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Postpartum Haemorrhage

From Mediwikis

This is the most common form of major obstetric haemorrhage, and remains the third highest direct cause of maternal death, with little change in rate, despite the majority of cases being preventable.[1]

Types

  • Primary: blood loss of 500ml or more from genital tract within 24hours of delivery.[2]
  • Secondary: excessive loss between 24 hours and 12 weeks after delivery.[3]

Volume- Measured accurately by collection drapes or weighing swabs

  • Minor- (500-1000ml)
  • Major- (>1000ml)
  • Life threatening (>40% of volume)
    • Normal volume is 100 ml/kg[4]

Causes

4 Ts[5]:

  • Tone: Failure of uterus to contract after deliver (uterine atony, 90%),
  • Trauma: Genital tract trauma (7%)
  • Thrombin: Coagulation disorders (hemophilia), excessive bleeding
  • Tissue: Abnormal placental site, retained products postpartum

Risk factors

Antenatal

Bold indicates need for consultant-led delivery

  • Placental abruption/ placenta praevia
  • Multiple Pregnancy
  • Pre-eclampsia/Gestational Hypertension
  • Previous PPH
  • Previous retained placenta
  • Low maternal Hb (<9 g/dl) at onset of labour
  • High BMI >35
  • Antepartum haemorrhage
  • Over distension of the uterus (multiple pregnancies or poly hydramnios)
  • Uterine abnormalities
  • Maternal age> 40
  • Big baby (> 4kg)

Intrapartum

  • Labour induction,
  • Pyrexia in ;labour
  • Any prolonged stage,
  • Oxytocin use,
  • Vaginal operative delivery,
  • CS.

Secondary haemorrhage is caused by retained products, endometritis or a tear.

Prevention

  • Active management of third stage of labour
  • Prophylactic oxytocics during third stage of labour
  • Previous Caesarean- Determine placental site with USS or MRI
    • Placenta accreta/percreta- needs intensive, consultant led delivery

Management[2]

Phased management plan

Blood loss 500-1000ml and no signs of shock

  • Close monitoring
  • IV access
  • Check FBC, Group & Save
  • Most women can cope with blood loss of this level

Resuscitation (Blood loss > 1000ml or clinical signs of shock)

Think ABCDE

  • A/B
    • High-flow oxygen regardless of maternal oxygen levels.
    • Any required airway interventions should be applied
  • C
    • Two large-bore cannulae
    • Blood tests- FBC, U&E, Cross match (4 units)
    • Position flat
    • Transfuse blood or if unavailable, colloid fluids

Then:

  • Oxytocin
  • Misopristol
  • Compress uterus

Surgical

  • Intrauterine balloon
  • Uterine artery emolisation and curettage
  • Hysterectomy

References

  1. Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000–2002. Sixth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004 [www.cemach.org.uk/Publications/Saving-Mothers-Lives-Report-2000-2002.aspx].
  2. 2.0 2.1 Royal College of Obstetricians and Gynaecologists- Postpartum Haemorrhage, Prevention and Management (Green-top Guideline No. 52) https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/
  3. Alexander J,Thomas PW, Sanghera J.Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev 2002;(1):CD002867.DOI: 10.1002/14651858.CD002867
  4. Jansen AJ, van Rhenen DJ, Steegers EA, Duvekot JJ. Postpartum haemorrhage and transfusion of blood and blood components. Obstet Gynecol Surv 2005;60:663–71.
  5. Schuurmans N, MacKinnon C, Lane C, Etches D. Prevention and management of postpartum haemorrhage. J Soc Obstet Gynaecol Can 2000;22:271–81.