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%

 

Causes:

Tone

·      Desensitised uterus (prolonged labour)

·      Big uterus (twins, macrosomia, polyhydramnios)

·      Upset uterus (infection)

Tissue

·      Placenta left behind

·      Placenta adherent (accreta, increta, percreta)

Trauma

·      Uterus

·      Birth canal (vagina, perineum)

·      Iliac artery -> retroperitoneum

Thrombin

·      Comorbidity (HELLP, DIC)

·      Bleeding (endothelial injury + hypoperfusion)

·      Dilution (RBC or CSL +++)

 

Evidence:

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

·      Cowie scan: empty LV

·      Imaging: CT abdo

 

Approach:

Temporise

Anaesthesia:

·      CSL bolus

·      Metaraminol 0.5mg

·      Oxytocin 5 units

O&G:

·      Pressure

·      Pack

·      Stitch

Diagnose

·      Cause of collapse: PPH vs other

·      If PPH: TTTT

Resuscitate

·      Vascular access

·      Whole blood

·      Clotting adjuncts

·      Warming

·      Testing

Treat cause

·      Tone -> oxytocics, fundal pressure, Bakri balloon

·      Tissue -> Bakri Balloon, theatre

·      Trauma -> theatre

·      Thrombin -> blood

If no improvement:

·      Reconsider cause

·      Consider DSA

·      Consider hysterectomy

 

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