Post Partum Hemorrhage Flashcards
Definition of post partum hemorrhage
Blood loss of >500mls for vaginal delivery and >1000mls for C/S
What is early and late PPH
Early is within 24hrs
Late is after 24 hrs but within 6weeks (the puerpenium)
What are the 4 etiology factors for PPH
- Tone (uterine atony) - Most common
- Tissue (retained placenta, clots)
- Trauma (laceration, inversion)
- Thrombogenic (coagulopathy)
What are the for causes of 4 Tone uterine atony
- Overdistention of uterus (polyhydramnios, multiple gestations, macrosomia)
- Uterine muscle exhaustion (Prolonged or rapid labour, grand multiparity, oxytocin, general anaesthetic, tocolytic therapy)
- Uterine distortion (fibroids, placenta previa, placental abruption due to Couvelaire’s uterus)
- Intra-amniotic infection (chorioamnionitis, prolonged ROM)
What are the 4 causes of Tissue (retained placenta, clots)
- Retained placental products (accessary lobe, membrances). Likely to occue <24 weeks gestation
- Retained blood clots in an atonic uterus
- Abnormal placentation (placenta previa, vasa previa)
- Gestational trophoblastic neoplasia
What are the 5 causes of Trauma
- Lacerations (vagina, cervix, uterus)
- Episiotomies
- Hematoma (vaginal, vulvar, retroperitoneal) - can be due to instrumentation or episiotomy repair
- Uterine rupture
- Uterine inversion
What are 3 causes of preexisting thrombogenic causes
- vWD Von willebrands disease (most common)
- Idiopathic thrombocytopenic purpura
- Hemophilia A and B
What are causes of acquired thrombogenic causes
HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) DIC Severe infections (leading to sepsis) Severe preeclampsia Amniotic fluid embolus Abruptio placentae Intrauterine demise Anticoagulant therapy
What is the initial management of PPH
- Call for HELP and start resuscitation ABCs. Establish airway, make sure they are breathing and site 2 large bore IVs
- Take blood for CBC, U&E, PT/PTT, GXM and request pRBC (either their match or O-ve in emergency)
- Fluid resuscitation with isotonic solutions like N/S or LR
- Catheterize and monitor input/output
How do you diagnose the cause of the PPH
Do history and examination during resuscitation
Get history of coagulopathy
Examine for tone, tissue, trauma
How do you manage Tone (Uterine atony)
Bimanual massage to stimulate contraction and expulsion of clots
Removal of clots via vaginal exam
Oxytocin 5U IV bolus
Ergometrine IV/IM
Syntometrine 1ml ampule IV/IM (oxytocin 5 IU/mL and ergometrine maleate 0.5 mg/mL)
Misoprostol 600-800mcg po/sub lingual
Carboprost 250mcg IM/intramyometrial q15mins to max 2mg
How do you manage Tissue
D&C dilation and currettage. Manual removal is the mainstay of management. Done in the OT under anaethesia
If bleeding isn’t heavy
Adequate analgesia, postpartum syntocinon infusion and controlled cord traction
Umbilical vein catheterised and syntocinon infusion injected. Causes contration of myometrium at site of placental bed causing shearing of the placent
How do you manage Trauma
Bleeding vessels identified can be sutured for haemostasis.
Bleeding coming from the cervical canal may suggest uterine rupture. Definitive treatment is hysterectomy but conservative measures can be employed to maintain fertility
How do you manage Thrombogenic
Vit K to patients on warfarin (causes production of clotting factors but in the long term). Give FFP to reverse it immediately.
Protamine sulphate to patients on heparin
Blood component therapy
Packed cells ideal for fluid resuscitation
FFP contained clotting factors and fibrinogen. 4 units of FFP transfused for every 6 units of packed cells
Cryoprecipitate contain higher conc of fibrinogen than FFP
Platelets
What to do if management fails
Laparotomy (except in DIC)
Uterine artery ligation
Internal iliac artery ligation (not proven)
Ovarian artery
Hypogastric artery
Compression sutures such as the B-Lynch or Cho sutures
Hysterectomy
