radiology
5- Hysterectomy

44
Q

What is the success rate of avoiding hysterectomy when using uterine balloon tamponade?

A

91 %

45
Q

How long the balloon tamponade should be left in place when managing PPH ?

A

4 - 6 hours should be adequate to achieve hemostasis, ideally should be removed during daytime in the presence of senior staff

46
Q

What is the overall failure rate of compression sutures to control PPH leading to hysterectomy? What are the risk factors for failure?

A

25 %
Risk factors:
1-increased maternal age
2-Vaginal delivery
3-Prolonged delay ( 2- 6 hours delay was associated with 4 folds increased risk of hysterectomy)

47
Q

What is the stepwise uterine devascularisation?

A

1- one uterine artery
2- both uterine arteries
3- low uterine arteries
4- one ovarian artery
5- both ovarian arteries

48
Q

What is the overall failure rate of illiac artery to control PPH leading to hysterectomy?

A

39%

49
Q

What is the success rate of arterial embolization in arresting the PPH ?

A

86 %

50
Q

What is the operation of choice in cases of PPH requiring hysterectomy?

A

Subtotal hysterectomy
Unless there is a trauma to the cervix OR an adherent placenta in the lower segment

51
Q

How should secondary PPH be managed?

A

1- assessment of vaginal micro biology: high vaginal & endocervical swabs ➡️ antimicrobial therapy
( clindamycin +gentamicin)
2- pelvic US to exclude the presence of retained products of conception RPOC
3- uterotonics: misoprestol & ergomethrine

52
Q

What are the main causes of secondary PPH?

A

1- endometritis
2- RPOC
3- subinvolution of the placental implantation site

53
Q

What are the US features that suggest RPOC as a cause of secondary PPH ?

A

echogenic mass
in the uterine cavity and an anteroposterior diameter of the cavity above the 90th centile (approximately
25 mm on days 1–7 postpartum) was associated with RPOC.

54
Q

What is the role of flow Doppler imaging in evaluation of secondary PPH ?

A

there is no strong evidence to support its use

55
Q

What is the morbidity associated with Surgical evacuation of the uterus for RPOC ?

A

1-uterine
perforation (1.5%)
2- Asherman’s syndrome.

56
Q

How to record an Accurate documentation of a delivery with PPH ?

A

It is important to record:

1-the staff in attendance and the time they arrived

2-the sequence of events

3-the administration of different pharmacological agents, their timing and sequence

4-the time of surgical intervention, where relevant

5-the condition of the mother throughout the different steps

6-the timing of the fluid and blood products given.

24-Obstetric Emergencies (6 decks)

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