PPH - POST PARTUM HAEMORRHAGE

PromptDefinition PPH

ResponsePrimary: >500 mL blood loss in first 24h
Secondary PPH: >24h (to 6-12 weeks)

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PromptRisk factors for PPH

ResponseHypotonia (Tone): (Think most O+G things here)
Overdistension of uterus (multiple gestations, polyhydramnios)
Prolonged labour
Infection - chorioamnionitis
Tocolytic use in labour

Trauma (think rough birth)
Instrumental delivery
uncontrolled delivery, Precipitous (rapid) delivery, macrosomia, malpresentation.
Episiotomy
Uterine rupture or inversion

Retained tissue (Hint. think abnormal anatomy here)
Previous C section
Placental abnormalities - accreta, increta, percreta, previous curettage.
Retained placenta (no active management of 3rd stage of labour)

Coagulopathy (Thrombin)
HELLP syndrome
Meds (Antiplatelet)
Others - Sepsis with DIC, preexisting disease eg: Haemophilia

Others
Previous PPH
Preeclampsia
Broken into the T’s as one question asked like this

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PromptPPH causes

ResponseThink the 4 T’s - Tissue (10%), Tone(75%!), Trauma, Thrombin (coagulopathy)

Tissue - Retained products of conception (Fragments vs whole placenta) (~10% of pph)

Examination incomplete placenta, non contracted uterus
Mgmt - OT for manual removal, oxytocin

Tone - Uterine Atony

Examination non contracted uterus
Mgmt - uterine massage, oxytocin, empty bladder

Trauma - vaginal/cervical laceration

Examination - direct inspection/spec shows a laceration
Mgmt - surgical

Trauma - Uterine rupture

Examination severe abdominal tenderness
Mgmt - surgical

Trauma - uterine inversion

Visual inspection of perineum shows inverted uterus, fundus too low.
Mgmt relocation in OT

Thrombin - Coagulopathy (hereditary or consumptive)

Examination - no other cause, blood not clotting
Mgmt - correct coagulopathy with blood products

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PromptImmediate intervention for PPH in ED

ResponseImmediate referral to O+G/theatres/surg
Ensure single pregnancy (ask, palpate, u/s)
MTP - recognise haemorrhagic shock and need for potentially large volumes of blood quickly
Deliver placenta + inspect for completeness to exclude RPOC
Uterine massage/bimanual compression
Uterotonic agent after ensuring no twin

Oxytocin 10U (syntocinon)

Empty bladder
Examine perineum, vagina, cervix for bleeding - repair wound or pack
Balloon tamponade (Bakri balloon)
TXA 1g, replace clotting factors

Non ED treatments
Radiologic embolisation
Hysterectomy

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PromptNon pharmacologic things you can do for PPH

ResponseDeliver placenta
Fundal rub
Empty bladder
Bimaual uterine compression
Surgical exploartion
Uterine balloon tamponade (Bakri balloon)
Uterine artery ligation (IR)
Hysterectomy

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PromptPharmacologic things you can do for PPH

(Worst q has asked for 4 medical therapies for PPH… might get away with things like analgesia but best to know at least 2-3!)

ResponseOxytocin 10 U IM (Uterine contraction) (Can also run infusion 40 u in 1L N/s until uterus is firm)
Ergometrine 250 mics IM
TXA
Carboprost 0.25mg (250 mics) IM q15min to 2mg - (Uterine contraction + Vasoconstriction)
Misoprostol 800-1000 mics PR once (Uterine contraction, but 60 min to onset - not great in emergency)

Blood products (recombinant factor VII - novo7)
TXA 1g IV (at any time)

According to D’Arcy (THANKS MATE) - Just use in this order:
Oxytocin, ergometrine, TXA, carboprost, misoprostol

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PromptO+G reg won’t come and play

ResponseCall the consultant
Continue resuscitating the patient (important this is in the answer)

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PromptManagement of third stage of labour

ResponseThird stage of labour = delivering placenta
Look for signs of placental separation - lengthening of cord, gush of blood, fundus globular
Gentle traction backwards and downwards whilst supporting the uterus with one hand placed suprapubic
Uterine massage
Observe for PV loss
Examine perineum for tears

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