Postpartum hemorrhage Flashcards Preview

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Flashcards in Postpartum hemorrhage Deck (44):
1

Definition for vaginal and C/S

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

2

Incidence

5-15%

3

Etiology 4Ts

Tone
Tissue
Trauma
Thrombin

4

Etiology of secondary PPH and what is the definition

After 24 hours
Retained products
Endometritis
Sub-involution of uterus

5

Labour causes of atonic uterus

prolonged, precipitous, induced, augmented

6

Overall causes of atonic uterus

Labour
Uterus
Placenta
Maternal
Pain releif

7

Uterine causes of atony

Chorioamnionitis
Overdistension

8

Causes of overdistended uterus

Multiples
Polyhydramnios
Macrosomia
Fibroids

9

Placenta causes of atony

Placenta previa
Placental abruption

10

Maternal factors associated with atony

Grandparity
Gestational HTN
Obesity

11

Tissue factors (3)

Retained products
Abnormal placenta
Blood clots

12

Trauma causes

Laceration
Episiotomy
Hematoma
Uterine rupture
Uterine inversion

13

Thrombin causes

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

14

Most common cause of PPH

Atonic uterus

15

Antenatal risk factors (11)

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

16

Intrapartum risk factors

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

17

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

Due to the reason for a cesarean often being an emergency

18

Post natal risk factors (4)

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

19

Drugs causing hypotonia used in labour

Anaesthetic
Magnesium sulphate

20

Prevention- antenatal, intrapartum and post-partum

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

Possible complication

Hypovolemic shock
AKI
ARDS
DIC
Sheehans syndrome
Hepatic failure

22

Management when high risk and refusal of blood products

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

Intrapartum management when high risk

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

Active management of third stage

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