What is primary post-partum haemorrhage?
- Loss of >500ml of blood per vagina within 24 hours of deliver - minor (500-1000ml), and major (1000ml+). Ax: 1) Tone 2) Tissue 3) Trauma 4) Thrombin
Tone as a cause for Primary PPH?
- Refers to uterine atony - most common cause.
- Uterus fails to contract adequately following delivery due to a lack of tone in the uterine muscle.
- RF for uterine atony:
1) Maternal profile - BMI >35, Age >40, Asian
2) Uterine over-distention - multiple pregnancy, macrosomia, polyhydramnios
3) Labour - induction, prolonged
4) Placental problems - praevia, abruption, previous PPH
Tissue as a cause for P-PPH?
-Retention of placental tissue preventing uterus from contraction - 2nd most common cause of primary PPH..
Trauma as a cause for P-PPH?
- Refers to damage sustained in the reproductive tract during delivery (vaginal tears, cervical tears)
- RF:
1) Instrumental delivery
2) Episiotomy
3) C-Section
Thrombin as a cause for P-PPH?
- Refers to coagulopathies and vascular abnormalities which increase risk of P-PPH?
1) Vascular - Placental abruption, hypertension, pre-eclampsia
2) Coagulopathies - von-Willebrand’s, haemophilia, ITP, or acquired coagulopathy (DIC and HELLP)
Clinical features and examination of P-PPH?
- Main feature is the bleeding from vagina, if substantial blood loss - palpitations, dizziness and shortness of breath.
O/E:
1) General - haemodynamic instability with tachypnoea, PCRT, tachycardia and hypotension.
2) Abdominal - may show signs of uterine rupture, palpation of foetal parts as it moves into the abdomen from the uterus.
3) Speculum - reveal sites of local trauma causing bleeding.
4) Placental - to ensure placenta is complete (missing cotyledon or ragged membranes could both cause PPH)
Investigations of P-PPH?
1) FBC
2) Cross match 4-6 units of blood
3) LFT
4) U+Es
5) Coagulation profile
Management of P-PPH?
- Simultaneous delivery of TRIM
1) Teamwork
2) Resuscitation
3) Investigations and monitoring
4) Measures to arrest bleeding
Intermediate management?
- Teamwork: involve appropriate colleagues - midwife, obstetricians, anaesthetists, blood bank, haematologist and porters.
- Resuscitation - Airway protection, Breathing - 15L of 100% oxygen through non-rebreathe.
Circulation - assess compromise (CR, HR, BP, ECG) + insert 2 large bore cannulas and take blood samples (give cross-matched bloodd ASAP and until then 2L of warmed crystalloid, 1-2L of warmed colloids, transfuse O negative or uncross matched group specific blood. Additional products - FFP, platelets, fibrinogen (discussion with blood bank).
Disability - monitor GCS
Expose patient to identify bleeding sources.
Definitive management (Atony)?
1) Bimanual compression to stimulate uterine contraction ensure bladder emptied by cauterisation)
2) Pharmacological measures to increase uterine myometrial contractions.
3) Surgical measures - IU balloon tamponade, haemostatic suture around uterus (B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (last resort).
Definitive management (Trauma)?
- Primary repair of laceration
- If uterine rupture: laparotomy and repair, hysterectomy last resort.
Definitive management (Tissue)?
- IV Oxytocin - manual removal of placenta with regional or general anaesthetic, and prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal.
Definitive management (Thrombin)?
- Correct any coagulation abnormalities with blood products under the advice of the haematology team.
Drugs used in Primary PPH?
1) Syntocinon (synthetic oxytocin)
2) Ergometrine
3) Carboprost
4) Misoprostol
Prevention of Primary PPH?
- Active management of the 3rd stage of labour routinely reduces PPH risk by 60%.
- Women delivering vaginally should be administered 5-10 unites of IM Oxytocin prophylactically.
- Women delivering via C-Section should be administered 5 units of IV Oxytocin.
What is secondary postpartum haemorrhage?
Defined as excessive vaginal bleeding in the period from 24 hours post-delivery to twelve weeks postpartum.
Aetiology and Risk Factors of S-PPH?
1) Uterine infection (endometritis) - due to C-section, premature rupture of membranes, or long labour.
2) Retained placental fragments or tissue
3) Abnormal involution of placental site (inadequate closure and sloughing of spiral arteries at placental attachment site)
4) Trophoblastic disease (very rare)
RF: Previous history of S-PPH
Clinical features of S-PPH?
- Main symptom - excessive vaginal bleeding.
- Not as severe as P-PPH (acute needing immediate management).
- May complain of spotting on and off for days after deliver with occasional gush of fresh blood.
- Rarely - massive haemorrhage leading to hyovolaemic shock.
- Clinical features depend on cause - endometritis (fever/rigors, lower abdomen pain or foul smelling lochia/discharge from uterus following delivery).
- O/E - lower abdomen tenderness (endometritis), uterus remains high (retained placenta), speculum to assess amount of bleeding, high vaginal swab at same time can assess for infection.
Investigations of S-PPH?
- If patient is haemdynamically unstable or bleeding heavily - call for help and follow resuscitation algorithm - should be commenced prior to establishing cause.
Lab tests:
1) FBC
2) U+E
3) Coagulation profile
4) Group and save sample
5) CRP
6) Cultures
Imaging:
1) Pelvic ultrasound - retained placental tissue
Management of S-PPH?
1) Antibiotics - Ampicillin (Clindamycin) and Metronidazole
- add gentamicin in cases of endomyometritis or overt sepsis.
2) Uterotonics - Syntocinon (oxytocin), Syntometrine (oxytocin and ergometrine), carboplast (prostaglandin F2) and misoprostol (Prostaglandin E1).
- Surgical measures if excessive and continuing bleeding - insertion of balloon catheter may be effective.
- In case of massive S-PPH - 4 measures: Communication, Resuscitation, Monitoring and Investigation, Arresting bleeding (uterotonics/surgical measures, depending on suspected cause).
