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pph

post-partum haemorrhage (PPH)

introduction

  • Primary PPH: Genital tract blood loss ≥ 500mL during the third stage of labour and up to 24 hours after birth
    • major PPH is defined as loss > 1000mL blood
  • Secondary PPH: Genital tract blood loss ≥ 500mL after 24 hours and up to 6 weeks after birth
  • PPH is a major cause of mortality, morbidity and long term disability related to pregnancy and birth

risk factors

antenatal

  • Previous PPH (>1000mL)
  • Previous retained placenta
  • Previous Caesarean section/uterine surgery
  • Grandmultiparity (five or more previous births)
  • Multiple pregnancy
  • Maternal Age (>40 years of age)
  • Obesity (BMI >35)
  • Coagulation disorders
  • Thrombocytopaenia
  • Hypertensive disorders
  • Therapeutic anticoagulation
  • Anaemia (Hb <9g/dL)
  • Polyhydramnios (AFI >30cm)
  • Macrosomia ( EFW >95th centile or AC >95th centile)
  • Fibroids (>5cm)
  • Placenta praevia (≤2cm clear of os)
  • Placental adhesive disorders (accreta/increta/percreta)
  • APH (>20 weeks gestation)

intrapartum

  • Physiological management of third stage
  • Prolonged labour (any stage)
  • Precipitate labour
  • Augmented labour
  • Fever
  • PPROM
  • Chorioamnionitis / sepsis
  • Placental abruption
  • Tocolytics: nifedipine, salbutamol and/or glyceryl trinitrate
  • Magnesium sulphate
  • General anaesthesia
  • Operative delivery
  • Placenta and/or membranes incomplete at delivery
  • Succenturiate lobe
  • Bipartite placenta
  • Amniotic fluid embolus
  • Thrombocytopaenia
  • Recent anticoagulant use

the 4 "T"s of primary PPH

  • TONE - abnormalities of uterine contraction account for 70% of primary PPH
  • TRAUMA - genital tract lacerations, etc account for 20% of primary PPH
  • TISSUE - RPOC account for 10% of primary PPH
  • THROMBIN - coagulation abnormailities account for 1% of primary PPH

preventive Mx of women with risk factors

  • Active management of the third stage of labour
  • IV access (e.g. consider 2 large bore cannulae )
  • FBE, group and save or cross match at the onset of labour
  • consider the need for a postpartum oxytocin infusion
  • consider the need for a senior obstetrician or anaesthetist to be present at birth or in theatre
  • consider need for use of cell salvage and / or rapid flow devices

Mx of primary PPH

  • if the placenta is retained, AVOID ergometrine and oxytocin/ergometrine (Syntometrine®)
  • if major PPH (>1000mL loss), activate massive transfusion protocol, call obstetrician, transfer to theatre, consider bimanual compression

ASSESS

  • early identification and response improves outcomes
  • if on ward access the PPH box containing the needed medications and call an obstetric alert if severe PPH
  • 2 large bore iv access and FBE, clotting screen, cross match if not already done
  • oxygen via face mask
  • 1-2L NSaline stat then blood if indicated
  • accurate fluid balance chart
  • 5-10 minutely maternal obs
  • look for the cause - see the 4 T's above

ARREST the bleeding

  • if genital trauma is the cause, apply pressure to bleeding perineal lacerations
  • RPOC - check placenta and membranes - if incomplete, organise transfer to theatre for EUA
  • if uterine atony is most likely the cause:
    • massage uterus
    • expel any clots
    • administer uterotonics:
        • if not already given in 3rd stage, give 10U IV over 3-5 minutes or im if no iv access
        • then start infusion 40U in 40mL NSaline and give at 10mL/hr for 4hrs
      • ergometrine IF placenta has been delived but still atony with PPH:
        • 250mcg im PLUS 250mcg slow iv if no C/I such as hypertension, cardiac disease, HS, retained placenta
        • can repeat dose if needed (max. 1500mcg or 3mL in 24hrs)
      • insert IDC if not already done and monitor urine output
        • off-label use in severe PPH but only for warrant holders
        • 250mcg deep im every 15 minutes prn to max. 8 doses but patient should be in theatre in needs 4th dose
        • C/I include acute PID, active cardiac, resp, renal or hepatic disease
  • consider uterine rupture as a cause
  • if there is uterine inversion, manually replace the uterus if possible. Do not attempt to remove the placenta even if it is still attached until the uterus is replaced. If efforts to replace the uterus are unsuccessful, transfer to theatre urgently for GA and manual replacement.

REPLACE BLOOD and CLOTTING FACTORS

  • activate massive blood transfusion protocol as soon as large volume losses are anticipated
  • operating theatre at Sunshine now has ROTEM (ROtational Thrombo-ElastoMetry) to allow point-of-care decisions regarding clotting factor replacement in Post-Partum Haemorrhage
  • engage the assistance of consultant haematologist and anaesthetist
pph.txt · Last modified: 2018/10/02 02:48 by wh