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Post partum haemorrhage (aetiology (thrombin - abnormal coagulation…
Post partum haemorrhage
definition
blood loss >500ml in the first 24h following vaginal delivery or >1000ml following c section
aetiology
tone: abnormal uterine contractility
atonic uterus (70%)
prolonged labour
rapid labour
high parity
IOL
physiological third stage
retained blood clots
overdistended uterus
multiple pregnancy
macrosomia
polyhramnios
infection
pyrexia in labour
anatomical distortion
fibroids
genital tract trauma
genital tract lacerations
episiotomy
haematoma
uterine rupture
prev c section
uterine inversion
strong cord traction
retained tissue (placenta/membranes)
retained placenta or cotyledon, or succenturiate lobe
Hx of retained placenta
hx of incomplete placenta
abnormal placenta
prev c section
placenta acreta
prev uterine surgery
thrombin - abnormal coagulation
abruption
APH
massive blood loss
prexia
sepsis
fetal death
severe infection
amniotic fluid embolus
inherited/acquired bleeding disorder
incidence
~5% if third stage managed actively
13% if third stage managed expectantly
clinical
signs
hypovolaemic shock
heavy vaginal bleeding
symptoms
pathophysiology
failure of uterine myofibrils to contract and retract
diagnosis
clinical
ancillary
treatment
ASSESS bleeding
ABCs
look for cause of bleeding
assess
abdomen for uterine tone and size
lower genital tract for trauma
placenta for completeness
estimate ongoing blood loss
ARREST bleeding
stimulate uterus to contract using firm massage over fundus
medical
1st line syntocin 5 iu IV
slow push to avoid hypotension
2nd line synometrine IM
rapid and sustained uterine contraction 2-3min
3rd line carboprost
contraindicated in asthmatics
insert IDC
surgical
emergency hysterectomy
REPLACE blood loss
two IV lines
FBC
coag screen
renal function
group and hold and antibody screen
rapid infusion 1L warmed crystalloid
consider 1-3L more if continous bleeding
prognosis
if bleeding controlled, good
if massive, bad
consider c section for future deliveries if significant
complications
ARDS
hypopituitarism
death
uterine perforation