Puerperium Flashcards
Define primary post-partum haemorrhage
Loss of > 500ml of blood per-vagina within 24 hours of delivery
- minor = 500-1000
- major = > 1000
Aetiology of primary PPH
Tone - uterine atony is most common cause
- maternal profile - age>40, BMI > 35, Asian ethnicity
- uterine overdistention - multiple pregnancy, polyhydramnios, foetal macrosomia
- labour - induction, prolonged
- placental problems - placenta praevia, placental abruption, previous PPH
Tissue
- retained placental tissue
Trauma
- instrumental delivery
- episiotomy
- c-section
Thrombin
- vascular - placental abruption, hypertension, pre-eclampsia
- coagulopathies
Clinical features of primary PPH
Bleeding per vagina
Dizziness, palpitations SOB
Investigations for primary PPH
FBC Cross match 4-6 units Coagulation profile U+E LFTs
Management of primary PPH
Immediate
- resuscitation
- involve whole team
- investigations and monitoring
Definitive management of primary PPH
Uterine atony
- bimanual compression to stimulate uterine contraction
- pharmacolgical measures
- intrauterine balloon, haemostatic suture, hysterectomy
Trauma
- repair of primary laceration
Tissue
- IV oxytocin, manual removal of placenta with regional or GA
Thrombin
- correct with blood products under advice of haemotolgy
Drugs used in primary PPH
Syntocinon
- synthetic oxytocin - act on receptors in myometrium
- SE = N+V, headache, rapid infusion, hypotension
- CI = hypertoninic uterus, severe CVS disease
Ergometrine
- multiple receptor sites
- SE = hypertension, nausea and bradycardia
- CI = hypertension, eclampsia, vascular disease
Carboprost
- prostaglandin analogue
- SE = bronchospasm, pulmonary oedema, HTN, cardiovascular collapse
- CI = cardiac disease, pulmonary disease
Misoprostol
- prostaglandin analogue
- SE = diarrhoea
Prevention of primary PPH
Active management of 3rd stage of labour
- 5-10 units IM/IV oxytocin
Define secondary post-partum haemorrhage
Excessive vaginal bleeding in period from 24 hours after delivery to 12 weeks postpartum
Risk factors for secondary PPH
Uterine infection - endometritis
- risk factors include C-section, premature rupture of membranes and long labour
Retained placental fragments or tissue
Abnormal involution of placental site
- inadequate closure and sloughing of spiral arteries at placental attachment site
Trophoblastic disease
Clinical features of secondary PPH
Excessive vaginal bleeding
- spotting on and off with occasional gush of fresh blood
Investigations for secondary PPH
FBC U+Es CRP Coagulation profile G+S Blood cultures USS pelvis - retained placental tissue
Management of secondary PPH
Antibiotics - ampicillin and metronidazole
Uterotonics - syntocinon, carboprost and misoprostol
Surgical if excessive of continuing - insertion of balloon catheter
Features of depression during pregnancy
Low mood Lethargy Anhedonia Poor sleep and appetite Worries about childbirth and caring for baby
Management of depression during pregnancy
Social support and psychological treatments
Seek specialist advise before prescribing antidepressants
