Tutorial 10: Post-Partum Haemorrhage (PPH)

Question 1

What is the definition of post-partum haemorhage?

Answer 1

a. blood loss of more than 500 mL following vaginal delivery
b. or blood loss more than 1000 mL following caesarean delivery.

Question 2

What are the 3x normal physiological processes which occur in the uterus following delivery?

Answer 2

1. Uterine involution
2. Establishment of lactation
3. Physical and mental adjustment to motherhood.

Question 3

What does uterine involution involve?

Answer 3

1. Uterus shrinks by retraction and atrophy of muscle fibre (from 1000g –> to its pre-pregnancy weight (50-100g)).
   * This usually occurs within the first 2 weeks post labour, in response to oestrogen withdrawal.
2. This is accompanied by lochia (a discharge consisting of blood and necrotic deciduas andfibrinous products). Lochia usually flows in diminishing amounts, for 6 weeks. The lochia is red for 4 days, turns pink and finally serous in appearance.

Question 4

What changes occur in the lochia?

Answer 4

1. Lochia Rubra (Red): 3-4 days
2. Lochia Serosa (Pink): 4-10days/3 weeks
3. Lochia Alba (serous): 10days - 4 weeks

lochia is present for dimishing amounts for 6 weeks

Question 5

What are the 4x main causes of Post-partum haemorrhage?

Answer 5

1. Tone (80%): abnormal uterine tone/fialure of uterine contraction and retraction following delivery
2. Trauma (20%): general trauma
3. Tissue (2.5%): retained products of conception (RPOC)
4. Thrombin (rare): coagulopahty/a bleeding disorder where there is failure of clotting

Question 6

What are the main cause of uteirne atony/failed uterine contraction and retraction following delivery?

Answer 6

1. Overdistention of the uterus:

• multiple pregnancy
• macrosomia
• polyhydramnios
• fetal abnormality (severe hydrocephalus)
• failure to deliver the placenta

2. Fatigue: prolonged/rapid forceful labour
3. Drugs: which inhibit contraction

Question 7

What are the main types of trauma resulting in Post-partum haemorrhage?

Answer 7

1. Perineal, vaginal, cervical laceration
2. Vaginal side wall laceration (spontaneous, episiotomy, manipulation)
3. uterine rupture - common w. previous c-sections

Question 8

What are the main causes of retained tissue/POC, resulting in post-partm haemorrhage?

Answer 8

1. Retained placenta or placental fragments
2. Retained succenturiate lobe
3. Placenta previa
4. Placenta accreta

NB: succenturiate lobg is an extra placental love which is torn from the placenta and retained following delivery. There is an increased risk of this occuring with extreme pre-term births.

Question 9

What are the main causes of thrombin/caogulopathy resulting in post-partum haemorrhage?

Answer 9

1. Thrombocytopenia:
   
   1. ITP, acquired 2 to HELLP syndrome, DIC r sepsis
2. Pre-existing condition: VWB, familial hypofibrinogen abnormalities
3. Dilution coagulopathy:
   
   1. following massive PPH and resuscitation with crystalloid and PRBCs

• Placental abruption
• Massive blood loss

Thrombin/coagulopathy following delivery is rare, as fibrin is typically eposited over the placental sites and clots within supplying vessels. This pays a significant role within hours and days post-delivery.

Therefore, thrombin/coagulopathy often lead to a) late PPH or b) can exaerbate pre-existing issues

Question 10

What are some risk factors for developing PPH?

Answer 10

1. Previous PPH
2. Prolonged and induced labour
3. Instrumental delivery or caesarean
4. Multiple pregnancies
5. Macrosomic baby
6. Polyhydramnios
7. Grand multiparity
8. Retained placenta
9. Coagulation defect/disorder
10. APH

Question 11

What are the 4x severities of presentation for a mother with post-partum haemorrhage?

Answer 11

1. 500-1000mL= Normal BP, no signs
2. 1000-1500mL= BP-_100mmHg_ (systolic), dizziness and tachycardia
3. 1500-2000mL= BP 70-80mmHg, restlessness, pallor and oliguria
4. 2000-3000mL= BP 50-70mmHg, collapse, SOB and anuria

Question 12

What can you do to prevent Post-partum haemorrhage?

