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Flashcards in PPH Deck (16)
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What is PPH?

Post partum haemorrhage. May be primary or secondary.
-Primary: first 24h after delivery.
-Secondary: 24h - 12w after delivery


Blood loss for PPH?

-500mL+ post vaginal delivery.
-1000mL+ post Caesarean delivery


By what mechanisms is haemostasis usually obtained post delivery?

- Contraction of the myometrium compressing vessels supplying placental bed: mechanical haemostasis
- Local decidual haemostatic factors and systemic coagulation factors: cause clotting


What are the causes of PPH?

- Atony
- Trauma
- Coagulopathy


What is the most common cause of PPH?

Atony (80% PPH)


How is atony diagnosed?

If uterus does not become firm after uterine massage and administration of uterotonic agents


RFx for PPH?

- Retained placenta
- failure to progress in 2nd stage
- Abnormal placentation
- Lacerations
- Instrumental delivery
- Macrosomia
- HTN disorders
- Prolonged first or second stage


Complications of PHH?

- Death
- Hypovolaemic shock and organ failure
- Fluid overload
- Abdominal compartment syndrome
- Sheehan syndrome


What is Sheehan syndrome?

Rare = postpartum hypopituitarism. Pituitary enlarged in pregnancy and prone to infarction from hypovolemic shock.


What should be suspected in patient remains hypotensive after control of haemorrhage and volume replacement?

Sheehan syndrome. She should be evaluated and treated for adrenal insufficiency immediately; evaluation of other hormonal deficiencies can be deferred until four to six weeks postpartum.


What are the causes of PPH?

Aetiology = 4Ts of early PPH:
-Tone (atony)
-Tissue (retained placenta, clots, GTD)
-Trauma (laceration, inversion)
-Thrombin (coagulopathy)


Initial Mx PPH?

-1. ABCs
-2. 2 large bore (16-18g) IVC + crystalloid IVF
-3. FBE, coag profile
-4. Cross match 4U PRBCs
-5. Treat underlying cause
-6. Medical therapy (uterotonics)
-7. Local control
- 8. Surgical Therapy


Medical therapy for PPH Mx?

- Oxytocin 20 U/L NS or continuous IV infusion. 10 U IM after delivery of the placenta
- methylergonavine maleate (ergotamine) 0.25 mg IM/IMM q5min up to 1.25 mg; can be given as IV bolus of 0.125 mg (may exacerbate HTN)
-carboprost (Hemabate®), a synthetic PGF-1 􏰀 analog 0.25 mg IM/IMM q15min to max 2 mg (major prostaglandin side effects and contraindicated in cardiovascular, pulmonary, renal and hepatic dysfunction)


Local control measures PPH?

• bimanual compression: elevate the uterus and massage through patient’s abdomen

• uterine packing (mesh with antibiotic treatment)

• Bakri Balloon for tamponade: may slow hemorrhage enough to allow time for correction of 
coagulopathy or for preparation of an OR


Surgical therapy for intractable PPH?

• D&C (beware of vigorous scraping which can lead to Asherman’s syndrome)

• embolization of uterine artery or internal iliac artery by interventional radiologist

• laparotomy with bilateral ligation of uterine artery (may be effective), internal iliac artery (not proven), ovarian artery, or hypogastric artery

• hysterectomy last option with angiographic embolization if post-hysterectomy bleeding 


What is the algorithm for PPH management?

- Help: call for help
- Assess: vitals, blood loss, resuscitate
- Etiology, ecbolics, ensure blood
- Massage: uterus
-Oxytocin infusion, PGs (IV, rectal, IM)
- Shift to OT
- Tissue and trauma to be excluded, Tamponade
- Apply compression sutures
- Systematic pelvic devascularisation
- Interventional radiology, uterine artery embolisation
- Subtotal or abdominal hyesterectomy