Postpartum Haemorrhage

Background

  • One of the major causes of maternal death in both developed and developing countries.
  • The mortality associated with PPH is preventable
  • Life-threatening PPH occurs in around 3.7/1000 pregnancies (minor PPH can occur in between 5-10% of pregnancies)
  • Minor PPH is considered between 500 and 1000 ml (provided there are no signs of shock; major (life-threatening) PPH is >1000ml (or bleeding with features of shock)
  • PPH can be primary (early); secondary PPH is late (usually once returned home) and is usually due to infection (endometritis) or retained POC

Aetiology/Risk factors

  • Causes
    • 4 Ts :
      • Tone
      • Trauma
      • Tissue
      • Thrombin
  • Antenatal
    • Antepartum haemorrhage
    • Placenta praevia (Thrombin) (OR 12)
    • Placental abruption (Thrombin) (OR 13)
    • Multiple pregnancy (Tone) (OR 5)
    • Polyhydramnios (Tone)
    • Pre-eclampsia or pregnancy induced hypertension (Thrombin) (OR 4)
    • Multiparity (Tone)
    • Previous PPH or retained placenta (Tone) (OR 3)
    • Obesity (Tone) (OR 2)
    • Age
    • Maternal anaemia (<90g/l) (OR 2)
      • NB This should ideally be optimised prior to delivery to reduce the risk
    • Placenta accreta
  • Intrapartum
    • Emergency or elective C section (Trauma) (Emergency (OR 4) > elective (OR 2))
    • Retained placenta (Tissue) (OR 5)
    • Mediolateral episiotomy
    • Induction of labour (OR 2)
    • Operative vaginal delivery (Trauma)
    • Prolonged labour (Tone) (OR 2)
    • >4kg baby (Tone/Trauma) (OR 2)
  • Pre-existing bleeding disorders e.g. Haemophilia A or B (factor 8 or 9 deficiency, respectively); von Willebrand’s disease

Reducing the risk

  • If a risk factor is identified antenatally or intrapartum, this should be noted and suitable care given to women both to avoid increasing further risk and prepare for possibility of PPH
  • Active management of the third stage of labour
    • For women without risk factors and delivering vaginally- IM injection of 5-10 IU of oxytocin should be administered during the third stage for prophylaxis against PPH
    • For women delivering by C-section, 5 IU of oxytocin should be given by slow IV infusion/injection
  • For women who have had a previous C-section, the location of the placenta and risk of placenta accreta should be assessed and delivery planned appropriately with back-up blood products with a consultant present

Management

  • If PPH is identified, the RCOG highlights 4 important components of care that should be dealt with appropriately
    • They are not in any order because they should be dealt with simultaneously
  • Communication
    • Minor PPH
      • Alert the midwife in charge and the first-line obstetric and anaesthetic staff (trained in managing PPH)
    • Major PPH
      • Call experienced midwife in addition to midwife in charge
      • Call obstetric middle grade and alert consultant
      • Call anaesthetic middle grade and alert consultant
      • Alert consultant haematologist on call
      • Alert blood transfusion lab
      • Call porters for delivery of specimens/blood products
      • Alert one member of the team to record events, fluids, drugs and vital signs
  • Resuscitation
    • ABCDE
      • Minor PPH
        • Fluid resuscitation is usually all that is required
      • Major PPH
        • Full ABCDE with transfusion of blood products ASAP
          • ideally cross-matched blood, but O-negative; Rhesus negative blood if not
        • Warmed crystalloid/colloid infusions should start prior to this if blood products are not immediately available
          • Maximum 3.5 litres- 2l Hartmann’s followed by 1.5l colloid
  • Monitoring/Investigation
    • Minor PPH
      • Bloods for group and save; FBC; Coagulation
      • BP/pulse every 15 minutes
    • Major PPH
      • Blood for crossmatch (4 units min); FBC; Coagulation; renal and liver function
      • Monitor temperature every 15 minutes and continuous monitoring of pulse, BP, respiratory rate and saturations
      • Foley catheter to monitor urine output
      • 2 large bore cannulae
      • Consider arterial monitoring; transfer to ICU once bleeding is controlled
  • Arresting the bleeding
    • Where tone is a causative factor
      • Bimanual uterine compressions to stimulate contraction
      • Ensure bladder is empty
      • Follow the following in order until bleeding stops
      1. Syntocinon 5 units by slow intravenous injection
      2. Ergometrine 0.5mg by slow IV or IM injection (contraindicated in hypertension)
      3. Syntocinon infusion (40 units in 500ml Hartmann’s at 125ml/hour) (unless fluid restriction necessary)
      4. Carboprost 0.25mg by IM injection repeated every 15 minutes to a maximum of 8 doses (contraindicated in asthma)
      5. Intramyometrial injection of carboprost 0.5mg
      6. Misoprostol 1000μg rectally
    • If pharmacological measures fail, begin surgical haemostasis sooner rather than later
      • Intrauterine balloon tamponade
      • Patient may require hysterectomy if bleeding continues after surgical measures fail

Management of Secondary PPH

  • Antibiotics if indicated (evidence of infection)
    • Ampicillin and metronidazole +/- gentamicin (if there is evidence of endomyometritis (e.g. tender uterus) or overt sepsis)
  • Surgical management is usually first line
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