Answer 12

Identify at risk women

• Mitigate risk factors during antenatal
  
  • Identify anaemia and treat
  • Discuss with the patient the options for the third stage of labour
• Mitigate risks during labour
  
  • Avoid instrumental deliveries

Question 13

What is the initial management for a woman with Post-partum haemorrhage?

Answer 13

• ABCs – IV access, resuscitate, give O2.
• Assess patient
  
  • Vitals (Pulse, BP) and quantify blood loss
  • Bloods – FBC, group & hold, coags
• Arrest (stop) haemorrhage
  
  • Uterine massage, oxytocics, search for trauma
• Determine cause ASAP
  
  • Urgent because uterine blood flow during near term pregnancy is between 500-700ml/min. Patient can quickly become unstable. In young and healthy women, signs of haemorrhage may be masked until serious intravascular depletion has occurred.

Question 14

What is the second part of management for Post-partum haemorrhage?

Answer 14

1. First place hand on the uterine fundus to assess tone
   * This is by far the most common cause and early compression and massage can begin stopping the flow of blood
2. Assess ABCs
3. Organisation – done while massaging uterus.

• Call for assistance (senior and junior). During management of PPH many people are required as many jobs are done simultaneously:
  
  • Brief catch up on situation – speak with nurse, midwife
  • How much blood has been lost
  • What are her vitals – HR and BP
  • Designate jobs:
    
    • Who is coordinating the situation? Who is Monitoring vitals, Drawing medication, Massaging uterus, reassuring father/mother, Vaginal examination

Question 15

What is a structured approach to resuscitation?

Answer 15

1. O2 mask
2. 2 large bore IV lines
3. Replacement fluids until blood arrive: 1L of blood loss requires 4L NaCl
4. Take blood: Group and hold, FBC, Coagulation
5. Monitor vital signs
6. Insert urinary catheter
7. Consider FFP, platelets: Call Haematology if concerns

Question 16

What is a structured approach to evaluating a patients haemodynamic stability?

Answer 16

1. Monitor vitals: BP, HR,
   
   1. Consider central venous monitoring in extreme/ICU cases
   2. NB/Warning: In a young fit women a massive blood loss may not necessarily cause a drop in BP or and increased HR
2. Urinary output
3. Regular FBC and coagulation test

Question 17

What is a structured approach to findings a cause for bleeding?

Answer 17

1. Abdominal examination
   
   • Uterine tone + Ensure the uterus is not inverted
   • Ruptured previous cesarean scar
2. Bi-manual exam
   
   • Uterine tone/size
   • Identify vaginal tears or bleeds
3. Inspect the placenta for evidence of retained portions
4. Review patients notes: PMHx, past anesthesia

Question 18

What is the treatment for uterine atony?

Answer 18

1. Commence vigorous uterine massage and compression: Helps to activate the muscle and expel clots
2. Syntocinon: Synthetic oxytocin, 5units IV. 10 IM. Stimulates upper segment of myometrium to contract rhythmically.
3. Syntometrine: syntocin on 5 unit + .5 mg of Ergometrine. Causes smooth muscle contraction in which upper and lower segment of uterus contract tetanically
   
   • contraindicated in 1) HTN disease (vasoconstrict vessels), 2) IHD and 3) migraines
4. Carboprost: Synthetic prostaglandin F2alpha analogue (PG F2a)
   
   • Enhance uterine contractility and cause vasoconstriction.
   • Contraindicated in asthma(bronchospasm). whereas PG used to induce labour (E2 analogue) won’t cause bronchospasm
5. Balloon to compress on placental site but if the uterus is atonic it won’t work

Question 19

What is the treatment for Retained tissue?

Answer 19

1. Suspect if the placenta fails to deliver spontaneously within 30mins
2. Methods for Removal from uterus:
   
   • Conservative management after 30mins (empty bladder, breastfeeding and nipple simulation, patient in upright position)
   • Manual evacuation and antibiotic prophylactic
   • Blunt curettage with USS guidance
   • In abnormal placentation, uterine contractile agents and methotrexate agent. In severe cases laporotomy and hysterectomy may be necessary
3. Carefully inspect delivered placenta for missing cotyledons or vessels in the membranes that might indicate missing accessory lobe.

Question 20

What are risk factors for retained tissue causing PPH?

Answer 20

1. Abnormal placentation (placenta acreta, percreta and increta)
2. Presence of accessory lobes of the placenta
3. Uterine abnormality
4. Full bladder.

