Primary Postpartum Haemorrhage

Question 1

AETIOLOGY:

Answer 1

1. Uterine atony(80%)
2. Retained placenta/placental tissue(2.5%)
3. Coagulopathy
   - congenital, DIC
4. Tears, genital trauma
   - Vaginal(20%), cervical(associated with precipitate labour and instrumental delivery)

Question 2

DEFINITION AND EPIDEMIOLOGY:

Answer 2

• Loss of >500 mL blood <24h of delivery
• Loss of 1000 mL blood after C-section
• 5-7% of pregnancies

Question 3

RISK FACTORS:

Answer 3

1. Previous History
2. Previous Caesarean delivery
3. Coagulation defect/anticoagulant therapy
4. Instrumental/Caesarean delivery
5. Retained placenta
6. APH
7. Polyhydraminos
8. Multiple pregnancy
9. Grand multiparity
10. Uterine malformations
11. Fibroids
12. Prolonged and induced labour
13. Pre-eclampsia
14. Increased maternal age
15. Placenta praevia, placenta accreta
16. Ritodrine(used for tocolysis)

Question 4

MANAGEMENT:

Answer 4

1. Resus(ABC)
   - Position flat and keep warm
   - IV access, wide-bore cannula(14G x 2)
   - Cross-match blood(4 units minimum)
   - Bloods: FBC, Group and Screen/crossmatch, coagulation, U&Es, LFTs
   - Obs: Monitor Sats, pulse, BP, respiratory rate every 15 mins
   - Urinary catheter: hourly urine volumes
   - Consider transfer to ITU when bleeding controlled
2. Initial Management(Atony most likely cause):
   a) Bimanual compression of uterus during transfer/waiting for experienced hands. Rub up fundus to stimulate contractions
   b) Empty bladder with Foley catheter
   c) Oxytocin 5 units slow IVI
   d) Ergometrine 0.5 mg slow IVI/IM(CI in hypertension)
   e) Oxytocin infusion(40 units in 500 mL isotonic crystalloid at 125 mL/h)
   f) Carboprost 0.25 mg IM at intervals ≥15 mins, max 8 doses(caution in asthma)
   g) Misoprostol 800 mcg sublingually
   h) Surgical management if persistent
   - Rusch balloon/Intrauterine balloon tamponade
   - Brace suture, B-Lynch suture
   - Ligation of uterine arteries/internal iliac arteries
   - Uterine artery embolization
   - Hysterectomy if all fails
3. Remove placenta manually if bleeding/not expelled by normal methods within 60 min delivery
4. Vaginal examination for lacerations
5. Bimanual compression of uterus.

Question 5

SECONDARY PPH:

1. Definition
2. Aetiology
3. Investigations
4. Treatment

Answer 5

1. Excessive blood loss btw 24h and 12w post-partum
2. a) Endometritis with or without retained placental tissue
   - characteristically causes chronic bleeding that slows with antibiotics and worsens after course is finished.
   b) Gestational trophoblastic disease or incidental gynaecological pathology(rare)
3. a) Vaginal swabs
   b) FBC, CRP, cross-match
   c) USS
   d) Histological examination of evacuated tissues to exclude gestational trophoblastic disease
4. a) Antibiotics
   b) Evacuation of Retained Products of Conception(ERPC) if heavy bleeding

Question 6

MINOR PPH(500-1000 mL blood loss without clinical shock):

Answer 6

1. IV access(14G cannula x1)
2. Bloods: Group and screen, FBC, coagulation ie fibrinogen
3. Pulse, RR, BP every 15 mins
4. Warmed crystalloid infusion

Question 7

SIGNS OF ONGOING HAEMORRHAGE:

Answer 7

1. Tachycardia
2. Hypotension
3. Decreased urine output <30 mL/h