PPH

Question 1

PPH definition

Answer 1

• > 1000 or

- blood loss with symptomatic anemia with 24h delivery

Question 2

Etiology of PPH

Answer 2

PRIMARY CAUSES
atony (most common)
lacerations
retained POC
accreta
DIC (associated with abruption and AFE (rare)
uterine inversion

SECONDARY CAUSES
placenta site subinvolution
ret POC
infection
inherited coagulapthy (vWD)

Question 3

Risk factors of PPH

Answer 3

none are predictive

Question 4

Prevention of PPH

Answer 4

• active management of third stage of labor recommended (though data not concrete)
  = Pitocin (IV or IM), methergine, porstaglandin, uterine massage, umbilical cord traction

Question 5

Management of PPH

Answer 5

1) uterine massage and bimanual compression + uterotonics
2) repair of lacerations and conservative or surgical treatment of hematoma
3) examination of placenta for retained POC (and manual vs banjo curette as indicated)
4) tamponade (manual compression, intrauterine packing, bark balloon, multiple foley ballon packing)
5) UAE (stable pts with continued bleeding)
6) surgery

Question 6

Oxytocin

Answer 6

• 10-40u/1000cc continuous infusion

- IM 10u

Question 7

methergine

Answer 7

0.2mg IM q2-4h
CI with HTN, cardiovascular disease
SE n/v, HTN when given IV which is not recommended

Question 8

15 methyl PGF

Answer 8

(hemabate)

0.25mg IM or intramyometrial q15-90m, max dose 8

CI: asthma
RCI: active hepatic, cardiovascular, pulmonary disease

Question 9

misoprostol

Answer 9

600-1000mcg po, sublingual, or rectally x1 dose

Question 10

TXA

Answer 10

not recommended ppx, but can be considered if above therapy fails

Question 11

vascular ligation

Answer 11

O Leary sutures (uterine artery ligation)
Urtero-ovarian artery ligation
hypogastric artery ligation is rarely performed today

Question 12

uterine compression

Answer 12

B-lynch #1 chromic (allows for rapid resorption and minimizes risk of bowel herniation through a persistent loop of suture

Question 13

hysterectomy

Answer 13

total or supracervical

• with placenta accreta with blood transfusion
• uterine conservation with focal accreta generally not successful
• for uterine rupture

Question 14

risk of accreta with previa according to CS

Answer 14

3%, 11%, 40%, 61%, and 67%

Question 15

Uterine inversion management

Answer 15

1) leave placenta attached to prevent further bleeding
2) give tocolytics
3) replace the inverted uterus (peripherally to centrally)
4) occasionally surgery is required:
- - Huntington procedure (serial clamping from above of the funds with allis clamp)
- - Haultian procedure (incising the cervix posteriorly to allow for reversion)

Question 16

transfusion

Answer 16

• give when hgb <7 and symptomatic, if asymptomatic then consider PRBC, oral or IV iron therapy
• consider when EBL 1500 + hypovolemic vital signs
• address hypovolemia and consumptive coagulpathy (hgb not a good marker in context of PPH)
• Massive transfusion = >10u or >4u PRBC in 1h for ongoing need for more blood
• MTP: 1:1:1 PRBC, FFP, Platelets
• cryo added if have consumptive coagulopathy

Question 17

massive transfusion is associated with

Answer 17

• HYPERkalemia
• citrate toxicity (preservative in blood products)
• HYPOcalcemia
• Pulmonary edema (when associated with excessive crystalloid infusion, transfusion reactions, and transmission of various pathogens)

Question 18

Alternatives to transfusion

Answer 18

• Cell salvage: seldom used
• Thrombin complex and fibrinogen concentrates (only used after successive rounds of massive transfusion)
• recombinant factor VII (controversial, only consider as a last resort)