Obstetric haemorrhage

Question 1

Define Obstetric Haemorrhage

Answer 1

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

• Minor = 500-1000mL
• Major >1000mL
  »Moderate = 1000-2000mL
  »Massive >2000mL OR 150mL/min

Question 2

Give 3 antenatal causes of Obstetric Haemorrhage

Answer 2

Previous PPH
Placeta abruption / Placenta pravia
Grand multiparity (>= 6 children prior)
HELLP syndrome
Over distended uterus (eg polyhydramnios - prevents contraction of uterus after)

Question 3

Give 3 intra-partum causes of Obstetric haemorrhage

Answer 3

Prolonged 1st or 2nd stage
Oxytocin use
Precipitate delivery (rapid delivery)
Operative vaginal delivery (episiotomy)
Second stage caesarean section

Question 4

Give 4 post-partum causes of Obstetric haemorrhage

Answer 4

4 T’s
Tone - uterine atony
Trauma - episiotomy
Tissue - retained tissue (eg retained placenta)
Thrombin - clotting abnormalities

Question 5

What is the presentation of Placenta previa?

Answer 5

Painless bleeding, could be life threatening

(usually diagnosed on 20 week scan, often as the uterus grows the placenta moves with it and placenta previa resolves)

Question 6

What is Placenta Accreta?

Answer 6

Serious pregnancy condition that occurs when the placenta grows too deeply into the uterine wall (grows deeply into endometrium)

Question 7

What is Placenta increta

Answer 7

Condition where the placenta attaches more firmly to the uterus and becomes embedded in the organ’s muscle wall (grows deeply into myometrium)

Question 8

What is Placenta percreta

Answer 8

Condition where placenta attaches itself and grows through the uterus and potentially to the nearby organs (such as the bladder)

Question 9

What is Vasa praevia

Answer 9

Presentation of Umbilical vessels lacking Wharton’s jelly below the presenting part, rupture of vessel causes bleeding from the baby
(fetal blood vessels cross or run near the internal opening of the uterus)

Question 10

What is the management for Placenta Previa?

Answer 10

Delivery by Caeserean section at fetal maturity (usually ~37 weeks) unless massive haemorrhage antenatally where CS is performed ASAP

Question 11

What is the presentation of Placental Abruption?

Answer 11

Painful bleeding? (due to separation and contractility) - massive Postpartum haemorrhage may occur

Reduced / Absent fetal movements (reduced oxygen supply to fetus - intrauterine fetal death may occur)

TENSE, Tender abdomen

Note, DIC may occur due to disruptions in the coagulation pathway

Question 12

What is the emergency management for Placental Abruption?

Answer 12

Immediate management by IOL or by Caesarean section

Also remember A-E approach. Major haemorrhage protocol. Empty bladder.

Question 13

What antenatal management steps can be used to prepare for Obstetric haemorrhage?

Answer 13

Consultant led care.

Optimise haemoglobin antenatally
- Hb check at booking, then 28/40

G&S at booking +/- Crossmatch (especially if risk of haemorrhage or atypical antibodies)

Prophylactic 10 units Oxytocin IM at delivery

Question 14

What is the management for Post-partum haemorrhage?

Answer 14

A-E approach; Resuscitation + Observations,
Empty bladder + Bimanual compression of uterus

Identify cause and treat:
o Tone&raquo_space; Uterine atony (Tone) = Compress uterus + Oxytocics
o Tissue (retained) = Remove placenta (EUA)
o Trauma = Suturing
o Thrombin = Coagulation correction

Fluid replacement&raquo_space; Crystalloids//Colloids; Blood +FFP +Cryoprecipitate +Platelets

Oxytocics (eg Oxytocin / Ergometrin / Misoprostol / Carboprost)

Massive haemorrhage = Massive haemorrhage protocol + Theatre + Thromboelastogram

Surgical management:
- Atony = Bakri balloon
- Uterine haemostatic sutures (B-lynch sutures)
- Internal iliac ligation (vasc surgeons); Selective artery occlusion/embolisation (by IR)
- Hysterectomy