Primary/Secondary PPH Flashcards
Define primary postpartum haemorrhage (PPH)
> 500ml blood loss per-vagina within 24hr
- Minor PPH = 500-1000ml
- Major PPH = >1000ml
Outline the aetiology and RF for primary PPH
TONE
- uterus fails to contract due to lack of tone
- RF = old, BMI >35, multiple preg, polyhydramios, placental problems
TISSUE
- retention of tissue which prevents the uterus contracting
TRAUMA
- damage
- RF = instrumental, episiotomy, CS
THROMBIN
- coagulopathies/vascular abnormalities
What are the clinical features of PPH?
Exam = haemodynamic instability with tachypnoea, prolonged CRT, tachycardia, hypotension
Abdo exam = uterine rupture i.e. palpation of fetal parts as it moves into the abdomen from the uterus
Speculum = sites of local trauma causing bleeding.
Examine the placenta to ensure that the placenta is complete (a missing cotyledon or ragged membranes could both cause a PPH).
How should PPH be investigated?
Bloods = FBC, x-match, coag, U+E, LFT
Outline the management of PPH
A-E
Uterine Atony = bimanual compression (stim contraction), intrauterine tamponade, suture (B-lynch), A ligation, hysterectomy
- IM ergometrine = contracts small vessels
- IM syntometrine = synthetic oxytocin
- PO/PV/PR Misoprostol = synthetic prostaglandin
Trauma = repair laceration, hysterectomy
Tissue = IV/IM oxytocin, manual removal of placenta (make sure complete)
Thrombin = correct coag abnormalities
How should PPH be prevented?
Women delivering vaginally = 5-10 units of IM Oxytocin prophylactically.
Women delivering via CS = 5 units of IV Oxytocin
Define secondary postpartum haemorrhage (SPH)
Excessive vaginal bleeding in the period from 24 hours after delivery to twelve weeks postpartum
Name the causes of SPH
Endometritis
Retained placental tissue
Abnormal involution of placental site
Trophoblastic disease
How does SPH present?
Excessive vaginal bleeding
Features of hypovolemic shock
Endometritis = fever, rigor, lower abdo pain/tenderness, foul smelling lochia
Retained placenta = high uterus
How is SPH best managed?
Abx = co-amoxiclav + metronidazole + cepharoxin
Uterotonics = syntocinon (oxytocin), syntometrine (oxytocin+ergometrine), carboprost (prostaglandin F2) and misoprostol (Prostaglandin E1)
Balloon catheter
Retained products = EVAC
What are the main causes of antepartum haemorrhage, and how might you be able to differentiate between them clinically ?
Miscarriage = urine PT, TV USS, serial serum beta-hCG
Placental previa = USS, painless
Placental abruption = PV bleed, uterine tenderness
Vasa previa = USS, painless
Uterine rupture = pain, PV bleed, rigid uterus
Trauma = Hx
