PPH

Question 1

Definition of primary and secondary PPH?

Answer 1

Primary = >500ml PV blood loss within 24 hours of delivery

Secondary = any excessive PV blood loss >24 hours and within 6 weeks of delivery

Major PPH = >1000 mL PV blood loss

Question 2

How can PPH be prevented?

Answer 2

Active 3rd stage management of labour
Reduces incidence from 8% to 4%
PPH = biggest cause of maternal death worldwide

Question 3

What are the causes of PPH?

Answer 3

The 4 Ts - tone, tissue, thrombin, tear

Uterine atony - most common

• Overdistention - macrosomia, polyanhydramnios, twins
• Grand multipara
• Long labour

Placenta acreta, praevia

Uterine inversion

Retained tissue/placenta

Bleeding disorder or tendency (i.e. PET, sepsis)

Uterine rupture, cervical, vaginal or perianal tear

Question 4

What are the components of active 3rd stage management?

Answer 4

1. Oxytocin
   - Synthetic pituitary hormone
   - Rapid onset, shorter time of action
   - Stimulates contractions of the uterus
   - N+V most common side effects, water intoxification (hyponatraemia) and transient hypotension, arrhythmias uncommon but serious
2. Ergometrine
   - Used in conjunction with oxytocin (enhanced effect)
   - Delayed onset, longer time of action
   - C/I if HTN or PET
   - S/E = N+V and HTN
3. ? Early cord clamping
4. Controlled cord traction with assistance of delivery of placenta and membranes
   - Fix uterus to prevent inversion
   - If unable to deliver within 10mins call for additional support

Question 5

What are risk factors for PPH?

Answer 5

Prolonged labour 
Failure to progress in labour
Instrumental delivery 
Large for gestational age baby
Hypertensive disease

Question 6

What is the birth suite management for PPH?

Answer 6

1. Recognise PPH and call for help
2. Simultaneous Ax & resus - 2xlarge bore cannulas, G&H, coagulation profile, FBE, fluids, position
3. Simultaneous bimanual compression of uterus while catheter inserted and additional tocolytics administered (oxytocin, ergometrine, misoprostol)
4. Speculum examination - repair any lacerations, remove any clots/tissues seen
5. Cord traction (if placenta not already delivered)

Question 7

What is the further Rx of PPH if birth suite management hasn’t controlled bleeding?

Answer 7

1. Advise anaesthetist/theatre and transfer
2. Continued simultaneous Ax and resus with blood/fluid
3. Examine under GA - remove any tissues retained and repair any trauma
4. Additional tocolytic - IM PGEF2 alpha
5. Bakri balloon (balloon tamponade)
6. Laparoscopy - B-lynch suture, uterine artery or internal iliac artery ligration, hysterectomy

Question 8

What are the causes of secondary PPH?

Answer 8

Most likely = infection (endometritis) - can be assoiated with retained products

Question 9

What are the clinical features of secondary PPH?

Answer 9

Bright PV bleeding - can be heavy
Tender, bulky uterus
Signs of infection - PV discharge, systemic symptoms (fever, tachycardia)

Question 10

What are the Ix for secondary PPH?

Answer 10

1. FBE, U&E, consider blood culture
2. High vaginal swabs - infection
3. U/S - ? retained products

Question 11

What is the Rx for secondary PPH?

Answer 11

1. Resuscitation if required
2. Tocolytics - if acute bleeding but benefit is variable
3. Broad spectrum antibiotics - IV amoxy, gent, metronidazole (oral amoxy/clav if outpatient)
4. Surgery if retained products

Question 12

What are risk factors for secondary PPH?

Answer 12

Long labour
PROM
Instrumental delivery
High fever in labour 
Manual removal of placenta 
Excessive vaginal examination