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Obstetrics and Gynaecology > Postpartum hemorrhage > Flashcards

Postpartum hemorrhage Flashcards

1
Q

Definition for vaginal and C/S

A

More than 500ml vaginal and more than 1l c/s

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2
Q

Incidence

A

5-15%

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3
Q

Etiology 4Ts

A

Tone
Tissue
Trauma
Thrombin

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4
Q

Etiology of secondary PPH and what is the definition

A

After 24 hours
Retained products
Endometritis
Sub-involution of uterus

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5
Q

Labour causes of atonic uterus

A

prolonged, precipitous, induced, augmented

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6
Q

Overall causes of atonic uterus

A 
Labour
Uterus
Placenta
Maternal
Pain releif
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7
Q

Uterine causes of atony

A

Chorioamnionitis

Overdistension

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8
Q

Causes of overdistended uterus

A

Multiples
Polyhydramnios
Macrosomia
Fibroids

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9
Q

Placenta causes of atony

A

Placenta previa

Placental abruption

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10
Q

Maternal factors associated with atony

A

Grandparity
Gestational HTN
Obesity

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11
Q

Tissue factors (3)

A

Retained products
Abnormal placenta
Blood clots

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12
Q

Trauma causes

A 
Laceration
Episiotomy
Hematoma
Uterine rupture
Uterine inversion
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13
Q

Thrombin causes

A

Maternal blood disorders- VWD, TTP, ITP, DIC, pre-eclampsia HELLP
Blood thinners

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14
Q

Most common cause of PPH

A

Atonic uterus

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15
Q

Antenatal risk factors (11)

A 
>35 years
Asian
Obesity
Grand multi
Uterine abnormalities
Blood disorders
Previous PPH
Anemia
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16
Q

Intrapartum risk factors

A 
Prolonged
Precipituous
Chorioamnionitis
Oxytocin use
AFE/DIC
Uterine inversion
Genital tract trauma
AVB
CS
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17
Q

Why is a CS more likely to have PPH in some circumstances

A

Due to the reason for a cesarean often being an emergency

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18
Q

Post natal risk factors (4)

A

Retained products
AFE/DIC
Full bladder not allowing uterus to contract
Drug induced hypotonia

19
Q

Drugs causing hypotonia used in labour

A

Anaesthetic

Magnesium sulphate

20
Q

Prevention- antenatal, intrapartum and post-partum

A

Antepartum->Identify risk factors early, document Mx plan. Refer to specialists as required
Intrapartum->manage high risk->IV access, GH, Xmatch, have synto infusion ready
Active management of third and fourth stage

21
Q

Possible complication

A 
Hypovolemic shock
AKI
ARDS
DIC
Sheehans syndrome
Hepatic failure
22
Q

Management when high risk and refusal of blood products

A

Identify placental site
Optimise pre-birth Hb
Active management third stage labour
Identify acceptable resuscitation fluid manageemnt
Consider pharmacological, mechanical and surgical procedures to avert use of banked blood
Folic acid
Vitamine B12
Discuss AHD
Alternative/salvage therapy
Discuss risks of uterin atonia with delay in stages 1 and 2 and corrective treatment such as augmentation with oxytocin

23
Q

Intrapartum management when high risk

A 
Episiotomy if required
Active management third stage
IV access
FBC, GH, xmatch
BC if suspect chorioamnionitis
IV fluids, IV antibiotics if infection
Call for senior if require cesaerean
24
Q

Active management of third stage

A 
IM oxytocin 10 IU
Syntometrine (CI in hypertension)
Suprapubic counterpressure 
Controlled cord traction
Cord clamping
25
Q

When should suprapubic counterpressure be applied

A

Prior to controlled cord traction

26
Q

Post natal risk management when risk factors

A 
Routine care
Oxytocin infusion post birth
1/4 hourly observation for 1 hour
Maintain IV access for 24 hours
Early recognition of puerperal hematoma
27
Q

