Post-partum haemorrhage

Basics:

Definitions

· PPH: >500mL

· Severe PPH: >1L

· Primary: <24 hours

· Secondary: >24 hours

Class of shock

1. <15%

2. 15-30%

3. 30-40%

4. >40%

Tone (70%)	· Desensitised uterus (prolonged labour, induced labour) · Distended uterus (twins, macrosomia, polyhydramnios) · Distressed uterus (infection) · Abnormal placenta (pre-eclampsia, adherence)
Tissue (20%)	· Placenta left behind · Placenta adherent (accreta, increta, percreta)
Trauma (10%)	· Uterus · Birth canal (vagina, perineum) · Iliac artery -> retroperitoneum
Thrombin (<1%)	· Consumption (i.e. 2° to bleeding itself) · Dilution (RBC or CSL +++) · Comorbidity (ITP, PET, HELLP, vWD, DIC)

Risk factors	· Tone: long labour, big uterus, upset uterus · Tissue: prev LUSCS, incomplete placenta · Trauma: VBAC (uterus), precipitous labour (canal) · Thrombin: big PPH
History	· Pre-syncope, syncope · Dyspnoea · Malaise
Examination	· General: pale, cold, drowsy vs agitated · Vital signs: ↑HR, ↑RR, ↓BP, ↓PP · Uterus: distension, boggy · Canal: damage, bleeding · Retroperitoneum: flank bruising
Investigations	· ↓Hb · ↓pH · ↑Lactate · POCUS: empty LV · Imaging: CT abdo

See massive transfusion document. In a nutshell

1. Resuscitation: access, warming, products

2. Haemostasis: stop bleeding, promote clotting

Tone	O&G: · Fundal pressure · Bakri Balloon · B-Lynch suture Anaesthesia: · Oxytocin 10 units (+ infusion 40 units in 4 hours) · Ergometrine 250mcg IV, 250mcg IM (+/- repeat x1 q15mins) · Carboprost 250mcg IM (+/- repeat x 8 q15-90mins) · Misoprostol 600mcg PR
Tissue	· Evacuation · Adherent tissue?
Trauma	· Pack · Suture
Thrombin	· See haemostasis · Early cryoprecipitate
If no improvement	· Reconsider cause · Interventional radiology (often unhelpful – venous bleeding) · Hysterectomy