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Flashcards in POSTPARTUM HAEMORRHAGE Deck (34):
1

What is the definition of postpartum haemorrhage with regard to normal vaginal delivery?

Bleeding from the genital tract of more than 500 mL after delivery of the infant.

2

What is the difference between primary and secondary postpartum haemorrhage?

Primary: Bleeding more than 500 mL within 24 hours of delivery

Secondary: Bleeding more than 500 mL that starts 24 hours after delivery and occurs within 12 weeks.

3

What is the incidence of primary post-partum haemorrhage?

5% in the developed world

28% in the developing world

4

What is the most common cause of primary post-partum haemorrhage?

Uterine atony 90%

5

What are the causes of primary postpartum haemorrhage?

Uterine atony

Genital tract trauma

Retained placenta / placenta accreta

Coagulation disorders

Uterine inversion

Uterine rupture

6

What are the risk factors for uterine atony and therefore postpartum haemorrhage?

Multiple pregnancy

Grand multiparity or nulliparity

Fetal macrosomia

Polyhydramnios

Fibroid uterus

Prolonged labour

Previous PPH

Antepartum haemorrhage

7

Why does multiple pregnancy increased the risk of PPH?

Placental site is larger than with a singleton. There is also over distension which increases risk of uterine atony.

8

What are the risk factors for genital tract trauma?

Macrosomia

Episiotomy

Instrumental delivery, especially Keilland's forceps

9

What is the average amount of blood loss with caesarian section?

500 mL, therefore PPH in this case is termed as anything above 1 L.

10

What are the symptoms of uterine inversion?

Blood loss

Abdominal pain

Feeling of prolapse

11

What is the main risk factor for uterine rupture as a cause of PPH?

Previous caesarian section

12

What are the coagulation disorders than might cause PPH?

Chronic:
Haemophilia
Von Willebrands

Acute:
DIC

13

What is placenta accreta?

This is when the placenta is morbidly adherent to the uterine wall.

14

What is placenta increta?

When the placenta invades into the myometrium.

15

What is placenta percreta?

When the placenta invades all the way through the myometrium.

16

What are the complications of primary postpartum haemorrhage?

Haemorrhagic shock and death

Sheehan's syndrome

17

What is Sheehan's syndrome?

Avascular necrosis of the pituitary gland resulting in hypopituitarism on the back of PPH.

18

How do we prevent primary PPH and the complications of it?

Monitoring and treatment of low Hb in antenatal period

Identify those with risk factors early on

Active management of the third stage of labour

19

What does the active management of the third stage of labour involve?

Use of oxytocic drugs prophylactically

Controlled cord traction to deliver placenta (Brandt-Andrews method)

Clamping and cutting umbilical cord

20

What is the oxytocic drug that we commonly use prophylactically in the active management of the third stage of labour?

IM syntometrine - 5 units of syntocinon and 0.5mg ergometrine

21

What is the contraindication to using syntometrine as part of active management of the third stage of labour? What is given instead?

Hypertension

Syntocinon is given instead

22

What are the causes of secondary postpartum haemorrhage?

Retained products

Endometritis (infection)

Persistent molar pregnancy / choriocarcinoma

23

What are the symptoms of retained products?

Prolonged heavy vaginal bleeding or persistent offensive discharge

24

How should you go about examining a woman with primary PPH?

ABCDE

Estimate blood loss (frequently underestimated)

Abdominal palpation should assess whether uterus is contracted or not

Assess fundal height - should be at or below umbilicus. If above indicated retained products or clots. If cannot be palpated consider uterine inversion.

Examine genital tract for trauma

Remember to examine placenta and membranes to see that cotyledons appear complete and there is no suggestion of a succentric lobe.

25

What investigations would you need to do in someone with primary PPH?

FBC
Clotting screen, including fibrin degradation
U+Es
Group and save or crossmatch

Urine output

USS - check for retained products if persisting

26

What investigations would you need to do in someone with secondary PPH?

FBC
Clotting screen, including fibrin degradation
U+Es
Group and save or crossmatch

Urine output

USS - check for retained products if persisting

High vaginal swab - endometritis

hCG - if stays high indicates molar pregnancy

27

How do you manage a patient suffering primary PPH caused by uterine atony?

1. ABCDE approach - think about giving transfusion

2. Massage uterus abdominally

3. IV syntocinon 10 units STAT and/or IV ergometrine 500 micrograms - followed by an IV infusion

4. IM carboprost - F2 alpha prostaglandin or Misoprostol PR

5. other options include: balloon tamponade, B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

6. if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

28

What is generally considered a massive postpartum haemorrhage?

Above 1500 mL in 24 hours

29

How would you manage a patient where there is evidence of retained or incomplete placenta causing PPH?

Manual removal under anaesthetic

30

How do we manage placenta accreta, where there is no sign of active bleeding?

May be appropriate to leave placenta in situ.

Abx should be given

Consider use of folate antagonist - methotrexate

31

How do we manage placenta accreta where there is active bleeding?

Surgery possibly including hysterectomy

32

How do we manage a patient with uterine inversion?

Resuscitate patient

Replace uterus either manually or hydrostatically

Oxytocin infusion

33

What is the most serious presentation of uterine inversion?

Severe lower abdominal pain followed by collapse due to neurogenic shock and haemorrhage.

34

Why has the rate of uterine rupture decreased recently?

Lower segment caesarian section rather than classical