When to suspect puerperal hematoma

A 
Unable to ID common causes of PPH
Excessive or persistent pain
Hypovolemic shock disproportionate to revealed blood loss
Pelvic pressure
Urinary retention
28
Q

How to manage hematoma

A

Resuscitate
Vaginal and PR exam to determine site and extent
?Transfer to OT for clot evacuation, primary repaire or tamponade of vessels

29
Q

Management of PPH resus and assess

A 
Assess blood loss
Adress woman's concerns
Lie flat, keep warm
DRABCS- call for help
Non-rebreather 02 15L
2 X 14-16 guage cannulas- send urgent FBC, GH, Xmatch, coags, UEC, Ca2+, lactate
IV1: fluid and blood component resuscitation->Avoid excess crystalloid, give 2-3L
Transfuse 2U RBCs 
IV2: drug therapies
Insert IDC
Assess/record vitals every 5 minutes and temp every 15 minutes
Treat the cause
30
Q

Treat the cause outline->questions to ask

A 
Placenta out and complete?
Fundus firm?
Genital tract intact?
Blood clotting?
Assess for unknown
31
Q

Unknown causes of PPH

A

Uterine rupture
Inversion
Puerperal hematoma
AFE, Subcapsular liver rupture

32
Q

Management when placenta not out or incomplete

A 
Do not massage fundus
Ensure third stage oxytocin given
Apply CCT and attempt delivery
Post delivery check if complete
Massage fundus and assess tone
Transfer to OT if needed
33
Q

Indications to transfer to OT for tissue issue

A

Placenta adherent/trapped

Cotelydon + membranes missing

34
Q

Management of atonic uterus (9)

A 
Massage fundus
Ensure 3rd stage oxytocin given
Expel clots
Empty bladder
IV oxytocin 5IU slowly
IV/IM ergometrine 250 micrograms
Oxytocin infusion 40IU/1L crystallois @ 125-250ml/hr
PR misoprostol 800-1000mcg
Administer second line drugs if required
35
Q

What are the second line drugs for uterus atony

A

Intramyometrial PGF2a (Dinoprost)

36
Q

Management of genital tract trauma

A

Identify/inspect cervix, vagina, perineum
Clamp obvious bleeders
Repair
T/F to OT if indicated

37
Q

When to transfer to OT with genital tract trauma

A

Cannot see/repair injury

38
Q

Management for blood clotting disorder

A

Urgent FBC, caugs, eLFTs, ABG
Monitor 30-60 minutely FBC, coags, Ca, ABG
Do not delay treatment waiting for blood results
Activate MTP

39
Q

Outline MTP

A

RBC, FFP, Platelets

Cryoprecipitate if Fibrinogen

40
Q

Two things to avoid in blood clotting abnormality and MTP

A

Hypothermia

Acidosis

41
Q

Management when bleeding not controlled

A

Bimanual compression
Transfer to OT->lay flat, oxygen
Consider criteria for MTP activation

42
Q

OT interventions based on cause

A

Tissue->manual remove +/- currette
Tone-> IU balloon tamponade, angiographic embolisation, laparotomy with BiLynch compression suture/uterin artery ligation/hysterectomy
Trauma-> anaesthetic, exposure, inspect, assess uterus intact, repair
Thrombin-> angiographic embolisation, uterine artery ligation, hysterectomy
Unknown->EUA

43
Q

Management once bleeding controlled

A 
Monitor->vitals, fundal tone, vaginal blood loss, Hb
Promote bonding
Transfer as needed
Document
Psychological support and debriefing
Treat anemia
VTE prophylaxis
Monitor for DVT/PE
Educate on self care
Advise re followup
44
Q

How to prepare dinoprost and administer

A

1mg mixed with 10ml normal saline (1mg/ml) Inject 1ml into myometrium via abdomen, rub uterine fundus.
Repeat at 1 minute intervals

Obstetrics and Gynaecology (45 decks)

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