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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?
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?
what is a common SE of ergotamine?
what is the MAJOR cause of PPH? (in 80%)
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?
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?
- vaginal swabs
what is the Rx of secondary PPH?
- ERPC if abx doesn't stop it
- histology of evacuated tissue to exclude gestational trophoblastic disease