PPH

Question 1

What does post partum haemorrhage refer to?

Answer 1

-bleeding after delivery of baby and placenta

Question 2

How much blood must be lost to be classified as PPH?

Answer 2

• 500ml after vaginal delivery

- 1000ml after c section

Question 3

What can PPH be classified into?

Answer 3

• minor PPH - <1000ml
• major PPH -> 1000ml (subclassified into moderate PPH 1000-2000ml and sever >2000ml)
• primary PPH: within 24hrs of birth
• secondary PPH: from 24hrs to 12 weeks after birth

Question 4

What are the causes of PPH?

Answer 4

4 Ts:

• Tone (uterine atony -most common cause)
• Trauma (e.g perineal tear_
• Tissue (retained placenta)
• Thrombin (bleeding disorder)

Question 5

What are some RFs for PPH?

Answer 5

• previous PPH
• multiple pregnancy
• obesity
• large baby
• failure to progress in 2nd stage
• prolonged third stage
• pre-eclampsia
• placenta accreta
• retained placenta
• instrumental delivery
• general anaesthesia
• episiotomy or perineal tear

Question 6

What measures can be done to reduce risk of PPH?

Answer 6

• treat anaemia during antenatal period
• give birth with empty bladder (as full bladder reduces uterine contraction)
• active management of 3rd stage
• IV tranexamic acid can be used during C section in high-risk pts

Question 7

What does management of PPH involve?

Answer 7

is an obstetric emergency:

• resus with ABCDE approach
• lie woman flat, keep her warm and communicate with her and partner
• insert two large-bore cannulas
• bloods for FBC,U&E and clotting screen
• group and cross match 4 units
• warmed IV fluid and blood resus as required
• oxygen (regardless of sats)
• fresh clotting abnormalities or after 4 units of blood transfusion

Question 8

What can the treatment options to stop the bleeding in PPH be split into?

Answer 8

• mechanical
• medical
• surgical

Question 9

What do mechanical treatment options involve in PPH?

Answer 9

• rubbing the uterus (fundus) to stimulate uterus contraction
• catheterisation (bladder distention prevents uterine contraction)

Question 10

What do medical treatment options involve in PPH?

Answer 10

• oxytocin (slow injection followed by continous infusion)
• ergometrine (IV or IM) stimulates smooth muscle contraction (contraindicated in hypertension)
• carboprost (IM) - prostogalandin analogue which stimulates uterine contraction
• misoprostol (sublingual) also prostaglandin analogue
• tranexamic acid (IV) - antfibrinolytic so reduced bleeding

Question 11

What do surgical treatment options involve in PPH?

Answer 11

• Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
• B-lynch suture - putting a suture around the uterus to compress it
• uterine artery ligation - stops supply to uterus reducing blood flow
• hysterectomy as a last resort

Question 12

What is secondary PPH most likely due to?

Answer 12

-retained products of conception (RPOC
or
-infection - endometritis

Question 13

What are the investigations for secondary PPH?

Answer 13

• US to look for RPOC

- endocervical and high vaginal swabs for infection

Question 14

What is the management of secondary PPH?

Answer 14

• surgical evaluation of retained products of conception

- antibiotics for infection