PPH (Postpartum haemorrhage)

Question 1

What does post partum haemorrhage refer to?

Answer 1

-bleeding after delivery of baby and placenta

Question 2

How much blood must be lost to be classified as PPH?

Answer 2

• 500ml after vaginal delivery
  -1000ml after c-section

- 1000ml after c section

Question 3

What can PPH be classified into?

Answer 3

• minor PPH - <1000ml
• major PPH -> 1000ml (subclassified into moderate major PPH 1000-2000ml and severe major >2000ml)
• primary PPH: within 24hrs of birth
• secondary PPH: from 24hrs to 12 weeks after birth (3months postpartum)

Question 4

What are the causes of PPH?

Answer 4

4 Ts:

• Tone (uterine atony -most common cause)
• Trauma (e.g perineal tear_
• Tissue (retained placenta)
• Thrombin (bleeding disorder)

Question 5

What are some RFs for PPH (mnemonic)?

Answer 5

• previous PPH
• multiple pregnancy
• obesity
• large baby
• failure to progress in 2nd stage
• prolonged third stage
• pre-eclampsia
• placenta accreta
• retained placenta
• instrumental delivery
• general anaesthesia
• episiotomy or perineal tear

PARTUM
o Prolonged labour/ Polyhydramnios/ Previous C-section
o APH (antepartum haemorrhage)
o Recent Hx of bleeding
o Twins
o Uterine fibroids
o Multiparity

Question 6

What measures can be done to reduce risk of PPH?

Answer 6

• treat anaemia during antenatal period
• give birth with empty bladder (as full bladder reduces uterine contraction)
• active management of 3rd stage
• IV tranexamic acid can be used during C section in high-risk pts

Question 7

What does management of PPH involve?

Answer 7

is an obstetric emergency:

• resus with ABCDE approach
• lie woman flat, keep her warm and communicate with her and partner
• insert two large-bore cannulas
• bloods for FBC,U&E and clotting screen
• group and cross match 4 units
• warmed IV fluid and blood resus as required
• oxygen (regardless of sats)
• fresh clotting abnormalities or after 4 units of blood transfusion

In severe cases, activate the major haemorrhage protocol. Each hospital will have a major haemorrhage protocol, which gives rapid access to 4 units of crossmatched or O negative blood.

Question 8

What can the treatment options to stop the bleeding in PPH be split into?

Answer 8

• mechanical
• medical
• surgical

Question 9

What do mechanical treatment options involve in PPH?

Answer 9

• rubbing the uterus (fundus) to stimulate uterus contraction
• catheterisation (bladder distention prevents uterine contraction)

Question 10

What do medical treatment options involve in PPH?

Answer 10

• oxytocin (slow injection followed by continous infusion):
  The intravenous infusion of oxytocin is given as 40 units in 500 mls. You may hear midwives or obstetricians referring only to “40 units” without specifying the drug. They are referring to an oxytocin infusion for PPH.
• ergometrine (IV or IM) stimulates smooth muscle contraction (contraindicated in hypertension)
• carboprost (IM) - prostogalandin analogue which stimulates uterine contraction
• misoprostol (sublingual) also prostaglandin analogue
• tranexamic acid (IV) - antfibrinolytic so reduced bleeding

Question 11

What do surgical treatment options involve in PPH?

Answer 11

• Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
• B-lynch suture - putting a suture around the uterus to compress it
• uterine artery ligation - stops supply to uterus reducing blood flow
• hysterectomy as a last resort

Question 12

What is secondary PPH most likely due to? management?

Answer 12

-retained products of conception (RPOC: USS)
or
-infection (endocervical and high vaginal swabs)- endometritis

Management depends on the cause:

1. Surgical evaluation of retained products of conception
2. Antibiotics for infection

Question 13

What are the investigations for secondary PPH?

Answer 13

• US to look for RPOC

- endocervical and high vaginal swabs for infection

Question 14

What is the management of secondary PPH?

Answer 14

• surgical evaluation of retained products of conception

- antibiotics for infection

Question 15

Causes of postpartum haemorrhage (mnemonic):

Answer 15

4Ts
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)

Question 16

RFs for PPH:

Answer 16

Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in the second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear

Question 17

Management of PPH:

Answer 17

1. Resucitation with ABCDE approach
   Consider activation of obstetric major haemorrhage protocol (2222) & contact blood bank
2. Lie the woman flat/keep her warm
3. Insert two large bore cannulas
4. Bloods including Group/Save and Crossmatch 4 units; VBG, FBC, U&E and clotting screen
5. Oxygen
6. Warmed IV fluids
7. Blood resuscitation if required : Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Further management
1. Mechanism
a) Rubbing the uterus: through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
b) Catheterisation (bladder distention prevents uterus contractions)

2. Medical
   a) Oxytocin (slow injection followed by continuous infusion):
   The intravenous infusion of oxytocin is given as 40 units in 500 mls. You may hear midwives or obstetricians referring only to “40 units” without specifying the drug. They are referring to an oxytocin infusion for PPH.

b) Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)

c) Carboprost (intramuscular) is a prostaglandin analogue (PGF2α) and stimulates uterine contraction (caution in asthma)

d) Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction

e) Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

3. Surgical treatment
   a) Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
   b)nB-Lynch suture – putting a suture around the uterus to compress it
   c) Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
   d) Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Question 18

classification(s) of PPH:

Answer 18

500ml after a vaginal delivery
1000ml after a caesarean section

It can be classified as:

Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss

Major PPH can be further sub-classified as:

Moderate PPH – 1000 – 2000ml blood loss
Severe PPH – over 2000ml blood loss

Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth

Question 19

Preventative methods for PPH:

Answer 19

1. Treating anaemia during the antenatal period
2. Giving birth with an empty bladder (a full bladder reduces uterine contraction)
3. Active management of the third stage (with intramuscular oxytocin in the third stage)
4. Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Question 20

causes of secondary PPH:

Answer 20

1. retained products of conception (RPOC)
2. infection (i.e. endometritis) with: fever, offensive discharge or previous C-section (retained placental tissue may be embedded in uterine scar from previous caesarian)

Question 21

Investigations/management of secondary PPH:

Answer 21

Investigations involve:

1. Ultrasound for retained products of conception
2. Endocervical and high vaginal swabs for infection

Management depends on the cause:

1. Surgical evaluation of retained products of conception
2. Antibiotics for infection

Question 22

what kind of prostaglandin is Carboprost? (main use)

Answer 22

PGF2α. Main use: PPH treatment

Question 23

different prostaglandins and their uses

Answer 23