postpartum haemorrhage
DESCRIPTION
obgynTRANSCRIPT
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Postpartum Haemorrhage
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Definitions
• Primary PPH – blood loss of 500ml or more within 24hours of delivery.
• Secondary PPH – significant blood loss between 24 hours and 6 weeks after birth.
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Why do we care?
Major obstetric haemorrhage – more than 1000ml
Very rapidly lead to maternal death
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• 3rd highest cause of direct maternal death in the UK and Ireland (2003-2005)
• 58% of these cases care was “seriously substandard”
• Major cause of severe maternal morbidity in “near-miss audits”
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Risk FactorsMost cases have no risk factors
• Previous PPH• Antepartum haemorrhage• Grand multiparity• Multiple pregnancy• Polyhydramnios• Fibroids• Placenta praevia• Prolonged labour (&oxytocin)
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Prevention
• Be aware of risk factors – may present antenatally or intrapartum
• Treat anaemia antenatally• Active management of the 3rd stage• Prophylactic oxytocics reduce the risk of PPH by
60% (oxytocin or oxytocin & ergometrine)• 5IU IM for vaginal delivery• 5IU IV for LSCS• Consider oxytocin infusions
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4 T’s
Tone
Tissue
Thrombin
Trauma
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Causes
TonePrevious PPHProlonged labourAge > 40 yearsBig babyMultiple pregnancyPlacenta praeviaObesityAsian ethnicity
TissueRetained placenta/membrane/clot
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ThrombinAbruptionPETPyrexiaIntrauterine deathAmniotic fluid embolism
DIC
TraumaCaesarean section(emergency > elective)Perineal traumaOperative deliveryVaginal and cervical tearsUterine rupture
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• Blood loss is commonly underestimated
• Loss may be well-tolerated
• Beware the “trickle” and the “moderate lochia”
• Minor PPH can easily progress to major PPH.
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Management
• Has the placenta been delivered and is it complete?
• Is the uterus well-contracted?
• Is the bleeding due to trauma?
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Resuscitation
A & B – 10 -15l/min O2 by facemaskC - 2 14 gauge cannulae
blood for Hb, U&E, LFTs, clotting crossmatch 4 units 2 litres of crystalloid rapidly
transfuse as soon as possible – consider O – ve blood if any delays.
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Uterine Contraction-First Line Drugs
• Oxytocin 5IU• Oxtocin infusion – 40IU in 500mls • Ergometrine 0.5mg• Carboprost (Haemabate©) 0.25mg IM every
15 minutes x 8 doses• Misoprostol 600 mcg sublingually
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Uterine Contraction – non-pharm• Empty uterus• Foley catheter• Rub up a contraction• Bimanual compression• Balloon tamponade• Brace suture• Uterine artery ligation• Internal iliac artery ligation• Interventional radiology
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• Hysterectomy – before it’s too late
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B-Lynch Suture
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Balloon Tamponade
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Haematological Management
DIC• Transfuse without delay• Involve haematology service at an early stage• Correct coagulopathy• Liase with consultant haematologist re use of
recombinant Factor V11 (Novoseven©) and Fibrinogen.
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• Traumatic for patient, family and staff.• Debriefing for patient and staff.• Case analysed to ensure care was of good
standard and any substandard care can be improved.
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Secondary PPH
• Infection• Retained placenta• Trophoblastic disease• Antibiotics• Evacuation of retained products if bleeding
persistent or significant amount of tissue retained.