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Obstetrics and Gynaecology > Postpartum hemorrhage > Flashcards

Postpartum hemorrhage Flashcards

(44 cards)

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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)

Study These Flashcards
A

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

19
Q

Drugs causing hypotonia used in labour

Study These Flashcards
A

Anaesthetic

Magnesium sulphate

20
Q

Prevention- antenatal, intrapartum and post-partum

Study These Flashcards
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

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

Management when high risk and refusal of blood products

Study These Flashcards
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

Study These Flashcards
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

Study These Flashcards
A 
IM oxytocin 10 IU
Syntometrine (CI in hypertension)
Suprapubic counterpressure 
Controlled cord traction
Cord clamping
25
When should suprapubic counterpressure be applied
Prior to controlled cord traction
26
Post natal risk management when risk factors
``` 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
When to suspect puerperal hematoma
``` Unable to ID common causes of PPH Excessive or persistent pain Hypovolemic shock disproportionate to revealed blood loss Pelvic pressure Urinary retention ```
28
How to manage hematoma
Resuscitate Vaginal and PR exam to determine site and extent ?Transfer to OT for clot evacuation, primary repaire or tamponade of vessels
29
Management of PPH resus and assess
``` 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
Treat the cause outline->questions to ask
``` Placenta out and complete? Fundus firm? Genital tract intact? Blood clotting? Assess for unknown ```
31
Unknown causes of PPH
Uterine rupture Inversion Puerperal hematoma AFE, Subcapsular liver rupture
32
Management when placenta not out or incomplete
``` 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
Indications to transfer to OT for tissue issue
Placenta adherent/trapped | Cotelydon + membranes missing
34
Management of atonic uterus (9)
``` 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
What are the second line drugs for uterus atony
Intramyometrial PGF2a (Dinoprost)
36
Management of genital tract trauma
Identify/inspect cervix, vagina, perineum Clamp obvious bleeders Repair T/F to OT if indicated
37
When to transfer to OT with genital tract trauma
Cannot see/repair injury
38
Management for blood clotting disorder
Urgent FBC, caugs, eLFTs, ABG Monitor 30-60 minutely FBC, coags, Ca, ABG Do not delay treatment waiting for blood results Activate MTP
39
Outline MTP
RBC, FFP, Platelets | Cryoprecipitate if Fibrinogen
40
Two things to avoid in blood clotting abnormality and MTP
Hypothermia | Acidosis
41
Management when bleeding not controlled
Bimanual compression Transfer to OT->lay flat, oxygen Consider criteria for MTP activation
42
OT interventions based on cause
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
Management once bleeding controlled
``` 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
How to prepare dinoprost and administer
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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