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Post-partum haemorrhage (Aetiology (Idiopathic (Uterine atony…
Post-partum
haemorrhage
Definition
Primary PPH
Blood loss >500mL from genital
tract <24h delivery
Secondary PPH
Excessive blood loss from genital
tract 24h-6wk after delivery usually
due to retained products
Epidemiology
High risk morbidity and death
Major cause of maternal death
Up to 10% of pregnancies
Risk factors
Intrapartum
Induction of labour
Prolonged 1/2/3 stage
Oxytocin use
Precipitate labour
Operative vaginal delivery
Caesarean section
Antenatal
Uterine abnormality
Low lying placenta
Previous PPH or retained placenta
Low maternal Hb
Increased maternal age
High BMI
Para 4+
Multiple pregnancy
Polyhydraminos
Aetiology
Idiopathic
Large placenta
Retained placenta
Uterine atony
Epidemiology
Commonest cause
Pathophysiology
Failure of uterus to contract after delivery
Risk factors
Multiple pregnancy, polyhydraminos, prolonged labour,
infection, retained products, placental abruption
Genetic
Coagulation disorder
Developmental
Uterine inversion
Abnormal placental site (PP, accrete, percreta)
Trauma
Uterine trauma
Ttear, episiotomy, laceration, rupture
Placental abruption
Drugs
Anticoagulants e.g. heparin
Metabolic
Liver disease (clotting)
Management
Initial ABCDE
Massive transfusion protocol if needed
Definitive
Medical
Oxytocin
MOA: promotes expulsion of retained products
E.g. oxytocin IV
Blood transfusion
Indication: massive haemorrhage, shock, Hb<80
E.g. packed red cells, FFP, Plts
Carboprost
Indication: uterine atony
MOA: prostaglandin, stimulates contraction
Abx
Indication: superimposed infection
e.g. IV ampicillin and metronidazole
Surgical
Uterus exploration
Indication: incomplete placenta, possible rupture
Placental delivery
Indication: complete placenta
MOA: patient in lithotomy, analgesia,
deliver by controlled cord traction
Hysterectomy
Indication: severe bleeding (rare)
Arterial ligation/embolisation
Indication: severe bleeding (rare)
MOA: uterine or internal iliac artery
Uterine packing
Indication: severe bleeding (rare)
Conservative
Admit ASAP
Refer to O+G ASAP
Anaesthatist (may need CVC)
Identify cause
Diagnosis
Examination
Uterine: tender, PV bleeding
Investigation
Bedside
Obs (shock, temp if infection), ECG
Bloods
FBC (anaemia, infection), CRP,
U+Es (AKI), LFTs (liver disease), clotting,
group&save
Imaging
USS - uterine trauma
History
PC/HPC: bleeding, recent preg, trauma
Gest history: APH, PP, multiple preg, surgery, oxytocin
Obst history: number, prev PPH
PMH: clotting disorder, liver disease,
DH: anticoagulants
SH: smoking, alcohol, drugs
Clinical
presentation
Tender abdomen
PV bleeding