Primary Post-Partum Haemorrhage

Question 1

What is primary postpartum haemorrhage?

Answer 1

Loss of >500ml of blood per vagina within 24 hours of delivery

Question 2

What are the classifications of primary PPH?

Answer 2

• Minor

- Major

Question 3

What is minor primary PPH?

Answer 3

500-1000ml blood loss

Question 4

What is major primary PPH?

Answer 4

> 1000ml blood loss

Question 5

What is the clinical importance of primary PPH?

Answer 5

It is a major cause of morbidity and mortality worldwide

Question 6

What can the causes of primary PPH be broadly classified into?

Answer 6

• Tone
• Tissue
• Trauma
• Thrombin

Question 7

What does ‘tone’ refer to in primary PPH?

Answer 7

Uterine atony

Question 8

What is the most common cause of primary PPH?

Answer 8

Uterine atony

Question 9

What is uterine atony?

Answer 9

When the uterus fails to contact adequately following delivery due to lack of tone in uterine muscle

Question 10

What does ‘tissue’ refer to in primary PPH?

Answer 10

Retention of placental tissue

Question 11

What is second most common cause of primary PPH?

Answer 11

Retention of placental tissue

Question 12

How does retention of placental tissue cause primary PPH?

Answer 12

It prevents the uterus from contracting

Question 13

What does ‘trauma’ refer to in primary PPH?

Answer 13

Damage sustained to the reproductive tract during delivery

Question 14

Give 2 examples of causes of trauma that can lead to primary PPH

Answer 14

• Vaginal tears

- Cervical tears

Question 15

What does ‘thrombin’ refer to in primary PPH?

Answer 15

Coagulopathies and vascular abnormalities

Question 16

What vascular abnormalities can cause primary PPH?

Answer 16

• Placental abruption
• Hypertension
• Pre-eclampsia

Question 17

What coagulopathies can cause primary PPH?

Answer 17

• Von Willebrand’s disease
• Haemophilia A or B
• ITP
• Acquired coagulopathies, e.g. DIC, HELLP

Question 18

What can the risk factors for uterine atony be divided into?

Answer 18

• Maternal factors
• Uterine over-distention
• Labour factors
• Placenta problems

Question 19

What maternal factors increase the risk of uterine atony?

Answer 19

• Age >40
• BMI >35
• Asian

Question 20

What can cause uterine over-distention therefore increasing the risk of uterine atony?

Answer 20

• Multiple pregnancy
• Polyhydraminos
• Fetal macrosomia

Question 21

What labour factors increase the risk of uterine atony?

Answer 21

• Induction of labour

- Prolonged labour (> 12 hours)

Question 22

What placental problems increase the risk of uterine atony?

Answer 22

• Placenta praevia
• Placental abruption
• Previous PPH

Question 23

What are the risk factors for traumatic PPH?

Answer 23

• Instrumental vaginal delivery
• Episiotomy
• C-section

Question 24

What is the main feature of primary PPH?

Answer 24

Bleeding from the vagina

Question 25

What symptoms may be present in primary PPH if there is substantial blood loss?

Answer 25

- Dizziness - Palpitations - Shortness of breath

Question 26

What examinations should be done in primary PPH?

Answer 26

- General examination - Abdominal examination - Speculum examination - Placenta examination

Question 27

What might be found on general examination in primary PPH?

Answer 27

Haemodynamic instability, with; - Tachypnoea - Prolonged CRT - Tachycardia - Hypotension

Question 28

What might be found on abdominal examination in primary PPH?

Answer 28

Signs of uterine rupture, e.g. palpation of fetal parts as it moves into abdomen from uterus

Question 29

What might be found on speculum examination in primary PPH?

Answer 29

May reveal sites of local trauma causing bleeding

Question 30

Why should you examine in placenta in primary PPH?

Answer 30

To ensure it is complete

Question 31

What initial laboratory tests should be done in primary PPH?

