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WH- Normal labour and delivery > PPH > Flashcards

PPH Flashcards

1
Q

What is PPH?

A

Excessive bleeding following delivery

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2
Q

How many types of PPH are there?

A

Two.

Primary and secondary.

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3
Q

What is primary PPH?

A

Primary postpartum haemorrhage (PPH) is loss of blood estimated to be >500 ml, from the genital tract, within 24 hours.

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4
Q

What is minor PPH?

A

o Minor PPH is estimated blood loss of up to 1000 mls.

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5
Q

What is major PPH?

A

o Major PPH is any estimated blood loss over 1000 mls.

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6
Q

What is secondary PPH?

A

-Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until six weeks postpartum.

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7
Q

Causes of PPH

A

The causes of PPH have been described as the “four T’s”:

  • Tone: uterine atony, distended bladder.
  • Trauma: lacerations of the uterus, cervix, or vagina.
  • Tissue: retained placenta or clots.
  • Thrombin: pre-existing or acquired coagulopathy.
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8
Q

What is the most common cause of PPH?

A

The most common cause of PPH is uterine atony, followed by retained placenta.

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9
Q

Causes of retained placenta

A

Placenta adherens, when the myometrium fails to contract behind the placenta.

Trapped placenta, when a detached placenta is trapped behind a closed cervix.

Partial accreta, when there is a small area of adherent placenta preventing detachment.

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10
Q

Treatment for retained placenta

A

Manual removal of the placenta

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11
Q

Antenatal risk factors for PPH

A 
Antepartum haemorrhage in current pregnancy
Pre-eclampsia or pregnancy-induced HTN
Maternal obesity 
Maternal anaemia 
Maternal age (40 years and over) 
Existing uterine abnormalities 
Multiple pregnancy. Other causes of uterine over-distension such as polyhydramnios or macrosomia. 
Placenta praaevia 
Placental abruption 
Previous PPH or hx of retained placenta
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12
Q

Risk factors relating to delivery for PPH

A 
Elective or emergency section
Retained placenta 
Mediolateral episiotomy 
Induction of labour 
Operative vaginal delivery 
Labour of >12 hours 
>4kg baby 
Maternal pyrexia in labour
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13
Q

Maternal risk factors for PPH

A

Haemophilia A carrier
Haemophilia B carrier
Von Willebrand’s disease

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14
Q

Symptoms and signs of PPH

A

Continuous bleeding, which fails to stop after delivery of the placenta - third stage.

Loss of >1000 ml may be accompanied by clinically apparent shock, i.e. tachycardia, hypotension.

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15
Q

Associated disease of PPH

A

Haemolysis, Elevated liver enzymes and low platelets (HELLP)

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16
Q

Management of primary PPH

A

Communiation
Resuscitation
Monitoring and investigation
Measures to arrest bleeding

17
Q

Why is communication important in the control of primary PPH?

A

Alert all relevant professionals. In minor PPH, this is the midwife in charge, and first-line obstetric and anaesthetic staff.
This is to ensure that there are enough people to deal with the process of treating PPH

18
Q

How do you resuscitate a patient with PPH?

A
  • IV access with a 14-gauge cannula, and commence crystalloid infusion for minor PPH.
  • For major PPH:
    • Assess airway, breathing, circulation.
    • Oxygen by mask at 10-15 litres per minute.
    • IV access with 2 x 14-gauge cannulae.
    • Keep the woman lying flat and warm.
    • Transfuse blood as soon as available. Until available, transfuse up to 2 litres of warmed crystalloid Hartmann’s solution and/or 1-2 litres of colloid.
    • Recombinant factor VIIa (rFVIIa) is increasingly frequently used for arresting bleeding in severe haemorrhage.
19
Q

Which investigation do you do for PPH?

A
  • For minor PPH, FBC, blood group, coagulation screen. Monitor pulse and blood pressure every 15 minutes.
  • For major PPH:
    • FBC, coagulation screen, baseline U&E, LFT.
    • Crossmatch 4 units of blood minimum.
    • Continuous monitoring of pulse, blood pressure, respiratory rate and urine output.
    • Temperature monitoring every 15 minutes.
    • Consider arterial line monitoring and ITU transfer.
    • Records of all parameters on flow chart - for example, the modified obstetric early warning system (MEOWS) charts.
20
Q

What are the measures to arrest bleeding?

A

Examination to establish cause and exclude other causes than uterine atony (the most common cause).

If the cause is established to be uterine atony, the following measures are taken in turn:
• Bimanual uterine compression to stimulate contraction.
• Ensure the bladder is empty.
• Oxytocin 5 units by slow IV infusion. May require repeat.
• Ergometrine 0.5 mg slow IV or IM unless there is a history of hypertension.
• Carboprost 0.25 mg IM repeated to a maximum of 8 doses unless there is a history of asthma.
• Misoprostol 1000 micrograms rectally

21
Q

Complications of PPH

A 
Hypovolaemic shock 
DIC 
AKI 
Liver failure 
ARDS 
Death
22
Q

Prevention of PPH

A

The active management of the third stage of labour significantly reduces the risk of PPH.

Prophylactic oxytocics should be routinely used in the third stage of labour, as they decrease the risk of PPH by 60%.

For most women delivering vaginally, oxytocin 5 or 10 IU IM is the prophylactic agent of choice. It is used as an infusion for women having caesarean sections.

Syntometrine® (oxytocin plus ergometrine) may also be used in the absence of hypertension.

23
Q

Causes of secondary PPH?

A

Infection- endometritis.

Retained products of conception.

24
Q

Risk factors for endometritis

A

Risk factors: Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor, long labour with multiple examinations, manual removal of placenta, mother’s age at extremes of the reproductive span, low socio-economic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.

25
Q

Symptoms and signs of secondary PPH?

A 
Fever
Abdominal pain
Offensive smelling lochia
Abdominal vaginal bleeding Abnormal vaginal discharge Dyspareunia
Dysuria
General malaise. 
Tachycardia,
Tenderness of the suprapubic area
Adnexa and elevated fundus which feels boggy in RPOC.
26
Q

Investigations of secondary PPH

A
  • FBC
  • Blood cultures
  • Check MSU
  • High vaginal swab; also, gonorrhoea/ chlamydia.
  • Ultrasound- may be used if RPOC are suspected.
27
Q

Management of secondary PPH

A

Urgent referral if sepsis is suspected.

Speculum examination will allow visualisation of the cervix and lower genital tract to exclude lacerations.

If a clot is visible within the cervical os, it may be removed with tissue forceps (although few GPs regularly carry these), allowing the cervix to close.

If RPOC are suspected, elective curettage with antibiotic cover may be required.

WH- Normal labour and delivery (2 decks)

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