PPH Flashcards
Percentage oxytocin’s reduce risk of PPH
50%
Percentage of women that PPH
5-15%
Blood flow to placenta at term
750ml/min
Mechanism physiological to avoid PPH
Construction of blood vessels supplying the placenta bed by uterine contraction
Placental causes of pph
Atony (prolonged lab, inc parity, oxy w/d, uterine overdistension (mult preg, poly, macrosomia), instrumental birth RPOC Praevia Accreta Inversion Bleeding disorder -thrombocytopenia -DIC -hereditary bleeding disorders
Total blood volume at term
100ml/kg
Ie 50kg-k=5000ml
Basic resus
ABC High flow o2 Wide bore iv access Bloods - FBC, cows, xmatch Warmed fluids O- if needed MTP Keep woman warm and flat
Ecbolics
Oxytocin 5IU IV
40IU over 4 hours
Ergometrine 0.25mg - can repeat every 5 min up to max 1 min.
Misoprostol up to 1000mcg rectally
15-methyl-PGF2alpha (Carboprost)- 0.25mg q15min up to 2.0mg
Other internal causes of bleeding
Ruptured uterus, broad ligament haematoma, subcapsular liver rupture, ruptured spleen, ruptured splenic artery, hepatic artery or pancreatic artery aneurysm
Surgical management
Balloon tampon are B-lynch Bilateral ligation of uterine arteries Bilateral ligation of internal iliacs Arterial embolisation Hysterectomy
Misoprostol in low income settings
Dosage
Benefits
800 sublingual
Safe, effective, easy admin, transient SE, stable at room temp, widely available
Measures for minor PPH
IV access 1 x 14G
Bloods
Vitals Q15min
Warmed crystalloid
Major pph and continuing to bleed or signs of clinical shock
ABC Flat Warm Transfuse if required Infuse 3.5L warmed clear fluids, initially 2l crystalloid Bloods: FBC, xmatch, coag, renal and lfts Temp q15min Remaining vitals continuous monitoring Foley and monitor out your 2 large bore cannula ?art line ?ITU MEOWS Documentation
Risk factors for pph
Multiple pregnancy previous PPH PET Macrosomia FTP 2nd stage Prolonged third stage Retained placenta Accreta Epis Perineal lac GA AMA Asian Obesity Nulliparit Abruption Anaemia Pyrexia in labour Op del Full bladder
Carbetocin
100mcg IV bolus over 1 min
Use for PPH in elcs
B-Lynch stepwise
Blunt semicircular needle with 1.0monocryl
Start R lower edge of the uterine incision and 3cm from R lat border
Go through uterine cavity to emerge at the upper incision margin 3cm above and 4cm from lateral border
Suture passed over to compress funds 3 to 4 cm from the right cornual border
Pass suture back posteriorly through same surface, on right side with suture lying horizontally
Suture fed posteriorly and vertically over the fundus
To lie anteriorly
Needle passed in same fashion on left side through uterine cavity and out approximately 3cm ant and below the lower incision margin on the left side
Stepwise uterine devascularisation
One uterine arty Both uterine arteries Low uterine arteries One ovarian artery Both ovarian arteries
Causes of secondary PPH
Endometritis
RPOC
Subinvolution of the placental implantation site
AV malformations
Bakri mech of action
Controls atony in upper segment
Controls placental bleeding in LS
