PPH

Question 1

PPH - definition

Answer 1

• Primary PPH = blood loss >500mL from genital tract within 24h of delivery
• Secondary PPH = excessive vaginal bleeding occurring between 24h and 6 weeks after delivery

Question 2

PPH - causes

Answer 2

Primary PPH

1. Tone (70%) = atonic uterus
2. Trauma (20%) = tears, episiotomy, uterine rupture
3. Tissue (10%) = retained placental tissue (placenta previa or placenta accreta)
4. Thrombin (1%) = coagulation disorders

Secondary PPH
5. Infection (often associated with retained products of conception), and rarely gestational trophoblastic disease

Question 3

PPH - RF

Answer 3

Antenatal
1. Previous PPH
2. APH
3. Low-lying placenta
4. Increased BMI
5. Para 4 or more
(Presence of any risk factors -> should deliver in obstetric unit)

Intrapartum

1. Induction of labour
2. Prolonged 1st, 2nd or 3rd stage
3. Precipitate labour
4. Vaginal instrumental birth
5. CS

Question 4

PPH - mx

Answer 4

Initial

1. Empty uterus (deliver fetus + remove placenta or retained tissue)
2. Massage uterus
3. Give drugs to increase uterine contraction (oxytocin IV + ergometrine IV/IM, then misoprostol rectally, carboprost IM if bleeding coninues)
4. Bimanual compression
5. Repair genital tract injuries (including cervical tears)

If all the above measures fail, examination under anaesthesia + further surgical mx.

1. Laparotomy
2. If bleeding from placental bed, may need oversewing and insertion of Rusch balloon
3. If uterus atonic, not responding to drug tx but bleeding decreasing with compression, should place B-Lynch or vertical compression suture
4. Internal iliac or uterine artery ligation (proceeds to hysterectomy in 50% of cases)
5. Total or subtotal hysterectomy

Question 5

Massive obstetric haemorrhage - def

Answer 5

Loss of 30-40% of pt’s blood volume (generally about 2L)

Question 6

Massive obstetric haemorrhage - cx

Answer 6

1. Acute hypovolaemia
2. Sudden and rapid cardiovascular decompensation -> shock
3. DIC
4. Pulmonary oedema
5. Multiorgan dysfunction/failure + Sheehan’s syndrome (hypopituitarism)

Question 7

Massive obstetric haemorrhage - resuscitation

Answer 7

Initial

1. Call for help (senior obstetrician, anaesthetist, haematologist)
2. Left lateral tilt if antepartum (relieve venocaval compression)
3. High-flow facial oxygen
4. Assess airway and respiratory effort (may require intubation if decreased LOC)
5. Two large-bore IV cannulae

Then:

1. Take blood for FBE, group and hold, UEC, LFTs, coagulopathy screen
2. IV crystalloids to correct hypovolaemia
3. Catheterise and measure hourly urine output
4. Blood transfusion - O negative until cross-matched blood available
5. Replace clotting factors - fresh frozen plasma