Question 21

What is the treatment for trauma causing PPH?

Answer 21

1. Suture lacerations with adequate analgesia
2. Management usually requires volume support, evacuation of haematoma, and closure of dead space.
   
   • Pressure dressing can be applied for vulvar haematoma
   • Vaginal pack is inserted for 12-24 hours to stem bleeding from vaginal haematoma

Question 22

What is the treatment of thrombosis/Caogulopathy causing postpartum haemorrhage?

Answer 22

-Unable to stop bleeding in the delivery unit?

1. Supportive therapy includes FFP or cryoprecipitate.
   
   • Replace platelet if it falls below 20k.
2. Balloon and alert anaesthesia and theatre –> Exploration under GA

Question 23

What are risk factors for Thrombosis/coagulopathy causing Post-partum haemorhage?

Answer 23

1. preeclampsia
2. placental abruption
3. idiopathic thrombocytopenia (ITP)
4. amniotic fluid embolism
5. hereditary coagulopathies

Question 24

What does stage 3 of labour involve?

Answer 24

1. Placental separation
2. Descent into the vaginal vault
3. Expulsion

Question 25

What is separation of the placental from the uterine wall due to?

Answer 25

1. A decrease in surface area within the intrauterine cavity shearing the placenta from the wall 2. Capillary haemorrhage behind the placenta due to the interruption of flow from the umbilical cord Bleeding indicates placental detachment: * A trickle of blood indicate separation at the margins * A gush indicates separation at the retroplacental site

Question 26

What is the relevance of the third stage of labour to post-partum haemorrhage?

Answer 26

* Penetrating through the latticework of smooth muscle fibres within the uterus, are **spiral arteries** which carry blood into the **low-resistance** placental bed at _500 to 800 mL/min_ during labour representing **10% to 15%** of **maternal cardiac output** * _Contraction_ of this lattice of smooth muscles causes _compression_ of the maternal spiral arteries and stops blood flow through these arteries (Third Stage of Labour) * This obstruction of blood flow into the placental bed helps to _control blood_ loss at the placental site and achieves haemostasis through **rapid clot formation and fibrin deposition** * During this stage agents such as **oxytocin** aswell as **local and exogenous prostaglandins** increases greatly which also cause myometrial contraction helping to reduce haemorrhage

Question 27

What does active management of the third stage of labour involve?

Answer 27

1. **Ecbolic Oxytocin**: Causes contraction and shortening of the uterus and helps occlude spiral arteries in the uterus. 2. **Early clamping** of the cord within 3 minutes: Not used at much 3. **Gental cord traction** 4. **Skin to skin** and **breast feeding** used also * Advocates of active management argue that administering prophylactic oxytocin promotes strong uterine contractions and leads to _faster retraction and placental delivery._ This decreases the amount of maternal blood loss and the rate of PPH. They also argue that the more _effective uterine activity_ leads to a r_eduction in the incidence of retained placenta_

Question 28

What does physiological management of third stage of abour involve?

Answer 28

1. **Cord clamping** after pulsation has stopped; 2. Early sustained **skin-to-skin** contact; 3. Early **breast-feeding** to facilitate optimal release of endogenous oxytocin. 4. **Placenta delivery** within 1 hour facilitated by maternal pushing effort.

Question 29

What is Secondary Post-partum haemorrhage?

Answer 29

any bleeding after the **first 24hrs** of delivery - to **6 weeks** (most frequently within _1-2weeks_).

Question 30

What are some features and causes of secondary post-partum haemorrhage?

Answer 30

Overall 2° PPH occurs **1-2%** women during **puerperium** (most commonly in **2nd** week). Common causes of 2 PPH: 1. **RPOC** (retained products of conception) 2. **Endometritis** 3. _non-involution_ of placental bed vessels (rare)

Question 31

What is the management of Secondary Post-partum haemorrhage?

Answer 31

1. **Conservative**, if no signs of infection and no signs of heavy vaginal bleeding. 2. **Offensive discharge**: suggests _endometritis_, and should be managed with **broad-spectrum antibiotics** while waiting for culture results from a **high vaginal swab**. 3. **Evacuation** of uterus (often oxytocic injection is also given) is required if there is: * heavy vaginal _bleeding_ * _tender_ uterus with an _open os_ * suggestion of _retained products on USS_.