PPH Flashcards
what is PPH (3)
- blood loss of 500ml after vaginal delivery
- 1000ml after cesarean section
- Blood loss significant enough to cause hemodynamic instability
what are primary causes of PPH (6)
- Uterine atony
- Retained placenta
- Abruptio placenta
- Extended tears
- Placenta previa
- Defects of coagulation
what are the causes of secondary PPH
- Retained products of conception
- Infection
what is primary PPH
Blood loss within 24hours after delivery
what is secondary PPH
Blood loss after 24hours to up to 12 weeks
what are maternal risk factors of PPH (7)
- Advanced maternal age
- Primiparity
- Grand multiparity
- Previous caesarean
- Bleeding disorders
- Previous PPH
- Obesity
what are intrapartum risk factors for PPH (4)
- Prolonged labour
- Caesarean section
- Episiotomy
- Instrumental delivery
what are fetal risk factors for PPH (3)
- Macrosomia
- Multiple pregnancy
- Polyhydraminos
what are causes of primary PPH (4)
- Atonic uterus (tone)
- Genital tract trauma (trauma)
- Coagulopathy (thrombin)
- Retained products of conception (tissue)
what are causes of secondary PPH (4)
- Uterine infections such as endometriotitis secondary to retained products of conception
- Retained placenta tissue
- Gestational trophoblastic disease
- uterine arteriovenous malformations
what are risk factors of uterine atony (8)
- uterine fatigue- prolonged/ induced labor, augmented labor, rapid labor
- grand multiparity
- overdistension of uterus (multiple gestation, polyhydraminios, fetal macrosomia, fetal hydrocephalus)
- uterine infection (chorioamnionitis)
- functional/ anatomic distortion of the uterus
- uterine relaxant drugs - nifedipine, magnesium sulphate
- bladder distension
- previous hx of uterine atony
what are risk factors for genital tract trauma to cause PPH (7)
- perineal laceration - episiotomy
- vaginal laceration
- cervical laceration- forceps/ vacuum delivery
- uterine rupture
- uterine inversion
- removal of retained placenta
- prolonged labor
what are risk factors for remnant tissue to cause PPH (4)
- retained blood clots
- retained cotyledon or succenturiate lobe
- abnormal placentation- placenta accreta, increta, percreta
- prematurity
what are risk factors for thrombin issues to cause PPH (7)
- thrombocytopenia
- ITP
- TTP
- hellp syndrome
- DIC
- anti coagulation agents- heparin
- pre exsting coagulopathy- von willebran disease, hemophilia A
what is uterine atony
failure of the uterus to contract after the delivery of the placenta
what is the most common cause of PPh
uterine atony
how do you prevent PPH (2)
- routine active management of third stage of labor
- routine prophylactic oxytocin 20 IU in 1L NS at 30 drops drops/min for:
- grand multiparity
- patients with APH
- multiple gestation
- polyhrdamnios
- macrosomia
- prolonged labor
what does active management of third stage labor include (3)
- oxytocin 10 IU IM immediately after delivery of the anterior shoulder ( SVD and c/s)
- controlled cord traction for delivery of the placenta
- uterine massage
** regular and frequent assessment of uterine tone by palpation of the fundus delivery of the placenta
if you dont have oxytocin what can you use instead during third stage of labor
misoprostol 600 ug administered orally
what is the initial management of PPH (8)
- STOP BLEEDING AS YOU CALL FOR HELP (i.e. Bimanual compression, aortic compression)
- Call for help and check circulation, airway, breathing (CAB)
- Obtain IV access and start IV fluids. If blood loss is greater than 1000 ml, insert 2 large-bore cannulae (i.e. 16G or
18G). - Oxygen 10-15 L/min if available
- Insert foley catheter
- Draw blood:
- X-match ≥ 4-6 units PRBC and 4-6 units FFP (at a 1:1 ratio with PRBC)
- Bedside clotting time
- FBC (if unavailable, then Hb)
7 Uterine massage to induce contractions - Place woman in supine position and keep warm
what is the management for uterine atony (7)
- Vigorous uterine massage
- Repeat oxytocin 40 IU IV in 1 liter NS @ 125cc/hr
- Misoprostol 800 mcg sublingual or PR or 600 mcg PO.
Note: misoprostol is not as effective as oxytocin and may not further increase uterine tone when used in combination with oxytocin. - The use of tranexamic acid 1 g IV STAT (PO if no IV) is recommended for the treatment of PPH if oxytocin and other uterotonics fail to stop the bleeding.
