postpartum haemorrhage. definitions primary pph – blood loss of 500ml or more within 24hours of...
Post on 19-Dec-2015
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Definitions
• Primary PPH – blood loss of 500ml or more within 24hours of delivery.
• Secondary PPH – significant blood loss between 24 hours and 6 weeks after birth.
• 3rd highest cause of direct maternal death in the UK and Ireland (2003-2005)
• 58% of these cases care was “seriously substandard”
• Major cause of severe maternal morbidity in “near-miss audits”
Risk FactorsMost cases have no risk factors
• Previous PPH• Antepartum haemorrhage• Grand multiparity• Multiple pregnancy• Polyhydramnios• Fibroids• Placenta praevia• Prolonged labour (&oxytocin)
Prevention
• Be aware of risk factors – may present antenatally or intrapartum
• Treat anaemia antenatally• Active management of the 3rd stage• Prophylactic oxytocics reduce the risk of PPH by
60% (oxytocin or oxytocin & ergometrine)• 5IU IM for vaginal delivery• 5IU IV for LSCS• Consider oxytocin infusions
Causes
TonePrevious PPHProlonged labourAge > 40 yearsBig babyMultiple pregnancyPlacenta praeviaObesityAsian ethnicity
TissueRetained placenta/membrane/clot
ThrombinAbruptionPETPyrexiaIntrauterine deathAmniotic fluid embolism
DIC
TraumaCaesarean section(emergency > elective)Perineal traumaOperative deliveryVaginal and cervical tearsUterine rupture
• Blood loss is commonly underestimated
• Loss may be well-tolerated
• Beware the “trickle” and the “moderate lochia”
• Minor PPH can easily progress to major PPH.
Management
• Has the placenta been delivered and is it complete?
• Is the uterus well-contracted?
• Is the bleeding due to trauma?
Resuscitation
A & B – 10 -15l/min O2 by facemaskC - 2 14 gauge cannulae
blood for Hb, U&E, LFTs, clotting crossmatch 4 units 2 litres of crystalloid rapidly
transfuse as soon as possible – consider O – ve blood if any delays.
Uterine Contraction-First Line Drugs
• Oxytocin 5IU• Oxtocin infusion – 40IU in 500mls • Ergometrine 0.5mg• Carboprost (Haemabate©) 0.25mg IM every
15 minutes x 8 doses• Misoprostol 600 mcg sublingually
Uterine Contraction – non-pharm• Empty uterus• Foley catheter• Rub up a contraction• Bimanual compression• Balloon tamponade• Brace suture• Uterine artery ligation• Internal iliac artery ligation• Interventional radiology
Haematological Management
DIC• Transfuse without delay• Involve haematology service at an early stage• Correct coagulopathy• Liase with consultant haematologist re use of
recombinant Factor V11 (Novoseven©) and Fibrinogen.
• Traumatic for patient, family and staff.• Debriefing for patient and staff.• Case analysed to ensure care was of good
standard and any substandard care can be improved.
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