PPH

Question 1

What is primary post-partum haemorrhage?

Answer 1

- Loss of >500ml of blood per vagina within 24 hours of deliver - minor (500-1000ml), and major (1000ml+).
Ax:
1) Tone
2) Tissue
3) Trauma
4) Thrombin

Question 2

Tone as a cause for Primary PPH?

Answer 2

• Refers to uterine atony - most common cause.
• Uterus fails to contract adequately following delivery due to a lack of tone in the uterine muscle.
• RF for uterine atony:
  1) Maternal profile - BMI >35, Age >40, Asian
  2) Uterine over-distention - multiple pregnancy, macrosomia, polyhydramnios
  3) Labour - induction, prolonged
  4) Placental problems - praevia, abruption, previous PPH

Question 3

Tissue as a cause for P-PPH?

Answer 3

-Retention of placental tissue preventing uterus from contraction - 2nd most common cause of primary PPH..

Question 4

Trauma as a cause for P-PPH?

Answer 4

• Refers to damage sustained in the reproductive tract during delivery (vaginal tears, cervical tears)
• RF:
  1) Instrumental delivery
  2) Episiotomy
  3) C-Section

Question 5

Thrombin as a cause for P-PPH?

Answer 5

• Refers to coagulopathies and vascular abnormalities which increase risk of P-PPH?
  1) Vascular - Placental abruption, hypertension, pre-eclampsia
  2) Coagulopathies - von-Willebrand’s, haemophilia, ITP, or acquired coagulopathy (DIC and HELLP)

Question 6

Clinical features and examination of P-PPH?

Answer 6

• Main feature is the bleeding from vagina, if substantial blood loss - palpitations, dizziness and shortness of breath.
  O/E:
  1) General - haemodynamic instability with tachypnoea, PCRT, tachycardia and hypotension.
  2) Abdominal - may show signs of uterine rupture, palpation of foetal parts as it moves into the abdomen from the uterus.
  3) Speculum - reveal sites of local trauma causing bleeding.
  4) Placental - to ensure placenta is complete (missing cotyledon or ragged membranes could both cause PPH)

Question 7

Investigations of P-PPH?

Answer 7

1) FBC
2) Cross match 4-6 units of blood
3) LFT
4) U+Es
5) Coagulation profile

Question 8

Management of P-PPH?

Answer 8

• Simultaneous delivery of TRIM
  1) Teamwork
  2) Resuscitation
  3) Investigations and monitoring
  4) Measures to arrest bleeding

Question 9

Intermediate management?

Answer 9

• Teamwork: involve appropriate colleagues - midwife, obstetricians, anaesthetists, blood bank, haematologist and porters.
• Resuscitation - Airway protection, Breathing - 15L of 100% oxygen through non-rebreathe.
  Circulation - assess compromise (CR, HR, BP, ECG) + insert 2 large bore cannulas and take blood samples (give cross-matched bloodd ASAP and until then 2L of warmed crystalloid, 1-2L of warmed colloids, transfuse O negative or uncross matched group specific blood. Additional products - FFP, platelets, fibrinogen (discussion with blood bank).
  Disability - monitor GCS
  Expose patient to identify bleeding sources.

Question 10

Definitive management (Atony)?

Answer 10

1) Bimanual compression to stimulate uterine contraction ensure bladder emptied by cauterisation)
2) Pharmacological measures to increase uterine myometrial contractions.
3) Surgical measures - IU balloon tamponade, haemostatic suture around uterus (B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (last resort).

Question 11

Definitive management (Trauma)?

Answer 11

• Primary repair of laceration

- If uterine rupture: laparotomy and repair, hysterectomy last resort.

Question 12

Definitive management (Tissue)?

Answer 12

• IV Oxytocin - manual removal of placenta with regional or general anaesthetic, and prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal.

Question 13

Definitive management (Thrombin)?

Answer 13

• Correct any coagulation abnormalities with blood products under the advice of the haematology team.

Question 14

Drugs used in Primary PPH?

Answer 14

1) Syntocinon (synthetic oxytocin)
2) Ergometrine
3) Carboprost
4) Misoprostol

Question 15

Prevention of Primary PPH?

Answer 15

• Active management of the 3rd stage of labour routinely reduces PPH risk by 60%.
• Women delivering vaginally should be administered 5-10 unites of IM Oxytocin prophylactically.
• Women delivering via C-Section should be administered 5 units of IV Oxytocin.

Question 16

What is secondary postpartum haemorrhage?

Answer 16

Defined as excessive vaginal bleeding in the period from 24 hours post-delivery to twelve weeks postpartum.

Question 17

Aetiology and Risk Factors of S-PPH?

Answer 17

1) Uterine infection (endometritis) - due to C-section, premature rupture of membranes, or long labour.
2) Retained placental fragments or tissue
3) Abnormal involution of placental site (inadequate closure and sloughing of spiral arteries at placental attachment site)
4) Trophoblastic disease (very rare)
RF: Previous history of S-PPH

Question 18

Clinical features of S-PPH?

Answer 18

• Main symptom - excessive vaginal bleeding.
• Not as severe as P-PPH (acute needing immediate management).
• May complain of spotting on and off for days after deliver with occasional gush of fresh blood.
• Rarely - massive haemorrhage leading to hyovolaemic shock.
• Clinical features depend on cause - endometritis (fever/rigors, lower abdomen pain or foul smelling lochia/discharge from uterus following delivery).
• O/E - lower abdomen tenderness (endometritis), uterus remains high (retained placenta), speculum to assess amount of bleeding, high vaginal swab at same time can assess for infection.

Question 19

Investigations of S-PPH?

Answer 19

• If patient is haemdynamically unstable or bleeding heavily - call for help and follow resuscitation algorithm - should be commenced prior to establishing cause.

Lab tests:

1) FBC
2) U+E
3) Coagulation profile
4) Group and save sample
5) CRP
6) Cultures

Imaging:
1) Pelvic ultrasound - retained placental tissue

Question 20

Management of S-PPH?

Answer 20

1) Antibiotics - Ampicillin (Clindamycin) and Metronidazole
- add gentamicin in cases of endomyometritis or overt sepsis.
2) Uterotonics - Syntocinon (oxytocin), Syntometrine (oxytocin and ergometrine), carboplast (prostaglandin F2) and misoprostol (Prostaglandin E1).

• Surgical measures if excessive and continuing bleeding - insertion of balloon catheter may be effective.
• In case of massive S-PPH - 4 measures: Communication, Resuscitation, Monitoring and Investigation, Arresting bleeding (uterotonics/surgical measures, depending on suspected cause).