Post-partum Haemorrhage

Question 1

Define PPH.

Answer 1

• >500ml in SVD
• >1,000ml in CS

Question 2

What is the difference between primary and secondary PPH?

Answer 2

• Primary PPH = within 24h
• Secondary PPH = 24h to 12 weeks

Question 3

What are the risk factors for PPH?

Answer 3

• Prev. PPH
• Prev. ELCS/EMCS
• Prolonged labour
• Macrosomia
• Pre-eclampsia
• APH
• Multiple pregnancy
• Grand multiparity
• Fibroids

Question 4

What are the causes of primary PPH?

Answer 4

• Tone - Uterine Atony (most common)
• Tissue - retained placental products - membranes, cotyledon, succenturiate lobe
• Trauma - laceration to vagina, cervix, uterus - includes episiotomy
• Thrombin - Coagulopathy

Question 5

How can uterine atony be avoided?

Answer 5

Administration of oxytocin with delivery of anterior shoulder or placenta

Question 6

What are the causes of uterine atony?

Answer 6

• Overdistended uterus – polyhydramnios, multiple gestations, macrosomia
• Uterine muscle exhaustion – prolonged or rapid labour, grand multiparity, oxytocin use in 2nd stage, GA
• Uterine anatomy abnormal – fibroids, placenta praevia, placental abruption
• Intra-amniotic infection – fever, prolonged ROM

Question 7

What are the causes of secondary PPH?

Answer 7

• Endometritis
• Retained products
• Abnormal involution of placental site
• Trophoblastic disease

Question 8

What are the signs and symptoms of primary PPH?

Answer 8

• General – shock (tachycardia, hypotension), signs of anaemia
• Abdomen – atonic uterus (above umbilicus)
• Speculum – exclude trauma
• Vaginal – possible uterine tenderness

Question 9

What are the signs and symptoms of secondary PPH?

Answer 9

• Abdomen – tender uterus
• Speculum – assess bleeding, is the cervical os open
• Vaginal – uterine tenderness

Question 10

What is classified as a major PPH?

Answer 10

• >1,000mL blood loss

OR

• Signs of shock

Question 11

What is the management of PPH?

Answer 11

• Ring the emergency buzzer
• Bimanual compression
• Step 1: IM/IV syntocinon 10U
• Step 2: IM ergometrine/syntometrine
• Step 3: IM carboprost
• Step 4: Balloon tamponade - i.e. Bakri Balloon
• Step 5: B-lynch suture
• Step 6: hysterectomy

Question 12

What are the complications of PPH?

Answer 12

• Death
• Hysterectomy
• VTE
• Renal failure
• DIC
• Sheehan’s syndrome

4^th most common cause of maternal death in the UK - leading cause world-wide

Question 13

What is the management of PPH with uterine hyperstimulation?

Answer 13

Tocolytics

Question 14

What are the contraindications of ergometrine/syntometrine?

Answer 14

• Hypertension
• Asthmatics

Question 15

What are the contraindications of carboprost?

Answer 15

• Asthmatics

Question 16

What are the kinds of incorrect attachment of the placenta?

Answer 16

• Accreta = strong attachment, not into muscle wall
• Increta = into uterine muscle wall
• Percreta = through the uterine wall

Question 17

What are the risk factors for placenta accreta/increta/percreta?

Answer 17

• History of accreta
• Previous CS/uterine surgery
• Endometrial curettage

Question 18

What are the appropriate investigations for suspected placenta accreta/increta/percreta?

Answer 18

• TVUSS
• MRI (assess depth of invasion)

Question 19

What is the management of placenta accreta/increta/percreta?

Answer 19

Managed delivery ± caesarean hysterectomy

• 35 to 36+6 weeks delivery