Primary/Secondary PPH

Question 1

Define primary postpartum haemorrhage (PPH)

Answer 1

> 500ml blood loss per-vagina within 24hr

• Minor PPH = 500-1000ml
• Major PPH = >1000ml

Question 2

Outline the aetiology and RF for primary PPH

Answer 2

TONE

• uterus fails to contract due to lack of tone
• RF = old, BMI >35, multiple preg, polyhydramios, placental problems

TISSUE
- retention of tissue which prevents the uterus contracting

TRAUMA

• damage
• RF = instrumental, episiotomy, CS

THROMBIN
- coagulopathies/vascular abnormalities

Question 3

What are the clinical features of PPH?

Answer 3

Exam = haemodynamic instability with tachypnoea, prolonged CRT, tachycardia, hypotension

Abdo exam = uterine rupture i.e. palpation of fetal parts as it moves into the abdomen from the uterus

Speculum = sites of local trauma causing bleeding.

Examine the placenta to ensure that the placenta is complete (a missing cotyledon or ragged membranes could both cause a PPH).

Question 4

How should PPH be investigated?

Answer 4

Bloods = FBC, x-match, coag, U+E, LFT

Question 5

Outline the management of PPH

Answer 5

A-E

Uterine Atony = bimanual compression (stim contraction), intrauterine tamponade, suture (B-lynch), A ligation, hysterectomy

• IM ergometrine = contracts small vessels
• IM syntometrine = synthetic oxytocin
• PO/PV/PR Misoprostol = synthetic prostaglandin

Trauma = repair laceration, hysterectomy

Tissue = IV/IM oxytocin, manual removal of placenta (make sure complete)

Thrombin = correct coag abnormalities

Question 6

How should PPH be prevented?

Answer 6

Women delivering vaginally = 5-10 units of IM Oxytocin prophylactically.

Women delivering via CS = 5 units of IV Oxytocin

Question 7

Define secondary postpartum haemorrhage (SPH)

Answer 7

Excessive vaginal bleeding in the period from 24 hours after delivery to twelve weeks postpartum

Question 8

Name the causes of SPH

Answer 8

Endometritis

Retained placental tissue

Abnormal involution of placental site

Trophoblastic disease

Question 9

How does SPH present?

Answer 9

Excessive vaginal bleeding

Features of hypovolemic shock

Endometritis = fever, rigor, lower abdo pain/tenderness, foul smelling lochia

Retained placenta = high uterus

Question 10

How is SPH best managed?

Answer 10

Abx = co-amoxiclav + metronidazole + cepharoxin

Uterotonics = syntocinon (oxytocin), syntometrine (oxytocin+ergometrine), carboprost (prostaglandin F2) and misoprostol (Prostaglandin E1)

Balloon catheter

Retained products = EVAC