Women's Health : Postpartum Haemorrhage

Question 1

What is postpartum haemorrhage (PPH)?

Answer 1

Loss of more than 500ml of blood from the genital tract within 24 hours of delivering a baby.

Question 2

What are the classifications of PPH by volume?

Answer 2

Minor, Major, Moderate, Severe

Question 3

What is Minor PPH?

Answer 3

500-1000ml

Question 4

What is Major PPH?

Answer 4

> 1000ml

Question 5

What is Moderate Major PPH?

Answer 5

1000-2000 ml

Question 6

What is Severe Major PPH?

Answer 6

> 2000ml

Question 7

What are the four Ts causes of PPH?

Answer 7

Tone, Tissue, Trauma, Thrombin

Question 8

What is the commonest cause of PPH?

Answer 8

Uterine atony

Question 9

What can affect tone in regards to causing PPH?

Answer 9

Inadequate contraction of the uterus after separation of the placenta leads to profuse bleeding from the decidua.

Question 10

What are the causes of uterine atony?

Answer 10

multiple pregnancy, macrosomia, polyhydramnios, retained placenta, prolonged second stage of labour.

Question 11

What can affect tissues in regards to causing PPH?

Answer 11

(tissue retained in uterus): Typically part of placenta, sometimes retention of part of foetal / maternal membranes. Prevents proper uterine contraction and resulting vessel occlusion.

Question 12

What are the causes of tissue retention in uterus?

Answer 12

placenta praevia, placenta accreta spectrum, succenturiate placental lobe, preterm delivery

Question 13

How does Trauma affect PPH?

Answer 13

Trauma to genital tract leading to bleeding - includes caesarean section.

Question 14

What are the causes of trauma in PPH?

Answer 14

vulvovaginal tears, instrumental delivery, episiotomy.

Question 15

How does Thrombin affect PPH?

Answer 15

Normal bleeding worsened by pre-existing / obstetric coagulopathy / thrombocytopenia.

Question 16

What are the causes of Thrombin affecting PPH?

Answer 16

pre-eclampsia, HELLP syndrome, DIC, puerperal sepsis, von Willebrand disease, dilutional coagulopathy (resuscitation with high volumes of crystalloid).

Question 17

What is the management of minor PPH?

Answer 17

IV access with 14-gauge cannula, G+S, FBC, coagulation screen, Frequent observations every 15 minutes, Warmed crystalloid infusion.

Question 18

What is the management of major PPH?

Answer 18

As for minor PPH, plus: Lie patient flat, give high flow oxygen, O-negative blood as soon as possible - warmed crystalloid until blood is available, Ongoing haemorrhage: blood component transfusion - FFP, platelets, cryoprecipitate - guided by blood counts and clotting profile.

Question 19

In both Minor and Major PPH, what is the treatment of underlying cause?

Answer 19

Fundal massage, Catheterisation, Oxytocin and ergometrine, Carboprost (uterotonic), Misoprostol.

Question 20

In both Minor and Major PPH, what are the second line surgical measures?

Answer 20

Intrauterine balloon tamponade, Haemostatic suturing (B-Lynch), Uterine devascularization / arterial ligation, Hysterectomy.