Answer 31

- FBC - Cross match 4-6 units of blood - Coagulation profile - U&Es - LFTs

Question 32

Who should be involved in the immediate management of PPH?

Answer 32

- Midwife in charge and midwives - Obstetricians - Anaesthetists - Blood bank - Clinical haematologists - Porters

Question 33

What is involved in the immediate management of primary PPH?

Answer 33

- Investigations and monitoring - Resuscitation using A-E approach - Consider catheterisation and insertion of a central venous line

Question 34

What monitoring should be done in primary PPH?

Answer 34

- RR - O2 sats - HR - BP - Temperature Done every 15 mins

Question 35

What does the definitive management of primary PPH depend on?

Answer 35

The underlying cause

Question 36

What is the management of primary PPH caused by uterine atony?

Answer 36

- Bimanual compression to stimulate uterine contraction - Pharmacological measures to increase uterine contraction - Surgical measures

Question 37

How is bimanual compression to simulate uterine contraction performed?

Answer 37

A gloved hand is inserted into the vagina, and a fist formed inside the anterior fornix to compress the anterior uterine wall. The other hand should apply pressure on the abdomen at the posterior aspect of the uterus

Question 38

What do you need to ensure when doing bimanual compression to stimulate uterine contraction?

Answer 38

The bladder is emptied by catheterisation

Question 39

What surgical measures can be used in uterine atony?

Answer 39

- Intrauterine balloon tamponade - Haemostatic suture around uterus - Bilateral uterine or iliac artery ligation - Hysterectomy (last resort)

Question 40

What drugs can be used primary PPH?

Answer 40

- Syntocinon - Ergometrine - Carboprost - Misoprostol

Question 41

What is syntocinon?

Answer 41

A synthetic oxytocin

Question 42

What does syntocinon do?

Answer 42

Acts on oxytocin receptors in the myometrium

Question 43

What are the side effects of syntocinon?

Answer 43

- Nausea - Vomiting - Headache - Rapid infusion can cause hypotension

Question 44

What are the contraindications to syntocinon?

Answer 44

- Hypertonic uterus | - Severe CVS disease

Question 45

What is the action of ergometrine?

Answer 45

Has action at multiple receptor sites

Question 46

What are the side effects of ergometrine?

Answer 46

- Hypertension - Nausea - Bradycardia

Question 47

What are the contraindications to ergometrine?

Answer 47

- Hypertension - Eclampsia - Vascular disease

Question 48

What is carboprost?

Answer 48

Prostaglandin analogue

Question 49

What are the side effects of carboprost?

Answer 49

- Bronchospasm - Pulmonary oedema - HTN - Cardiovascular collapse

Question 50

What are the contraindications to carboprost?

Answer 50

- Cardiac disease - Pulmonary disease, i.e. asthma - Untreated PID

Question 51

What is misoprostol?

Answer 51

Prostaglandin analogue

Question 52

What are the side effects of misoprostol?

Answer 52

Diarrhoea

Question 53

How is primary PPH caused by trauma managed?

Answer 53

Primary repair of any laceration

Question 54

How is primary PPH caused by uterine rupture managed?

Answer 54

Laparotomy and repair, or hysterectomy

Question 55

How is primary PPH caused by placental retention managed?

Answer 55

- Administer IV oxytocin - Manual removal of placenta with regional or general anaesthetic - Prophylactic antibiotics in theatre

Question 56

Where should the IV oxytocin infusion be started in primary PPH caused by placental retention?

Answer 56

In theatre

Question 57

How should primary PPH caused by coagulation problems be managed?

Answer 57

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

Question 58

How can the risk of primary PPH be reduced?

Answer 58

- Active management in 3rd stage of labour | - Prophylactic oxytocin

Question 59

By how much does active management in the 3rd stage of labour reduce the risk of PPH?

Answer 59

60%

Question 60

How much prophylactic oxytocin should be given to women delivering vaginally?

Answer 60

5-10units IM

Question 61

How much prophylactic oxytocin should be given to women delivering by C-section?

Answer 61

5 units IV