Postpartum haemorrhage

Question 1

Definition of primary PPH

Answer 1

Blood loss of 500 ml or more from the genital tract within 24 hours of delivery

Question 2

Definition of secondary PPH

Answer 2

Excessive blood loss 500ml between 24 hours and 12 weeks after delivery

Question 3

Causes of primary PPH ( 4x Ts)

Answer 3

1. Tissue - Placenta being retained or abnormal placental site
2. Tone - Uterine atony
3. Thrombosis problem - coagulation problem
4. Trauma - of the genital tract

Question 4

Most common cause of PPH

Answer 4

1. Uterine atony - failure of uterus to contract after delivery

Question 5

Antenatal risk factors for PPH

Answer 5

1. Previous PPH
2. Low lying placenta ( placenta previa)
3. Maternal age > 35
4. High BMI

Question 6

Medical management

Answer 6

1. IV synctocinon / Oxytocin

2. IV Carboprost

Question 7

Surgical management

Answer 7

Intra unterine balloon tamponade

Question 8

What are the risk factors for uterine atony and therefore postpartum haemorrhage? ( all increase distention of uterus )

Answer 8

Multiple pregnancy

Grand multiparity or nulliparity

Fetal macrosomia

Polyhydramnios

Fibroid uterus

Prolonged labour

Previous PPH

Question 9

Why does multiple pregnancy increased the risk of PPH?

Answer 9

Placental site is larger than with a singleton. There is also over distension which increases risk of uterine atony.

Question 10

What is the main risk factor for uterine rupture as a cause of PPH?

Answer 10

Previous caesarian section

Question 11

What are the complications of primary postpartum haemorrhage?

Answer 11

Haemorrhagic shock and death

Sheehan’s syndrome

Question 12

What is Sheehan’s syndrome?

Answer 12

Avascular necrosis of the pituitary gland resulting in hypopituitarism on the back of PPH.

Question 13

How do we prevent primary PPH and the complications of it?

Answer 13

Monitoring and treatment of low Hb in antenatal period

Identify those with risk factors early on

Active management of the third stage of labour

Question 14

What are the causes of secondary postpartum haemorrhage?

Answer 14

Retained products

Endometritis (infection)

Persistent molar pregnancy / choriocarcinoma

Question 15

What investigations would you need to do in someone with primary PPH?

Answer 15

FBC
Clotting screen, including fibrin degradation
U+Es
Group and save or crossmatch

Urine output

USS - check for retained products if persisting

Question 16

What investigations would you need to do in someone with secondary PPH?

Answer 16

FBC
Clotting screen, including fibrin degradation
U+Es
Group and save or crossmatch

Urine output

USS - check for retained products if persisting

High vaginal swab - endometritis

hCG - if stays high indicates molar pregnancy

Question 17

How do you manage a patient suffering primary PPH caused by uterine atony?

Answer 17

1. ABCDE approach - think about giving transfusion
2. Massage uterus abdominally
3. IV syntocinon 10 units STAT and/or IV ergometrine 500 micrograms - followed by an IV infusion
4. IM carboprost - F2 alpha prostaglandin or Misoprostol PR
5. other options include: balloon tamponade, B-Lynch suture, ligation of the uterine arteries or internal iliac arteries