-
what is primary post partum haemorrhage (PPH) defined as?
loss of > 500mls of blood in within 24 hours after delivery
-
what % of women does PPH occur in?
10%
-
what are the 2 main changes to blood during pregnancy?
- 1. plasma volume increases, get haemodilution
- 2. clotting factors increase
-
what 2 factors usually protect from PPH?
- 1. pressure from uterine contractions
- 2. clotting factors
-
what is given to all women as routine to prevent PPH?
- injection of syntometrine: combination of 5 units syntocinon (oxytocin) & 0.5mg ergotamine
- this is called active management of 3rd stage of labour
-
who is ergotamine contraindicated in?
hypertensives
-
what is a common SE of ergotamine?
vomiting
-
what is the MAJOR cause of PPH? (in 80%)
uterine atony
-
what are the antepartum risk factors of PPH?
- 1. polyhydramnios: causes overdistension of uterus and more likely to get atony
- 2. big baby
- 3. DM
- 4. multiple pregnancies: causes overdistension of uterus and more likely to get atony
- 5. grand multiparty (>4): as used up muscles over time, so less uterine contraction to prevent PPH
- 6. placenta praevia: placenta is in lower segment of uterus where there are less muscle fibres
- 7. anaemia
- 8. previous hx of PPH or CS
- 9. primigravida as longer labour usually
- 10. coagulation defect
- 11. fibroids: causes overdistension of uterus and more likely to get atony
-
what are the intrapartum causes of PPH?
- 1. prolonged labour or induced labour
- 2. use of oxytocin
- 3. placental abruption
- 4. perineal trauma
- 5. high vaginal tear (forceps), cervical tear
- 6. C-section
-
what are the post partum causes of PPH?
- 1. retained placenta
- 2. trauma: eg forceps use,
- 3. uterine rupture
- 4. DIC
-
what are the 2 factors for uterine failure that lead to PPH?
- 1. atony
- 2. retained placenta
-
what 3 factors contribute to uterine atony?
- 1. prolonged labour
- 2. grand multiparity
- 3. overdistension of uterus
-
what 3 factors contribute to overdistension of uterus?
- 1. polydramnios
- 2. multiple pregnancies
- 3. fibroids
-
what are 3 vaginal causes of PPH?
- 1. perineal tear
- 2. episiotomy
- 3. high vaginal tear due to instrumentation
-
what is the pre-partum management of PPH - ie in case it happens (3)
- 1. FBC
- 2. group and save, cross match
- 3. iv access: 16G grey, 14G white
-
what do you have to ask the midwife in PPH?
was the placenta complete? if not take it out, may need to take to theatre to explore!
-
what is the medical management of PPH?
- 1. resuscitation: pt lying flat, ABC (anaesthetist involved) give oxygen, 2 iv lines, 6U blood is cross matched and blood volume is restored - transfuse
- 2. retained placenta needs to be removed
- 3. through 1 iv line: FBC, U&E, coating, cross match 6 U, misoprostol, cannulate and give colloids
- 4. through other iv line: OXYTOCIN INFUSION: 40 units in 500mls: 125mls/hour or 10 units/hour
- 5. PRESSURE
- 6. catheterise
- 7. find and treat cause: do VE to exclude rare uterine invasion
-
what is the main problem with misoprostol?
takes long time to work, but PPH can kill in 30 mins!
-
what are the 2 ways of applying pressure to the uterus in PPH?
- 1. stimulate uterine contractions by massaging the uterus (need to catheterise first)
- 2. bimanual compression: one hand in vagina, one on top pressing down
-
why do you need to do a VE in PPH?
exclude rare cause: uterine inversion
-
what is the surgical management of PPH?
- 1. EUA: cavity of uterus explored - make sure nothing in there, remove any clot or retained placental fragments. examine cervix and vagina for tears which should be sutured
- 2. pressure: pressure pack, bark balloon (uterine catheter), sengstaken balloon
- 3. laparotomy: do compression test and if stops bleeding you know that putting a brace on the uterus will help. B lynch sutures - brace suture.
- 4. ligate vessels or uterine artery embolisation
-
if all surgical techniques fail, what is the ultimate treatment of PPH?
hysterecomy
-
what are the 4 'T' causes of PPH?
- tools: instrumentation, CS
- tissue: retained placenta
- trauma: tears, rupture
- thrombin: clotting problem
-
what is the definition of secondary PPH?
excessive blood loss between 24h and 6 wks after delivery
-
name 4 causes of secondary PPH?
- 1. endometritis
- 2. retained placenta/membranes
- 3. incidental gynae pathology
- 4. gestational trophoblastic disease
-
what are the signs of secondary PPH?
- enlarged uterus
- tender uterus
- open cervical internal os
-
what Ix need to be done in secondary PPH?
- FBC
- vaginal swabs
- ultrasound
-
what is the Rx of secondary PPH?
- antibiotics
- ERPC if abx doesn't stop it
- histology of evacuated tissue to exclude gestational trophoblastic disease
|
|