- If bleeding persists, arrange for EUA. Check for cervical lacerations or any missed vaginal lacerations, or possible retained products
- Consider intrauterine balloon tamponade using a condom catheter (300-500 mL saline)
- If above steps fail, then consider laparotomy for B-Lynch suture, bilateral uterine artery ligation (O’Leary sutures), or hysterectomy. While awaiting OT, perform bimanual uterine or aortic compression.
what is the management of vaginal/ cervical lacerations (2)
- Identify apex before initiation of repair
- Consider repair in OT if difficult to visualize apex at bedside
how do RPOC cause PPH
prevent a uterus from contracting efficiently until the tissue is removed
how does coagulation abnormalities contribute to PPH
Abnormal blood clotting (‘thrombin’) can contribute to an excessive blood loss
how do you manage RPOC (4)
- If able to tolerate, give Pethidine 100 mg IM and perform manual removal of placenta at bedside
- If unable to tolerate, then manual removal and/or evacuation with banjo curette in OT under anesthesia
- If morbidly adherent or retained, then consult senior doctor immediately
- A single dose of antibiotics (ampicillin or first-generation cephalosporin) is recommended if manual removal of the placenta is practised.
what is the management for coagulopathy (2)
- Evaluate for coagulation abnormality via bedside clotting time. A clotting time greater than six minutes is
considered abnormal. - Draw blood for platelet count, PT and PTT, and fibrinogen (if available)
- If deranged, then transfuse PRBC, FFP, +/- platelets, +/- whole blood
what is the management for uterine inversion (6)
- Consult anesthesia
- Suspect if on bimanual examination, the finding of a firm mass below or near the cervix, coupled with the absence
of identification of the uterine corpus on abdominal examination - If the inversion occurs before placental separation, detachment or removal of the placenta should not be undertaken
- Place palm of the hand against the fundus as if holding a tennis ball, with the fingertips exerting upward pressure
circumferentially - Uterine relaxant may be necessary- terbutaline, magnesium sulfate, halogenated general anesthetics, and
nitroglycerin have been used - If not successful, then laparotomy
- Huntington procedure - progressive upward traction on the inverted corpus using Babcock or Allis forceps
- Haultain procedure - incising the cervical ring posteriorly, allowing for digital repositioning of the inverted
corpus, with subsequent repair of the incision
what is the clinical presentation of PPH (3)
- Per vaginal bleeding with or without symptoms of hypovolemic shock
- Enlarged uterus
- Bleeding visible at the introitus
what exam do you do for PPH (3)
- Bimanual pelvic exam after emptying the bladder
- Speculum exam of the vagina and cervix
- Ultrasound
what are complications of PPH (3)
- Anaemia
- Hypovolemic shock
- Sheehan syndrome( a condition of hypopituitarism caused by ischemia and necrosis of the pituitary gland due to severe postpartum haemorrhage) - women wont be able to lactate after >72 hrs
what questions would you ask a woman to ascertain if she had PPH in previous pregnancy (3)
- were any interventions done to stop bleeding
- did she receive blood
- was she taken to theatre after delivery
- was she managed in HDU or ICU - did she notice any bleeding after delivery
- when did the bleeding occur
when trying to assess for shock in PPH what should you check first
peripheral pulse- radial pulse
why should RPOC be removed in theatre
the vagus nerve can be stimulated when you pull the cervix which can result i bradycardia resulting in shock- hence should be done in a controlled environment
what are side effects of massive blood transfusion (4)
- fluid overload
- hypothermia
- hemolysis - hyperkalemia
- toxic lung injury
PRBC increase Hb by how much
3
whole blood increases Hb by how much
1
what is the management algorithm mnemonic for PPH
H- ask for help and hands on uterus (uterus massage)
A- assess and resuscitate
E- establish cause, ensure availability of blood and ecbolic ( medication for stimulating uterine contractions)
M- massage uterus
O- oxytocin infusion/ prostaglandins (misoprostol)
S- shift to theatre whilst doing aortic pressure/ anti shock garment/ bimanual uterine compression
T- tamponade balloon/ uterine packing after exclusion of tissue and trauma
A- apply compression sutures ( B-lynch)
S- systemic pelvic devascularization ( uterine/ ovarian/ internal iliac)
I- interventional radiology if available and if appropriate uterine artery embolization
S- subtotal/ total hysterectomy
